Cultural Sociology of

M E N TA L
ILLNESS
Cultural Sociology of
M E N TA L
ILLNESS
An A-to-Z Guide

VOLUME 1

ANDREW SCULL
EDITOR
University of California, San Diego
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SAGE Publications Ltd.
1 Oliver’s Yard Cultural sociology of mental illness : an A-to-Z guide /
55 City Road Andrew Scull, general editor, University of California,
London EC1Y 1SP San Diego.
United Kingdom 2 volumes ; cm
Includes bibliographical references and index.
SAGE Publications Asia-Pacific Pte. Ltd. ISBN 978-1-4522-5548-4 (set : hardcover : alk. paper)
3 Church Street 1. Psychology, Pathological--Cross-cultural studies.
#10-04 Samsung Hub 2. Cultural psychiatry. 3. Mental illness--Social aspects--
Singapore 049483 History. 4. Mentally ill--Care--Social aspects. I. Scull,
Andrew, 1946-
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 Contents
Volume 1
List of Articles vii
Reader’s Guide xiii
About the Editor xix
List of Contributors xxi
Introduction xxvii
Chronology xxxv

Articles

A 1
B 69
C 95
D 173
E 247
F 305
G 321
H 345
I 373
J 429
K 437
L 443
M 475

Volume 2
List of Articles vii
Articles
N 567
O 603
P 609
R 733
S 767
T 865
U 907
V 929
W 955
Glossary 971
Resource Guide 979
Appendix: Federal Reports on Mental Illness 985
Index 1043
Photo Credits 1113
 List of Articles

A B
Acculturation Bangladesh
Adolescence Barbiturates
Afghanistan Benzodiazepines
Age Bereavement
Ageism Biological Psychiatry
Agoraphobia Bipolar Disorder
Alcoholism Board and Care Homes
Algeria Brazil
Alzheimer’s Disease Burma (Myanmar)
American Psychiatric Business and Workplace Issues
Association
American Psychological C
Association Canada
Amphetamines Care, Sociology of
Anthropology Case Managers
Antidepressants Case Records
Antipsychiatry Children
Antisocial Behavior China
Anxiety, Chronic Chronic Pain
Architecture Chronicity
Argentina Clinical Psychologists, Training of
Art and Artists Clinical Psychology
Assessment Issues in Mental Health Clinical Sociology
Asylums Clinical Trials
Attention Deficit Hyperactivity Disorder Clozapine
(ADHD) Cognitive Behavioral Therapy
Atypical Antipsychotics Cognitive Disorder
Australia Colombia
Autism Commitment Laws

vii
viii List of Articles

Community Mental Health Centers Electrotherapy

Community Psychiatry Emergency Rooms
Competency and Credibility Emotions and Rationality
Compulsory Treatment Employment
Conduct, Unwanted Environmental Causes
Congo, Democratic Republic of the Epidemiology
Consumer-Survivor Movement Ethical Issues
Costs of Mental Illness Ethiopia
Courts Ethnicity
Creativity Ethnopsychiatry
Critical Theory Eugenics
Cross-National Prevalence Estimates Euthanasia
Cultural Prevalence Exclusion

D F
Dangerousness Family Support
Deinstitutionalization Fiction
Delirium Food and Drug Administration, U.S.
Delusions Forensic Psychiatry
Dementia Foucault, Michel
Dementia Praecox France
Denmark Freud, Sigmund
Department of Health and Human Services, U.S.
Depression G
Deviance Gender
Diagnosis Genetics
Diagnosis in Cross-National Context Geography of Madness
Diagnostic and Statistical Manual of Mental Germany
Disorders. See DSM-III, DSM-IV, DSM-5 Global Mental Health Movement
Diazepam Globalization
Disability Grandiosity
Disasters Group Homes
Dissociative Disorders
Dopamine H
Double Bind Theory Hallucinations
Drug Abuse Health Insurance
Drug Abuse: Cause and Effect Help-Seeking Behavior
Drug Development Homelessness
Drug Treatments, Early Hospitals for the Criminally Insane
Drugs and Deinstitutionalization Human Rights
DSM-III Huntington’s Disease
DSM-IV Hydrotherapy
DSM-5 Hypersexuality
Durkheim, Émile Hypnosis
Hysteria
E
Eating Disorders I
Economics Iatrogenic Illness
Egypt Identity
Electroconvulsive Therapy Imperial Psychiatry
 List of Articles ix

Impulse Control Disorder Mass Media

Incidence and Prevalence Measuring Mental Health
India Mechanical Restraint
Indonesia Medicalization, History of
Inequality Medicalization, Sociology of
Informed Consent Medicare and Medicaid
Insanity Defense Melancholia
Insulin Coma Therapy Mental Health America
Integration, Social Mental Hygiene
Intelligence Mental Illness Defined: Historical Perspectives
Intelligibility Mental Illness Defined: Psychiatric Perspectives
International Classification of Diseases Mental Illness Defined: Sociological Perspectives
International Comparisons Mental Institutions, History of
Internet and Social Media Merleau-Ponty, Maurice
Interpersonal Dynamics Mesmerism
Iran Mexico
Iraq Migration
Italy Milieu Therapy
Military Psychiatry
J Mind–Body Relationship
Jails and Prisons Minor Tranquilizers
Japan Monoamine Oxidase Inhibitor (MAOI)
Jung, Carl Gustav Antidepressants
Mood Disorders
K Moral Insanity
Kenya Morocco
Kleptomania Mortality
Kraepelin, Emil Movies and Madness
Munchausen Syndrome
L
Labeling N
Lacan, Jacques National Alliance on Mental Illness
Laing, Ronald David National Institute of Mental Health
Law and Mental Illness Nazi Extermination Policies
Lay Conception of Illness Neighborhood Quality
Learning Disorders Neo-Kraepelinian Psychiatry
Legislation Neurasthenia
Life Course Neurosyphilis
Life Expectancy Trends Neurotransmitters and Psychiatry
Life Skills Nigeria
Lithium “Normal”: Definitions and Controversies
Lobotomy Nursing
Nursing Homes
M
Malaria Therapy O
Malpractice Obsessive-Compulsive Disorder
Mania
Marginalization P
Marital Status Pakistan
Marketing Panic Disorder
x List of Articles

Pathological Gambling Rationality

Patient Accounts of Illness Refrigerator Mother
Patient Activism Religion
Patient Rights Religiously Based Therapies
Peer Identification Reserpine
Personality Disorder, Borderline Right to Refuse Treatment
Personality Disorders Right to Treatment
Pervasive Developmental Disorders Ritalin
Pharmaceutical Industry Role Strains
Philippines Russia
Phobias
Placebo Effect S
Poland Sadomasochism
Police, Sociology of Schizoaffective Disorder
Policy: Federal Government Schizophrenia
Policy: Medical Scientology
Policy: Military Self-Esteem
Policy: Police Self-Help
Policy: State Government Self-Injury
Polypharmacy Serotonin Reuptake Inhibitors
Popular Conceptions Service Delivery
Post-Traumatic Stress Disorder Service User Involvement
Prevention Sex
Primary Care Sex Differences
Prison Psychiatry Sexual Surgery
Prozac Shell Shock
Psychiatric Social Work Side Effects
Psychiatric Training Sleep Disorders
Psychiatric Treatment, Pathways to Social Causation
Psychiatry and Neurology Social Class
Psychiatry and Neuroscience Social Control
Psychiatry and Sexual Orientation Social Isolation
Psychoanalysis, History and Social Security
Sociology of Social Support
Psychoanalysis and Literary Theory Sociopathic Disorders
Psychoanalysis and Popular Culture Somatization of Distress
Psychoanalysis and the Social Sciences South Africa
Psychoanalytic Treatment South Korea
Psychopharmacological Research Spain
Psychopharmacology Spiritual Healing
Psychosocial Adaptation State Budgets
Psychosomatic Illness, Cultural Comparisons of Stereotypes
Psychosomatic Illness, History and Sociology of Sterilization
Public Education Campaigns Stigma
Stigma: Patient’s View
R Stress
Race Sudan
Race and Ethnic Groups, American Suicide
Racial Categorization Suicide: Patient’s View
Randomized Controlled Trial Szasz, Thomas
 List of Articles xi

T Unemployment
Tanzania United Kingdom
Tardive Dyskinesia United States
Television Unquiet Mind, An
Thailand Urban Versus Rural
Theater
Therapeutics, History of V
Therapy, Group Veterans
Therapy, Individual Veterans’ Hospitals
Thorazine and First-Generation Antipsychotics Vietnam
Tourette Syndrome Violence
Trade in Lunacy Visual Arts
Trauma: Patient’s View Voluntary Commitment
Trauma, Psychology of Vulnerability
Treatment
Tricyclic Antidepressants W
Turkey War
Welfare
U Women
Uganda Work–Family Balance
Ukraine World Health Organization
 Reader’s Guide

Cultural Comparisons of Mental Melancholia

Health Disorders Mood Disorders
Agoraphobia Moral Insanity
Alcoholism Munchausen Syndrome
Alzheimer’s Disease Neuroses
Antisocial Behavior Neurosyphilis
Anxiety, Chronic Obsessive-Compulsive Disorder
Attention Deficit Hyperactivity Disorder Panic Disorder
(ADHD) Paranoia
Autism Personality Disorder,
Bereavement Borderline
Bipolar Disorder Personality Disorders
Cognitive Disorder Pervasive Developmental
Delirium Disorder
Delusions Phobias
Dementia Post-Traumatic Stress Disorder
Dementia Praecox Sadomasochism
Depression Schizoaffective Disorder
Dissociative Disorders Schizophrenia
Double Bind Theory Sleep Disorders
Drug Abuse Sociopathic Disorders
Eating Disorders Tourette Syndrome
Hallucinations
Huntington’s Disease Cultural Sociology of Mental Illness
Hypersexuality Around the World
Hysteria Afghanistan
Impulse Control Disorder Algeria
Kleptomania Argentina
Learning Disorders Australia
Mania Bangladesh

xiii
xiv Reader’s Guide

Brazil Epidemiology
Burma (Myanmar) Age
Canada Cross-National Prevalence Estimates
China Diagnosis in Cross-National Context
Colombia Drug Abuse: Cause and Effect
Congo, Democratic Environmental Causes
Republic of the Epidemiology
Denmark Ethnicity
Egypt Eugenics
Ethiopia Gender
France Genetics
Germany Incidence and Prevalence
India International Classification
Indonesia of Diseases
Iran Marital Status
Iraq Measuring Mental Health
Italy Race
Japan Sex Differences
Kenya
Mexico Mental Health Practitioners
Morocco American Psychiatric Association
Nigeria American Psychological Association
Pakistan Case Managers
Philippines Community Psychiatry
Poland Military Psychiatry
Russia Nursing
South Africa Primary Care
South Korea Prison Psychiatry
Spain Psychiatric Social Work
Sudan Psychiatric Training
Tanzania
Thailand Nondrug Treatments
Turkey Cognitive Behavioral Therapy
Uganda Electroconvulsive Therapy
Ukraine Electrotherapy
United Kingdom Hydrotherapy
United States Hypnosis
Vietnam Insulin Coma Therapy
Lobotomy
Economics Malaria Therapy
Costs of Mental Illness Milieu Therapy
Economics Prevention
Employment Psychoanalytic Treatment
Health Insurance Religiously Based Therapy
Measuring Mental Health Self-Help
Medicare and Medicaid Sexual Surgery
Pharmaceutical Industry Spiritual Healing
Social Security Sterilization
State Budgets Therapy, Group
Welfare Therapy, Individual
 Reader’s Guide xv

The Patient DSM-IV

Adolescence DSM-5
Ageism Ethnopsychiatry
Art and Artists Food and Drug Administration, U.S.
Children Forensic Psychiatry
Chronicity Freud, Sigmund
Competence and Credibility Jung, Carl Gustav
Consumer-Survivor Movement Kraepelin, Emil
Creativity Labeling
Emotions and Rationality Lacan, Jacques
Ethical Issues Laing, Ronald David
Euthanasia Malpractice
Family Support Mental Illness Defined: Psychiatric Perspectives
Grandiosity National Institute of Mental Health
Help-Seeking Behavior Neo-Kraepelinian Psychiatry
Iatrogenic Illness “Normal”: Definitions and Controversies
Informed Consent Psychiatric Training
Intelligence Psychiatry and Neurology
Intelligibility Psychiatry and Neuroscience
Life Course Psychoanalysis, History and Sociology of
Life Expectancy Trends Psychosocial Adaptation
Life Skills Psychosomatic Illness, History and Sociology of
Migration Role Strains
Mind–Body Relationship Scientology
Mortality Szasz, Thomas
Patient Activism Trauma, Psychology of
Patient Rights
Peer Identification Psychiatry and Space
Psychiatric Treatment, Pathways to Architecture
Self-Injury Asylums
Sex Board and Care Homes
Social Isolation Community Mental Health Centers
Somatization of Distress Deinstitutionalization
Stereotypes Emergency Rooms
Stigma: Patient’s View Geography of Madness
Stress Globalization
Suicide: Patient’s View Homelessness
Trauma: Patient’s View Hospitals for the Criminally Insane
Unemployment Imperial Psychiatry
Veterans Jails and Prisons
Violence Migration
Neighborhood Quality
Psychiatry and Psychology Nursing Homes
Antipsychiatry Urban Versus Rural
Assessment Issues in Mental Health Veterans’ Hospitals
Biological Psychiatry War
Clinical Psychology
Conduct, Unwanted Psychopharmacology
Diagnosis Amphetamines
DSM-III Antidepressants
xvi Reader’s Guide

Atypical Antipsychotics Social Security

Barbiturates Voluntary Commitment
Benzodiazepines World Health Organization
Clinical Trials
Clozapine Social History
Diazepam Anthropology
Dopamine Case Records
Drugs and Deinstitutionalization Disability
Lithium Disasters
Marketing Fiction
Minor Tranquilizers Legislation
Placebo Effect Mass Media
Polypharmacy Mechanical Restraint
Prozac Medicalization, History of
Psychopharmacological Research Mental Hygiene
Randomized Controlled Trial Mental Illness Defined: Historical Perspectives
Reserpine Mental Institutions, History of
Ritalin Mesmerism
Seratonin Reuptake Inhibitors Movies and Madness
Side Effects Nazi Extermination Policies
Tardive Dyskinesia Neurasthenia
Thorazine and First-Generation Patient Accounts of Illness
Antipsychotics Popular Conceptions
Tricyclic Antidepressants Refrigerator Mother
Religion
Public Policy Shell Shock
Board and Care Homes Television
Commitment Laws Theater
Compulsory Treatment Therapeutics, History of
Courts Trade in Lunacy
Department of Health and Unquiet Mind, An
Human Services, U.S. Visual Arts
Human Rights
Inequality Sociology
Insanity Defense Acculturation
Law and Mental Illness Business and Workplace Issues
Legislation Care, Sociology of
Medicare and Medicaid Clinical Sociology
Mental Health America Courts
National Alliance on Mental Illness Critical Theory
Policy: Federal Government Cultural Prevalence
Policy: Medical Dangerousness
Policy: Military Deviance
Policy: Police Durkheim, Émile
Policy: State Government Emotions and Rationality
Public Education Campaigns Exclusion
Right to Refuse Treatment Foucault, Michel
Right to Treatment Identity
Service Delivery Integration, Social
Social Control International Comparisons
 Reader’s Guide xvii

Internet and Social Media Race and Ethnic Groups, American

Interpersonal Dynamics Self-Esteem
Lay Conception of Illness Social Causation
Marginalization Social Class
Medicalization, Sociology of Social Isolation
Mental Illness Defined: Sociological Social Support
Perspectives of Stigma
Merleau-Ponty, Maurice Suicide
Police, Sociology of Treatment
Psychiatry and Sexual Orientation Vulnerability
Public Education Campaigns Women
Race Work–Family Balance
 About the Editor

Andrew Scull was born Guggenheim Foundation, and the Shelby Cullom
in Edinburgh, Scotland. Davis Center for Historical Studies at Princeton
He obtained his B.A. with University, and he has served as director of a
first-class honors from National Endowment for the Humanities Sum-
Balliol College at the Uni- mer Seminar on “Madness and Society.” From
versity of Oxford in poli- 1992 to 1993, he was president of the Society for
tics, philosophy, and eco- the Social History of Medicine.
nomics, and an M.A. and Scull’s work has been translated into Korean,
Ph.D. in sociology from Japanese, French, Spanish, Italian, and German.
Princeton University. From He has published more than 100 articles in leading
1976 to 1977, he was a journals in law, psychiatry, sociology, medical his-
postdoctoral fellow in medical history at Univer- tory, social history, neurology, and medicine. His
sity College London. He has held faculty appoint- many books include Decarceration (1977, 2nd ed.
ments at the University of Pennsylvania, Princeton 1984); Museums of Madness: The Social Organi-
University, and the University of California, San zation of Insanity in Nineteenth Century England
Diego, where he has been Distinguished Professor (1979); The Most Solitary of Afflictions: Madness
of Sociology and Science Studies since 1994. and Society in Britain, 1700–1900 (1993); Mad-
Among others, he has held fellowships from house: A Tragic Tale of Megalomania and Modern
the American Council of Learned Societies, the Medicine (2005); and Hysteria (2009).

xix
 List of Contributors

Apryl Alexander April Bradley

Florida Institute of Technology University of North Dakota
Joseph Daniel Anson Loretta L. C. Brady
Florida State University Saint Anselm College
Katherine L. Applegate Hope Brasfield
Duke University Medical Center University of Tennessee, Knoxville
Matthew E. Archibald Joel Tupper Braslow
Colby College University of California, Los Angeles
Steven Arenz Candace S. Brown
Winona State University Virginia Commonwealth University
Taj Artis Lisa M. Brown
University of Southern California University of South Florida
Aisha Asby Rose Brown
Prairie View A&M University University of North Carolina
Camela S. Barker at Chapel Hill
B and D Behavioral Health Vivienne Brunsden
John H. Barnhill Nottingham Trent University
Independent Scholar W. Jeff Bryson
Kris Bevilacqua Alabama Psychological Services Center
Albert Einstein College of Medicine Kathryn Burrows
Shannon Bierma Rutgers University
University of Tennessee, Knoxville Bonnie Burstow
Thomas R. Blair Ontario Institute for Studies
University of California, Los Angeles in Education
Bonnie Ellen Blustein Joan Busfield
West Los Angeles College University of Essex, Wivenhooe Park
Dieter Bögenhold David Buxton
Alpen-Adria-University Klagenfurt Harvard Massachusetts General Hospital
Sarah Boslaugh Goldie Byrd
Kennesaw State University North Carolina A&T State University

xxi
xxii List of Contributors

Paul Cantz Miriam Feliu

University of Illinois, Duke University Medical Center
Chicago College of Medicine Fabrice Fernandez
Corey R. Carlson École des Hautes Études en
Prairie View A&M University Sciences Sociales
Erika Carr Bradley Fidler
Memphis VA Medical Center University of California, Los Angeles
Roger J. Casey Steven L. Foy
VA National Center for Duke University
Homelessness Among Veterans Debra L. Frame
Tanya M. Cassidy University of Cincinnati
University of Windsor Julie L. Framingham
Padmaja Chalasani Florida Department of Children
Aneurin Bevan Health Board and Families
James J. Chriss Alexis T. Franzese
Cleveland State University Elon University
Sarah Clement Ron Fritz
King’s College London Independent Scholar
Bruce Macfarlane Zarnovich Cohen Dustin Bradley Garlitz
University of Auckland University of South Florida
Justin Corfield Dashiel Geyen
Independent Scholar Texas Southern University
Israel Cross Camille Gibson
University of Maryland, Baltimore County Prairie View A&M University
Gareth Davey Brian Gifford
Hong Kong Shue Yan University Integrated Benefits Institute
Fernando G. De Maio Alyssa Gilston
DePaul University University of the Rockies
Tara DeBraber Jeffrey I. Goatcher
University of Southern California Nottingham Trent University
Suzanne Delle Diane C. Gooding
Salve Regina University University of Wisconsin, Madison
Christina DeRoche Robin Green
McMaster University Albert Einstein College of Medicine
Kendall Dodge Alyssa Gretak
Elon University Southern Illinois University, Edwardsville
Sapna Doshi Natasha Gulati
Potomac Behavioral Solutions Gonzaga University
Nicholas R. Eaton Jessica Smartt Gullion
Stony Brook University Texas Woman’s University
Christopher L. Edwards Seth Donal Hannah
Duke University Harvard University
Joel P. Eigen Kathleen Harrison
Franklin and Marshall College Emmanuel College
JoAnna Elmquist Tammy Hatfield
University of Texas–Pan American Lindsey Wilson College
Troy Ertelt Julie Henderson
University of North Dakota Flinders University
Jeniimarie Febres Jason A. Helfer
University of Tennessee, Knoxville Knox College
 List of Contributors xxiii

Steven C. Hertler Sara Konrath

College of New Rochelle University of Michigan
LaBarron K. Hill Ayelet Krieger
Duke University Medical Center George Washington University
Andrea Hobkirk Jennie Kronenfeld
Duke University Medical Center Arizona State University
Trina L. Hope Bill Kte’pi
University of Oklahoma Independent Scholar
Allan V. Horwitz Lindsay Labrecque
Rutgers University Brown University
James Edward Houston Brenda A. LeFrancois
Nottingham Trent University Memorial University of Newfoundland
Andrew Hund Samuel Lézé
Umea University École Normale Superieure de Lyon
Alishia Huntoon Lloyd L. Liang
Oregon Institute of Technology Colby College
Kathryn Hyer Alisa Lincoln
University of South Florida Northeastern University
David Ingleby Andrea Liner
University of Amsterdam George Washington University
José R. Irizarry Samantha J. Lookatch
Cambridge College University of Tennessee, Knoxville
Farah Islam Hector E. Lopez
York University Inter American University of Puerto Rico
Kimberly Jinnett Kim Lorber
Integrated Benefits Institute Ramapo College of New Jersey
Deborah Johnson Marilyn D. Lovett
University of California, San Francisco Livingstone College
Laura Johnson Meghan R. Lowery
Chicago School of Professional Psychology Psychological Associates
Shama K. Kanwar James E. Maddux
National Health Service George Mason University
Moira J. Kelly Sarah Mauck
Queen Mary University of London University of Tennessee, Knoxville
Alex Kertzner Melanie McCabe
University of California, Los Angeles North Carolina Central University
Abigail Keys Camela McDougald
Duke University B and D Behavioral Health
Alex Khaddouma Sally McManus
University of Tennessee, Knoxville National Centre for Social Research
Nazilla Khanlou Tara McMullen
York University University of Maryland, Baltimore County
Katherine King Marcia Meldrum
Duke University University of California, Los Angeles
Eileen Klein Katie Miller
Ramapo College of New Jersey University of North Dakota
Virginia Elizabeth Klophaus Shari Parsons Miller
University of North Dakota Independent Scholar
Paul Komarek Lauren Mizock
Independent Scholar Boston University
xxiv List of Contributors

Todd M. Moore Eve S. Puffer

University of Tennessee, Knoxville Duke University
Mary Beth Morrissey Michael G. Rank
Fordham Graduate School of Social Service University of Southern California
Krysia N. Mossakowski Gretchen M. Reevy
University of Hawai‘i, Manoa California State University, East Bay
Malik Muhammad Kathrin Ritter
Elite Biobehavioral Health University of Tennessee, Knoxville
Joel T. Nadler Louise Roberts
Southern Illinois University, Edwardsville Flinders University
Andrew Ninnemann Christopher C. C. Rocchio
Brown University University of Hawai‘i, Manoa
Gerald E. Nissley, Jr. Ward Rodriguez
East Texas Baptist University California State University, East Bay
Vinai Norasakkunkit Richard Lee Rogers
Gonzaga University Youngstown State University
Keisha O’Garo Richard Ruth
Yale University George Washington University
Ifetayo I. Ojelade Stephanie Elias Sarabia
A Healing Paradigm Ramapo College
Lauren D. Olsen Jennifer C. Sarrett
University of California, San Diego Emory University
Riley Olstead Christine M. Sarteschi
St. Francis Xavier University Chatham University
Erin Olufs Anne-Maree Sawyer
University of North Dakota La Trobe University
Jamie L. Owens Teresa L. Scheid
University of Hawai‘i, Manoa University of North Carolina, Charlotte
Yok-Fong Paat Rob Schraff
University of Texas, El Paso University of California, Los Angeles
Stephen D. Parker Ariane Schratter
University of Queensland Maryville College
Anna Patterson Stephen T. Schroth
Elon University Knox College
Courtney Peasant Joseph A. Scimecca
University of Memphis George Mason University
Lori Peek Andrew Scull
Colorado State University University of California, San Diego
Georgina Perez Steven P. Segal
University of North Carolina at Chapel Hill University of California, Berkeley
Daniel W. Phillips III John E. Senior
Lindsey Wilson College Linacre College, University of Oxford
Christopher Philo Holly Sevier
University of Glasgow University of Hawai‘i, Manoa
Ricardo Pietrobon Brent Mack Shea
Duke University Medical Center Sweet Briar College
Maribel Plasencia David Shern
Brown University Mental Health America
Kelsey Price Ryan C. Shorey
Elon University University of Tennessee, Knoxville
 List of Contributors xxv

Dena T. Smith Shayna Vi

Goucher College University of Hawai‘i, Manoa
Kelly M. Smith Scott Alexander Vieira
University of South Florida Sam Houston State University
Leonard Smith Erin Voss
University of Birmingham University of Southern California
Justin Snyder Bavna Bagyalakshmi Vyas
Saint Francis University Independent Scholar
Wajma Soroor Elaine Walsh
York University University of Washington
Sally Spencer-Thomas Kira Walsh
Carson J. Spencer Foundation Emory University
Raja Staggers-Hakim Elizabeth A. Wangard
Eastern Connecticut State University George Washington University
Sarah M. Steverman Adele Weiner
M. S. W. Catholic University Metropolitan College of New York
Wendy Ellen Stock Jenny Weinstein
Independent Scholar Kingston University
Victor B. Stolberg Eugenia L. Weiss
Essex County College University of Southern California
Joan Striebel Keith E. Whitfield
University of California, San Francisco Duke University
Gregory L. Stuart Rebecca Wilkinson
University of Tennessee, Knoxville University of California, Los Angeles
Akihito Suzuki Veeda Williams
Keio University Prairie View A&M University
Angela Sweeney Derek Wilson
University College London Prairie View A&M University
Christine Tarleton Sarah M. Wilson
University of California, Los Angeles Duke University
Samuel Terrazas Mark Wolfson
University of Texas at El Paso Wake Forest School of Medicine
Garth Terry Mary Wood
University of California, Los Angeles Duke University Medical Center
Jay Trambadia Vania Regina De Angeli Wood
Duke University North Carolina Central University
Eugenia Tsao Edward C. Wright
University of Toronto University of Texas Health Science Center,
Emma Tseris San Antonio
University of Sydney Susan J. Wurtzburg
Russell Vaden University of Hawai‘i, Manoa
University of Wisconsin, Rebekah M. Zincavage
La Crosse Brandeis University
Darci Van Dyke Heather Zucosky
University of North Dakota University of Tennessee, Knoxville
 Introduction

Mental illness, as the eminent historian of psychi- cross-culturally? How have societies responded
atry Michael MacDonald once aptly remarked, to the presence of those who do not seem to share
“is the most solitary of afflictions to the people commonsense notions of reality? Who embraces
who experience it; but it is the most social of mal- views of reality that strike others as delusional?
adies to those who observe its effects” (MacDon- Who sees objects and hears voices invisible and
ald 1981: 1). It is precisely the many social and inaudible to the rest of us? Who commits heinous
cultural dimensions of mental illness that have offenses against law and morality with seem-
made the subject of such compelling interest to ing indifference? Or whose mental life seems so
sociologists. denuded and lacking in substance as to cast doubt
This encyclopedia is testimony to the enor- on their status as autonomous human actors?
mously wide social ramifications of mental ill- Mental illness has profoundly disruptive effects
ness and the inextricable ways in which the cul- on individual lives and the social order we all take
tural and the social are implicated in what some for granted. Erving Goffman, whose mid-20th-
might view as a purely intrapsychic phenom- century writings still constitute some of the most
enon. Psychiatry has typically, though far from provocative and profound sociological medita-
always, focused on the individual who suffers tions on the subject, is perhaps best known for his
from various forms of mental disorder. For the searing critique of mental hospitals as total insti-
sociologist, it is naturally the social aspects and tutions and engines of degradation and destruc-
implications of mental disturbance for the indi- tion that falsely put on a medical gloss (Goffman
vidual, their immediate interactional circle, the 1961). But he also spoke eloquently of “the social
surrounding community, and society as a whole significance of the confusion [the mental patient]
that have been the primary intellectual puzzles creates,” arguing that it “may be as profound and
drawing attention. basic as social existence can get.” He insisted,
How, for example, are we to define and draw rightly in my view, that “mental symptoms are
boundaries around mental illness and distin- not, by and large, incidentally a social infraction.
guish it from eccentricity or mere idiosyncrasy, By and large, they are specifically and pointedly
to draw the line between madness and malinger- offensive. . . . It follows that if the patient persists
ing, mental disturbance and religious inspiration? in his [sic] symptomatic behavior, then he must
Who has social warrant to make such decisions create organizational havoc and havoc in the
and why? Do such things vary temporally and minds of members [of society].”

xxvii
xxviii Introduction

Characteristically, Goffman then proceeded to Germany, and the United States, at first often out-
critique the response of our contemporary creden- side university settings, as in the British social sur-
tialed experts in the treatment of mental illness: vey tradition pioneered by Charles Booth (1889,
“It is this havoc that psychiatrists have dismally 1891, and 1892–97) and Benjamin Seebohm
failed to examine.” But he was equally scathing Rowntree (1901), but soon enough within the
about many of his contemporaries in the socio- walls of academic institutions. The earliest aca-
logical profession, who then sought to dismiss demic sociologists often secured niches in other
mental illness as a purely socially constructed cat- disciplines; Émile Durkheim’s first appointment at
egory, a mere matter of labels. Sociologists who Bordeaux was in social science and pedagogy and
adopted this romantic view were equally guilty of his later chair at the Sorbonne was as professor of
playing down or ignoring the profoundly disrup- education. Max Weber’s at Freiburg was in eco-
tive effects of madness on the individual and on nomics, as was his next appointment at Heidel-
society (Goffman 1971: 356–357). berg, but soon enough the discipline managed to
institutionalize itself as a separate and legitimate
Accepting the Concept of Mental Illness academic endeavor.
Accepting, then, that there is such a thing as men- Durkheim played a critical role in this process
tal illness (all the while acknowledging that some in France and aggressively sought to claim for
sociologists and even some renegade psychiatrists sociology a distinctive realm of social facts, exter-
have questioned its reality, and still others have nal and constraining on the individual. Much of
debated its designation as a specifically medical his work thus had an overtly polemical cast, and
problem), a whole series of further questions then even the subject matter he chose was often influ-
arises: How much of it is there, and how do we enced by its value in establishing the intellectual
know, if indeed we do? What is its social location? legitimacy of sociology and its status as a distinct
Does it differ by class, age, gender, race, ethnicity, and autonomous science as well as demonstrating
and so forth? Do these social variables have impli- the unique power of “the social” in the explana-
cations for the way mental illness is reacted to and tion of sociological phenomena. “Every time,” he
socially managed? What are the costs of such epi- boldly and wrongly proclaimed, “a social phe-
sodes of mental disturbance to individuals, fami- nomenon is directly explained by a psychological
lies, and society as a whole, and how are those phenomenon, we may rest assured that the expla-
costs distributed? How have societies character- nation is false” (Durkheim 1895: 129).
istically responded to mental illness, and what Two years later, he deliberately chose an appar-
institutions have they constructed to contain and ently quintessentially individual act—suicide—and
perhaps cure it? What changes in these responses attempted to account for it in social terms. More
have occurred over time, and what accounts for precisely, he claimed to detect in the statistics on
these changes? How has mental illness been con- suicide a whole series of distinct regularities, for
ceptualized by professionals, but also by the laity? which he proffered a sociological explanation
And how have these differing cultural meanings (Durkheim 1897). Necessarily, he was thereby led
been captured, refracted, and distorted in popular to confront the question of insanity and its possi-
culture? One could go on, and the body of this ble relationship to suicide—mental illness in both
encyclopedia deals with an even broader array of its most florid manifestations and in borderline
sociologically relevant topics, but the vital impor- examples of mental disturbance such as alcohol-
tance of a sociological perspective on mental ill- ism and what was then called neurasthenia, or
ness should by now be apparent. weakness of the nerves. To his own satisfaction, at
least, Durkheim claimed to have shown that while
Early Viewpoints all of these conditions might predispose an indi-
It should come as no surprise to learn that from vidual toward suicide, it was social factors rather
the discipline’s first days, many sociologists have than individual psychopathology that explained
had something to say about the subject. Sociol- the rate at which people killed themselves.
ogy as a discipline began to coalesce in the late To the extent that sociopsychological states led
19th and early 20th centuries in France, Britain, vulnerable people to commit suicide, those states
 Introduction xxix

were themselves the product of sociological fac- with deviance that the Chicago school exhibited,
tors; in modern societies, most commonly the and the preoccupation of many of the sociologists
condition he labeled “anomie,” or the failure of it trained with ethnographic approaches to the
the social order to adequately regulate the beliefs study of social life, can be traced in many of the
and behaviors of its members. (For critiques of works of postwar American sociology, not least
Durkheim’s arguments, see H. W. Douglas 1967; many of the classic studies emerging in the 1950s
S. M. Lukes 1973.) and 1960s that were devoted to the sociology of
mental illness.
The Chicago School
If Durkheim and the Durkheimian school dealt Post–World War II Ideologies
with mental illness only tangentially, another World War II and its aftermath marked a turning
major school of sociological thought that was point for American social science and for Ameri-
emerging in the early 20th century, the Chicago can universities more broadly. The mobilization
school, led by Robert Park and Ernest Burgess, of society for total war broke down the barriers—
frequently tackled the subject more directly. In legal and ideological—to the expansion of central
important ways, the sociologists trained at the state powers, as well as finally vanquishing the
University of Chicago were heirs to the social Great Depression. The upshot was a vast increase
survey tradition that had emerged in late 19th- in the size and reach of the American federal gov-
century Britain. Park, Burgess, and their students ernment, a development that proved permanent
treated the city as their laboratory and set forth to and has only accelerated in the years since. In
document its structures and its pathologies (Park, war’s shadow, there was little disposition to rein
Burgess and R. McKenzie 1925). in the expanded scope of federal authority, and
Like their British predecessors, the Chicago soci- what resistance there was melted away with the
ologists employed both statistical techniques and outbreak of the Cold War in 1947.
ethnographic observation, both mapping the sta- Science, including social science, had played an
tistical distribution of social problems and provid- enormous role in the war effort, and as the con-
ing detailed ethnographic studies of their place in flict drew to a close, efforts were made to rethink
specific neighborhoods in the city. Psychoses were the role of science and society in the soon-to-be
only one of a number of what they termed social postwar world. The most notable instance of
pathologies that fell under their gaze, alongside this new thinking was Vannevar Bush’s extended
homelessness, alcoholism, suicide, homicide, pros- memorandum to President Franklin D. Roosevelt,
titution, juvenile delinquency, and crime. Char- subsequently published as Science: The Endless
acteristically, the psychological disorganization Frontier (Bush 1945). Written by the wartime
that characterizes mental illness (and other forms director of the Office of Scientific Research and
of deviance) was linked to the social disorganiza- Development, it presented a wide-ranging over-
tion of particular communities—the prevalence of view of the conditions of scientific research, its
anonymous and transitory social relationships and potential contributions to public welfare, the
the weakness of social ties, all associated with the reconfigurations that would be necessary after the
breakdown of social controls. (For discussions of war, and the potential role of Washington, both in
the Chicago School, see M. Bulmer 1984; R. E. L. securing the training of scientific talent and in the
Faris 1967.) prosecution of scientific research.
The culmination of this perspective on the soci- Though its primary remit was the natural
ological study of mental illness came with the 1939 sciences and medicine, it ranged broadly over
publication of Robert E. Faris and Henry War- its chosen terrain, and in the Harry S. Truman
ren Dunham’s monograph Mental Disorders in administration it would serve as the inspiration
Urban Areas, a volume that, its title notwithstand- for the formation of the National Science Foun-
ing, focused primarily on Chicago (See Faris and dation and the National Institutes of Health, both
H. W. Dunham 1939; and for an attempt to gen- of which would transform the environment for
eralize their findings to other cities, C. W. Schroe­ research and the nature of the modern university.
der 1942). But in a broader sense, the fascination The era of Big Science and the modern research
xxx Introduction

university may be said to be its progeny. Where shift occurred in the locus of psychiatric practice
before the war, federal involvement in scientific as increasing numbers of professionals opted for
and medical research—let alone the social sci- the outpatient sector and traditional mental hos-
ences—had been vanishingly small, from the late pitals were left with the dregs of the profession.
1940s onward and particularly since the Cold The number of psychiatrists rose rapidly, and
War, it started down the pathway of exponential for at least a quarter-century, the most ambitious
growth that has continued ever since. With bur- among them for the most part embraced some
geoning federal investment, the process of knowl- version of Freudian psychoanalysis.
edge creation and major characteristics of the NIMH adopted an extremely broad definition
academic world were irrevocably altered. of what constituted research relevant to its mis-
Military conflict had an even more direct sion of understanding mental illness and improv-
impact on the psychiatric sector. Modern indus- ing its treatment. The bulk of its research funding
trialized and mechanized warfare has repeatedly was directed to the social sciences, not to psychia-
had drastic effects on the mental health of mili- try, in part because psychoanalysts spurned the
tary personnel, and World War II, like the first, sort of research the agency was willing to fund
saw a massive number of psychiatric casualties and in part because they were such inept grants-
spawned by the horrors of combat. Many of these men. Though the great bulk of social science fund-
were permanently harmed, so military authorities ing went in turn to the discipline of psychology, a
faced the immediate emergency of coping with considerable fraction of federal money was cap-
soldiers breaking down—the effects on fighting tured by sociologists, and for the three decades
efficiency and morale—and the postwar prob- after World War II, much of the flourishing state
lems posed by disabled veterans with grave and of the sociology of mental illness can be attrib-
continuing psychiatric problems. The exigencies uted to this flow of federal research dollars (Scull
of wartime prompted a massive expansion in the 2011a; 2011b).
number of medics deployed to deal with psychiat- Some of this work was conducted intramurally
ric emergencies as well as a continuing, expanded at the Laboratory of Socio-Environmental Stud-
demand for psychiatrists after the war ended. The ies, headed by sociologist John Clausen (1956),
knowledge that even the apparently psychiatri- and at the Biometry branch, where the collection
cally healthy broke down in large numbers under of systematic statistical data and the development
enormous stress, combined with the heroic status of epidemiological research were encouraged.
of these psychiatric casualties, also helped change But much also took the form of NIMH training
popular attitudes to mental illness and encour- grants and extramural research grants. Substan-
aged the psychiatric profession to believe that tively, much of the work in the 1950s built upon
many cases of mental illness could be treated out- the intellectual foundations provided by the Chi-
side the walls of the traditional mental hospital cago school in its dual emphasis on quantitative
(A. Scull 2010). and ethnographic techniques. Large-scale studies
of social class and mental illness, mental illness
The National Institute of Mental Health and the family, and popular conceptions of men-
The consequences of this situation were many. tal illness were undertaken and in some instances
Direct provision of mental health services stretched over several decades. The centrality of
remained a state rather than a federal responsibil- the mental hospital in the mental health sector,
ity, with the exception of a considerable increase both prewar and postwar, and the relevance of
in the number of veterans’ hospitals devoted to sociological perspectives for the understanding of
providing psychiatric services. But both the Vet- these complex organizations meant that these too
erans Administration and the newly established became a focus of much-funded research.
National Institute of Mental Health (NIMH)
were soon pouring funds into the training of A Common Endeavor
mental health professionals, and NIMH also In the early 1950s, much of this research was collab-
embarked on a program of basic research in the orative in nature, linking together psychiatrists or
mental health sector. Within psychiatry, a rapid other mental health professionals and sociologists
 Introduction xxxi

in a common endeavor. Notable examples include Life in such places is a product of their structural
Alfred Stanton and Morris Schwartz’s (1954) eth- features, and their defects are not removable by
nography of the Chesnut Lodge private mental any conceivable sets of reforms. Instead, life in
hospital and the work by August B. Hollingshead a mental hospital inexorably tends to damage,
and Fredrick C. Redlich (1958) and their team of dehumanize, and destroy. Psychiatrists are ridi-
researchers on social class and family dynamics culed as members of a “tinkering trade” who
and mental illness (J. K. Myers and B. H. Rob- induce their subordinates to stage elaborate rituals
erts 1959; see also A. H. Leighton, J. A. Clausen designed to show that they preside over a medical
and R. N. Wilson 1957; T. A. Rennie and L. Srole establishment devoted to humane care and cure,
1956; M. Greenblatt, D. J. Levinson, and R. H. when in reality, they are little better than prison
Williams 1957; M. R. Yarrow, C. G. Schwartz, guards helping to generate the very pathologies
H. S. Murphy, and L. C. Deasy 1955). Soon, how- they claim to treat. As Goffman put it a decade
ever, sociological work began to embrace a far later, mental hospitals were no more than “hope-
more critical stance toward psychiatry and psychi- less storage dumps trimmed in psychiatric paper.”
atric institutions, a shift in intellectual perspective As for the patient, he has been duped, suffering
that emerged particularly strongly in studies of “dislocation from civil life, alienation from loved
mental hospitals and institutional psychiatry. ones who arranged for the commitment, mortifi-
The altered intellectual stance was evident cation due to hospital regimentation and surveil-
as early as 1956, with the appearance of Ivan lance, permanent post-hospital stigmatization.
Belknap’s study of a Texas mental hospital and This has not merely been a bad deal; it has been a
its conclusion that “mental hospitals are prob- grotesque one” (Goffman 1971: 390).
ably themselves obstacles in the development of
an effective plan of treatment for the mentally Differing Views
ill” so that “in the long run the abandonment of From the late 1960s through the 1980s, the intel-
the state hospitals might be one of the greatest lectual distance and even hostility between sociolo-
humanitarian reforms and the greatest financial gists and psychiatrists often seemed to be growing.
economy ever achieved” (I. Belknap 1956: xi, Within five years of the appearance of Asylums, the
212). It is equally evident in such later works as California sociologist Thomas Scheff had authored
Dunham and S. K. Weinberg (1960) and R. Per- an in some ways still more radical assault on psy-
rucci (1974) and perhaps achieved its apotheo- chiatry, dismissing the medical model of mental ill-
sis in Erving Goffman’s devastating portrait in ness and attempting to replace it with a societal
1957 of mental hospitals as “total institutions” reaction model, wherein mental patients were por-
was reprinted in his 1961 Asylums: Essays on the trayed as victims—victims, most obviously, of psy-
Social Situation of Mental Patients and Other chiatrists (Scheff 1966). Noting that despite cen-
Inmates, which became one of the more enduring turies of effort, “there is no rigorous knowledge
works of mid-20th-century American sociology of the cause, cure, or even the symptoms of func-
(Goffman 1961). tional mental disorders,” he argued that we would
Goffman was trained at Chicago, and his be better off adopting “a [sociological] theory of
research for Asylums, undertaken while he was mental disorder in which psychiatric symptoms are
on staff at the NIHM Laboratory of Socio-Envi- considered to be labeled violations of social norms,
ronmental Studies, included a year of fieldwork and stable ‘mental illness’ to be a social role” and
at St. Elizabeth’s Mental Hospital in Washington, “societal reaction [not internal pathology] is usu-
D.C. But while in one sense rooted in the Chicago ally the most important determinant of entry into
school tradition, Goffman’s work was in many that role” (Scheff 1966: 7, 25, 28).
ways Durkheimian in inspiration. In contrast to During the 1960s and 1970s, the societal reac-
the symbolic-interactionist emphasis on the fluid- tion theory of deviance enjoyed a broad popular-
ity of social interaction, Goffman’s is a portrait of ity and acceptance among many sociologists, and
structural determinism. Mental hospitals resem- Scheff’s was one of the principal works in that
ble prisons and concentration camps as well as tradition. But besides attracting derision and hos-
monasteries, nunneries, and boarding schools. tility from psychiatrists (M. Roth 1973), where
xxxii Introduction

they deigned to notice his work at all, it came alternative explanations of the shift in social policy,
under increasing criticism from within sociology and a series of studies began to suggest some of the
on both theoretical (D. Morgan 1975) and empir- defects of the new approach to the management of
ical (W. R. Gove 1970; Gove and P. Howell 1974) chronic mental illness (S. A. Kirk and M. Thierren
grounds. In the face of an avalanche of well- 1975; U. Aviram, S. I. Syme and J. B. Cohen 1976;
founded objections, Scheff was eventually forced C. Windle and D. Scully 1976; Scull 1977, 1984;
to back away from many of his more extreme S. Rose 1979; Gronfein 1985b). The hegemony of
positions, and by the time the third edition of his the DSM began to attract attention, with critics
book appeared (Scheff 1999), most of its bolder examining both the processes by which the succes-
ideas had been quietly abandoned. Labeling and sive editions had been produced and the intended
stigmatization of the mentally ill have remained and unintended effects of its widespread use (Kirk
important subjects for sociologists, even if few and H. Kutchins 1992; Kutchins and Kirk 1997;
would now argue that they have the etiological A. V. Horwitz and J. C. Wakefield 2007; 2012).
significance once attributed to them. The sources and impact of the psychopharmaco-
logical revolution drew increased interest, with
Major Changes in the Past Half-Century attention paid to both the role of the pharmaceu-
Though the skeptical claims of the labeling theo- tical industry and changes in the intellectual ori-
rists have now been sharply curtailed, much of the entation of the psychiatric profession (D. Healy
sociological work being done on mental illness has 1997, 2002; D. Herzberg 2008).
retained its critical edge. Four major interrelated All of this occurred in a context where much of
changes have occurred in the psychiatric sector in the federal money that had once underwritten soci-
the past half-century or so: the progressive aban- ological work on mental illness had been sharply
donment of the prior commitment to segregative curtailed. In the 1960s and 1970s, NIMH con-
responses to serious mental illness and the run- tinued to broadly define its research mission and
down of the state hospital sector; the collapse of fund an extensive array of psychological and socio-
psychoanalysis and its replacement by a renewed logical research. Subjected to political pressures to
emphasis on the biological basis of mental illness; direct funding toward the solution of social prob-
the psychopharmacological revolution; and the so- lems, the agency underwrote a broad array of stud-
called neo-Kraepelinian revolution, the rise of the ies on such topics as crime, drug and alcohol addic-
American Psychiatric Association’s Diagnostic and tion, suicide, and even rape—all topics of some
Statistical Manual of Mental Disorders (DSM) to relevance to mental health issues and all ensuring a
a position of overwhelming importance, not just continual flow of federal research money into the
to the practice of psychiatry in the United States social sciences, but scarcely central concerns for
but also to developments elsewhere in the world. those focused on psychiatric disorders.
Sociologists have played a crucial role in analyzing During the 1980s, however, this pattern of
the sources and impact of most of these changes, research funding abruptly altered. The Repub-
and sociological perspectives have spread and been lican administration elected in 1982 ordered
highly influential among others attempting to make NIMH to redirect its funding priorities away
sense of these profoundly important developments. from social problem–oriented research toward
Deinstitutionalization, for example, was ini- work more directly pertinent to the understand-
tially presented as a grand reform, ironically just ing of mental disorders (L. C. Kolb, S. H. Frazier,
as the mental hospital had originally been (D. and P. Sivrotka 2000). Simultaneously, the intel-
Rothman 1971; Scull 1979, 1993). From the mid- lectual center of gravity within psychiatry was
1970s, however, a more skeptical set of perspec- shifting decisively away from psychoanalysis and
tives emerged. Psychiatrists had assumed that the a biosocial model of mental disorder and toward
new generation of antipsychotic drugs had been a biologically reductionist view of mental illness.
the main drivers of the expulsion of state hospi- The social, so far as most psychiatrists were con-
tal patients. A series of studies demonstrated the cerned, went from being directly relevant to being
fallacy of this claim (Scull 1976, 1977; P. Ler- at best marginal to their research. Thus, politi-
man 1982; W. Gronfein 1985a). Others sought cal pressures to avoid controversial and sensitive
 Introduction xxxiii

work on the sociological dimensions of mental Durkheim, D. E. Suicide. English trans. New York:
disorder were reinforced by the demands of psy- Free Press, 1997.
chiatry for an increased focus on neuroscience Faris, R. E. L. Chicago Sociology: 1920–1932. San
and psychopharmacological research. Francisco: Chandler, 1967.
Scholars working on the sociology of mental Faris, R. E. L. and H. W. Dunham. Mental
illness thus now confront a very different research Disorders in Urban Areas: An Ecological Study
environment than the one that prevailed a quarter of Schizophrenia and Other Psychoses. Chicago:
century ago. The range of intellectual and policy University of Chicago Press, 1939.
issues thrown up by the dramatic changes that Goffman, E. Asylums: Essays on the Social Situation
have marked the mental health sector in the same of Mental Patients and Other Inmates. Garden
period mean, however, that there is an abundance City, NY: Doubleday, 1961.
of challenging topics for the study of which socio- Goffman, E. “The Insanity of Place.” Psychiatry, v.32
logical perspectives are indispensable. The range (1971).
and scope of this encyclopedia create a vivid tes- Gove, W. R. “Societal Reaction as an Explanation
timony to the intellectual vitality of the field and of Mental Illness: An Evaluation.” American
will hopefully make a useful contribution to the Sociological Review, v.35 (1970).
next generation of sociological research on the Gove, W. R. and P. Howell. “Individual Resources
cultural sociology of mental illness. and Mental Hospitalization: A Comparison and
Evaluation of the Societal Reaction and Psychiatric
Andrew Scull Perspectives.” American Sociological Review, v.39
Editor (1974).
Greenblatt, M., D. J. Levinson, and R. H. Williams.
Further Readings The Patient and the Mental Hospital. New York:
Aviram, U., S. I. Syme, and J. B. Cohen. “The Effects Free Press, 1957.
of Policies and Programs on the Reduction of Gronfein, W. “Incentives and Intentions in Mental
Mental Hospitalization.” Social Science and Health Policy: A Comparison of the Medicaid and
Medicine, v.10 (1976). Community Mental Health Programs.” Journal of
Belknap, I. Human Problems of the State Mental Health and Social Behavior, v.26 (1985).
Hospital. New York: McGraw-Hill, 1956. Gronfein, W. “Psychotropic Drugs and the Origins
Booth, Charles. Life and Labour of the People in of Deinstitutionalization.” Social Problems, v.32
London. 1st ed., vol. 1. London: Macmillan, (1985).
1889. Healy, D. The Antidepressant Era. Cambridge, MA:
Booth, Charles. Life and Labour of the People in Harvard University Press, 1997.
London. 1st ed., vol. 2. London: Macmillan, 1891. Healy, D. The Creation of Psychopharmacology.
Booth, C. Life and Labour of the People in London. Cambridge, MA: Harvard University Press,
2nd ed., 9 vols. London: Macmillan, 1892–97. 2002.
Bulmer, M. The Chicago School of Sociology. Herzberg, D. Happy Pills in America: From Miltown
Chicago: University of Chicago Press, 1984. to Prozac. Baltimore, MD: Johns Hopkins
Bush, V. Science: The Endless Frontier: A Report to University Press, 2008.
the President. Washington, DC: U.S. Government Hollingshead, A. B. and F. Redlich. Social Class and
Printing Office, 1945. Mental Illness: A Community Study. New York:
Clausen, J. A. Sociology and the Field of Mental Wiley, 1958.
Health. New York: Russell Sage Foundation, 1956. Horwitz, A. V. Creating Mental Illness. Chicago:
Douglas, J. D. The Social Meanings of Suicide. University of Chicago Press, 2003.
Princeton: Princeton University Press, 1967. Horwitz, A. V. and J. C. Wakefield. All We Have
Dunham, H. W. and S. K. Weinberg. The Culture of to Fear: Psychiatry’s Transformation of Natural
the State Mental Hospital. Detroit, MI: Wayne Anxieties Into Mental Disorders. New York:
State University Press, 1960. Oxford University Press, 2012.
Durkheim, D. E. The Rules of Sociological Method. Horwitz, A. V. and J. C. Wakefield. The Loss of
English trans. New York: Free Press, 1982. Sadness: How Psychiatry Transformed Normal
xxxiv Introduction

Sorrow Into Depressive Disorder. New York: Rothman, D. The Discovery of the Asylum: Social
Oxford University Press, 2007. Order and Disorder in the New Republic. Boston:
Kirk, S. A. and H. Kutchins. The Selling of DSM: Little, Brown, 1971.
The Rhetoric of Science in Psychiatry. New York: Rowntree, B. S. Poverty: A Study of Town Life. New
de Gruyter, 1992. York: Macmillan, 1901.
Kirk, S. A. and M. Thierren. “Community Scheff, T. Being Mentally Ill: A Sociological Theory.
Mental Health Myths and the Fate of Formerly Chicago: Aldine, 1966.
Hospitalized Patients.” Psychiatry, v.38 (1975). Scheff, T. Being Mentally Ill: A Sociological Theory,
Kolb, L. C., S. H. Frazier, and P. Sirovatka. “The 3rd ed. New York: Aldine De Gruyter, 1999.
National Institute of Mental Health: Its Influence Schroeder, C. W. “Mental Disorders in Cities.”
on Psychiatry and the Nation’s Mental Health.” American Journal of Sociology, v.48 (1942).
In American Psychiatry After the War, R. C. Scull, A. Decarceration: Community Treatment and
Menninger and J. C. Nemiah, eds. Washington, the Deviant. Englewood Cliffs, NJ: Prentice-Hall,
DC: American Psychiatric Press, 2000. 1977.
Kutchins, H and S. A. Kirk. Making Us Crazy: DSM: Scull, A. Decarceration: Community Treatment and
The Psychiatric Bible and the Creation of Mental the Deviant. 2nd ed. Cambridge: Polity Press,
Disorders. New York: Free Press, 1997. 1984.
Leighton, A. H., J. A. Clausen, and R. N. Wilson, eds. Scull, A. “The Decarceration of the Mentally Ill:
Explorations in Social Psychiatry. New York: Basic A Critical View.” Politics and Society, v.6 (1976).
Books, 1957. Scull, A. “The Mental Health Sector and the Social
Lerman, P. Deinstitutionalization and the Welfare Sciences in Post–World War II USA. Part I: Total
State. New Brunswick, NJ: Rutgers University War and its Aftermath.” History of Psychiatry,
Press, 1982. v.22 (2011).
Lukes, S. M. Émile Durkheim: His Life and Work: A Scull, A. “The Mental Health Sector and the Social
Historical and Critical Study. London: Allen Lane, Sciences in Post–World War II USA. Part II: The
1973. Impact of Federal Research Funding and the Drugs
MacDonald, M. Mystical Bedlam: Madness, Anxiety, Revolution.” History of Psychiatry, v.22 (2011).
and Healing in Seventeenth Century England. Scull, A. The Most Solitary of Afflictions: Madness
Cambridge: Cambridge University Press, 1981. and Society in Britain, 1700–1900. New Haven,
Morgan, D. “Explaining Mental Illness.” European CT: Yale University Press, 1993.
Journal of Sociology, v.16 (1975). Scull, A. Museums of Madness: The Social
Myers, J. K. and B. H. Roberts. Family and Class Organization of Insanity in Nineteenth-Century
Dynamics in Mental Illness. New York: Wiley, 1959. England. London: Allen Lane, 1979.
Park, R. E., E. Burgess, and R. McKenzie. The City. Scull, A. “Psychiatry and the Social Sciences,
Chicago: University of Chicago Press, 1925. 1940–2009.” History of Political Economy,
Perrucci, R. Circle of Madness: On Being Insane and Suppl. v.42/5 (2010).
Institutionalized in America. Englewood Cliffs, NJ: Stanton, A. and M. Schwarz. The Mental Hospital:
Prentice-Hall, 1974. A Study of Institutional Participation in Mental
Rennie, T. A. and L. Srole. “Social Class Prevalence Illness and Health. New York: Basic Books, 1954.
and Distribution of Psychosomatic Conditions in Windle C. and D. Scully. “Community Mental Health
an Urban Population.” Psychosomatic Medicine, Centers and Decreasing Use of State Mental
v.18 (1956). Hospitals.” Community Mental Health Journal,
Rose, S. “”Deciphering Deinstitutionalization: v.12 (1976).
Complexities in Policy and Analysis.” Milbank Yarrow, M. R., C. G. Schwartz, H. S. Murphy, and
Memorial Fund Quarterly, v.57 (1979). L. C. Deasy. “The Psychological Meaning of
Roth, M. “Psychiatry and Its Critics.” British Journal Mental Illness in the Family.” Journal of Social
of Psychiatry, v.122 (1973). Issues, v.11/4 (1955).
 Chronology

1290: In England, the Act De Praerogative Regis writes that everyone has some degree of madness
gives the king custody of the lands and property in them.
of the mentally incapable; it also gives officers of
the king, known as escheators, the right to hold 1700: The British lawyer John Brydall publishes a
inquisitions to determine the mental competency commentary summarizing the legal status of per-
of individuals. sons deemed to be mentally incompetent, including
drunks, “lunatics,” “idiots,” and “mad persons.”
1377: In England, King Edward III establishes a
“lunatic asylum” in the religious priory of St. Mary 1789: The American physician Benjamin Rush
of Bethlehem; this institution gives rise to the term publishes an article defining “phobia” as “fear of
bedlam for an institution housing the mentally ill. an imaginary evil, or undue fear of a real one”
and lists 18 specific examples of phobias.
1520: The German physician Paracelsus (Phil-
lipus Aureolus Theophratus Bombastus von 1797: The French physician Jean Marc Gaspard
Hohenheim) writes a book, Diseases Which Lead Itard begins treating the “wild boy of Avalon,”
to a Loss of Reason, describing mental illness as who had apparently grown up in the woods with-
caused by physical diseases rather than supernat- out human care. Now considered an early case
ural causes; it is published in 1657. of autism, the “wild boy” died in 1828, and his
story became known through Itard’s writings and
1621: The British scholar Robert Burton publishes particularly through the 1970 film L’Enfant Sau-
The Anatomy of Melancoly, What It Is: With All vage, directed by François Truffaut.
the Kinds, Causes, Symptomes, Prognostickes,
and Several Cures of It, a collection of opinions 1801: The French physician Philippe Pinel, direc-
from various authors on melancholia (depres- tor of the Salpetriere asylum in Paris, publishes A
sion). The first edition is almost 900 pages and Treatise on Insanity. The book describes different
includes poetry and historical accounts as well as types of insanity and outlines his ideas on what he
excerpts from medical and scientific authorities. called the “moral” treatment of the insane.

1690: In An Essay Concerning Human Under- 1812: The American physician Benjamin Rush
standing, the English philosopher John Locke publishes Inquiries and Observations on Diseases

xxxv
xxxvi Chronology

of the Mind, the first psychiatric textbook pub- 250 beds. By the mid-20th century, some state
lished in the United States. hospitals contain as many as 10,000 beds.

1829: Dorothea Dix, an American schoolteacher, 1868: A report from Surgeon-Major R. F.

begins her crusade to improve conditions for the Hutchinson details conditions in British “luna-
mentally ill after observing insane people being tic asylums” in Bengal, India. The asylums were
held in inhumane conditions in a jail. One mea- founded after the British established their rule in
sure of her success is that she succeeded in getting 1858 and segregated patients by origin—Euro-
32 U.S. states to build hospitals specifically for peans were treated in modern private asylums,
mental patients. while Indians were housed in poorly maintained
public institutions.
1843: The Scottish craftsman Daniel M’Naghten,
believing that his life is in danger, attempts to kill 1872: The German neurologist Otto Westphal
British prime minister Robert Peel but instead introduces the term agoraphobia in a paper
shoots and kills Peel’s secretary, Edward Drum- describing three male patients who suffer from
mond. M’Naghten pleads not guilty by reason of a dread or fear of public places. Westphal also
“moral insanity”; the plea is successful and he is remarks that the patients could be distressed sim-
found not guilty of murder but is confined to an ply by thinking of a feared situation without actu-
asylum. In response to this case, a panel of British ally being in it.
judges develop what is known as the M’Naghten
Rules, a series of questions to determine if a per- 1872: In British Columbia, Canada, the first insane
son is legally insane. asylum is established by the Royal Hospital in a
cottage previously used for quarantined patients.
1844: The Association of Medical Superinten- It is closed in 1878 and the patients moved to a
dents of American Institutions for the Insane is newly built asylum in New Westminster.
founded in Philadelphia by superintendents from
13 of the 24 mental hospitals existing in the 1873: The French physician Ernest Charles
United States. The purposes of the association Lasègue identifies anorexia nervosa as a clinical
include professional study, communication, and diagnosis; he believes it is caused by the patient’s
assistance to improve the treatment of the insane. desire to conceal emotional disturbances.

1850: Patients at the Utica State Lunatic Asylum 1874: The American physician George Miller
in New York State begin publishing a monthly Beard publishes Cases of Hysteria, Neurasthenia,
newsletter, The Opal, including poems, essays, Spinal Irritation, or Allied Affections, in which
and reflections written by the patients. Proceeds he describes a new disease, neurasthenia, which
from the sale of The Opal are used to buy books he believes is caused by an oversupply of nervous
for the patients’ library. energy due to the demands of modern life.

1852: The Swedish scientist Magnus Huss coins 1879: At the University of Leipzig, the German
the term alcoholism, which he describes as an physician Wilhelm Wundt establishes the world’s
abusive level of alcohol consumption that he first experimental laboratory for psychological
labels alkoholismus chronicus. research; for this reason, Wundt is often cited as
the father of experimental psychology.
1865: In the United States, a trend toward large
mental hospitals is established as the Willard 1881: The Italian physician August Tamburini
State Hospital begins operation in New York. It publishes “A Theory of Hallucinations,” a paper
has 1,000 beds, a contradiction to the recommen- detailing different explanations offered for hal-
dation of the Association of Medical Superinten- lucinations (peripheral, intellectual, psychosenso-
dents of American Institutions for the Insane that rial, and sensorial); it becomes one of the most
mental hospitals should contain no more than cited papers in neuropsychiatry of its era.
 Chronology xxxvii

1882: The German neurologist Richard von of suicides. Among his findings: suicide rates are
Krafft-Ebing publishes Psychopathia Sexualis. higher in men than in women, among Protestants
Written partly in Latin, this book describes many than among Catholics or Jews, and among single
sexual disorders, including sadism and masoch- people than among those who are married.
ism, and was also one of the first books to discuss
homosexuality and bisexuality. 1898: The Russian neurologist Sergei Korsakoff
describes a syndrome seen in some long-term
1883: In his book, Inquiries Into Human Faculty alcoholics as well as in some individuals with
and Its Development, British scientist Francis head injuries, brain tumors, or poisoning. Symp-
Galton coins the term eugenics for his advoca- toms of Korsakoff’s syndrome include disorienta-
tion of improving the human race by encouraging tion, loss of memory, and confabulation (making
or discouraging reproduction depending on the up stories).
“merit” of the parents. His concepts continue to
support eugenic ideas up to his death in 1912 and 1899: The Austrian physician Sigmund Freud
into the 1930s. publishes The Interpretation of Dreams, intro-
ducing key concepts of psychoanalysis such as
1883: The German psychiatrist Emil Kraepe- the Oedipus complex and the revelation of the
lin publishes Compendium der Psychiatrie, the unconscious through dreams.
basis for the modern system of classifying mental
disorders. It calls for expanded study of mental 1901–02: At the University of Edinburgh in Eng-
disorders, including research into their physical land, American philosopher and physician Wil-
causes, and case studies to clarify their typical liam James delivers the Gifford Lectures in natu-
progression. ral theology. An edited version of these lectures is
published as The Variety of Religious Experience:
1887: American reporter Nelly Bly publishes Ten A Study in Human Experience in 1902.
Days in a Mad-House, an exposé based on her
undercover reporting (posing as a patient) in the 1903: The French psychologist Pierre Janet clas-
Women’s Lunatic Asylum on Blackwell’s Island sifies neurotic disorders as either hysteria (distur-
(now Roosevelt Island) in New York City. bances in consciousness, sensation, and move-
ment) or psychasthenia (including depression,
1893: The French physician Jacques Bertillon obsessions, phobias, and anxiety).
introduces the Bertillon Classification of Causes
of Death, which is widely adopted in other 1904: The Russian scientist Ivan Pavlov is
countries. It forms the basis of the International awarded the Nobel Prize in Physiology or Medi-
Classification of Diseases system now used by cine. In the course of his research on digestion at
the World Health Organization and many other the Institute of Experimental Medicine, Pavlov
organizations. discovered the principle of operant conditioning
and of conditioned reflexes.
1895: The Austrian physician Sigmund Freud
publishes Obsessions and Phobias: Their Psychi- 1906: The German psychiatrist Alois Alzheimer
cal Mechanism and Their Aetiology. In the book, performs an autopsy on a patient who had suf-
he distinguishes between phobias and obses- fered from short-term memory loss and other
sions by noting that while various emotions are symptoms, and identifies within this patient’s
involved in obsession, phobias are always accom- brain the characteristic neurofibrillary tangles and
panied by a state of anxiety. amyloid plaques now identified with Alzheimer’s
disease.
1897: The French sociologist Émile Durkheim
publishes Suicide, which includes an exploration 1908: The publication of A Mind That Found
of suicide rates among different demographic Itself, the autobiography of Clifford Beers,
groups and a characterization of different types describes the poor conditions in mental asylums
xxxviii Chronology

in the United States and leads to the founding of Criminally Insane opens with just nine patients
the advocacy group called the National Commit- but houses 99 by the end of the year.
tee for Mental Hygiene.
1920: The American psychiatrist Edward Kemp
1911: The Swiss psychiatrist Eugene Bleuler coins coins the term homosexual panic to refer to the
the term schizophrenia, derived from the Latin fear that one will be sexually assaulted by a mem-
roots schizo (split) and phrenia (mind) to replace ber of one’s own sex, or the fear that one may in
Emil Kraepelin’s term for the same condition, fact be homosexual. Homosexual panic is some-
dementia praecox. times cited as a cause for attacks on gay men,
suggesting that the attacker is responding to an
1914–18: During World War I, over 600,000 Ger- imagined threat caused by their discomfort with
man servicemen are treated in military hospitals homosexuality.
for nervous disorders, including “male hysteria”
(shell shock or post-traumatic stress disorder). 1921: Fritz Lenz publishes the eugenics textbook
The cause is believed to be shocks delivered to the Human Selection and Race Hygiene, synthesizing
nervous system. By 1918, 5 percent of hospital many contemporary ideas from medicine, anthro-
beds are reserved for patients with hysteria. pology, and genetics and arguing for the obliga-
tion to bar “undesirables,” including the mentally
1916: The psychologist Lewis Terman, working ill, from reproducing. It becomes a standard text-
at Stanford University, publishes a revised version book in Germany, and Lenz later helps to draft
of an intelligence test originally created in 1905 the Nazi government’s 1933 sterilization law.
by the French psychologist Alfred Binet and the
French physician Alfred Simon. The Stanford- 1927: In the United States, Carrie Buck, a “fee-
Binet Intelligence Scales compare a child’s perfor- ble minded” woman involuntarily committed
mance with that expected of children of the same to the Virginia Colony for Epileptics and Feeble
age, an approach still used in contemporary intel- Minded, is sterilized in October; the state law that
ligence testing. permits this type of sterilization for the purpose
of eugenics is not repealed until 1974.
1917: The Austrian psychiatrist Julius Wagner-
Hauregg begins investigating the benefits of 1929: The German psychiatrist Hermann Simon
induced fevers in mental patients and produces publishes “Active Therapy in the Lunatic Facil-
these fevers by inoculating the patients with ity.” This article outlines the results of an experi-
blood infected with malaria. Wagner-Hauregg ment begun in 1905, when he observes that mental
was awarded the Nobel Prize for Physiology or patients assigned some job to do become calmer
Medicine in 1927, and induced fever by malaria and more orderly. Although the original purpose
continued to be used to treat mental patients until for having the patients work is to overcome a staff
approximately 1950. shortage, it proves so beneficial that when Simon
becomes director of a different psychiatric facil-
1917: During World War I, the American psychol- ity, he has almost 90 percent of the patients doing
ogist Robert Woodworth develops the Personal some kind of work as part of their treatment.
Data Sheet to screen recruits for the U.S. Army.
The Personal Data Sheet, a brief, self-reporting 1930: The American physician John Mayo Berk-
questionnaire about symptoms such as sleepwalk- man publishes the first large-scale report on
ing and suicidal thoughts, proves remarkably suc- patients with anorexia. He discusses 117 patients
cessful in separating mentally disturbed individu- treated over a period of 10 years and is often
als from those functioning normally. credited with bringing anorexia back into the
consciousness of modern medicine.
1919: The first forensic psychiatric facility in
British Columbia, Canada, is opened on Vancou- 1930: In the United States, the creation of the
ver Island. The Provincial Mental Home for the Mental Hygiene Division within the Public Health
 Chronology xxxix

Service is originally concerned with operating two regulated in Canada in 1923 but was deregulated
hospitals dedicated to treating addictions but also in 1925.
acts as a forerunner of the National Institute for
Mental Health. 1939: William Griffith Wilson and Dr. Bob Smith,
founders of Alcoholics Anonymous, publish Alco-
1932: The German neurologist Johannes Heinrich holics Anonymous: The Story of How More Than
Schultz develops the technique of autogenic train- One Hundred Men Have Recovered From Alco-
ing to treat high blood pressure. Autogenic train- holism. Known within AA as the Big Book, this
ing is now used for stress relief and the treatment volume was the first published statement of the
of sleep disorders and many other conditions. In Twelve-Step Method used in Alcoholics Anony-
autogenic training, the patient learns to achieve mous to help alcoholics achieve and maintain
relaxation and induce a state similar to hypnosis. sobriety.

1933: The Austrian psychiatrist Manfred Sakel 1939: Robert E. Lee Faris and Warren H. Dun-
begins administering insulin shock therapy to ham publish Mental Disorders in Urban Areas:
mental patients. In the procedure, the patient An Ecological Study of Schizophrenia and Other
receives progressive doses of insulin until they Psychoses, an early example of a study linking
go into a coma, then receives a sugar solution socioeconomic status with mental health. In look-
to restore consciousness. By 1941, almost three- ing at residents of Chicago, Faris and Dunham
quarters (71 percent) of American psychiatric find a strong relationship between the stressful
facilities are using insulin shock therapy. conditions present in certain neighborhoods and
mental illness in individuals.
1933: About six months after Adolf Hitler is
named chancellor of Germany and the Nazi Party 1942: The psychologist Starke Rosecrans Hatha-
forms a governing coalition, Germany passes the way and the psychiatrist John Charnley McKinley
Law for the Prevention of Hereditarily Ill Off- introduce the Minnesota Multiphasic Personality
spring, providing for sterilization of those con- Inventory (MMPI), a commonly used method of
sidered to have hereditary diseases, including the assessing personality. The original MMPI requires
insane. individuals to agree or disagree with 550 state-
ments and assesses them on nine personality scales:
1935: William Griffith Wilson and Dr. Bob Smith hypochondria, hypomania, depression, hysteria,
found Alcoholics Anonymous (AA) in Akron, schizophrenia, psychopathic deviate, masculine-
Ohio. AA is a self-help organization for alcohol- feminine interest, paranoia, and psychasthenia.
ics, with the goal of helping them achieve and
maintain sobriety. Members of AA sometimes 1944: American child psychiatrist Leon Kanner
call themselves “friends of Bill W” after the AA creates the diagnosis of “early infantile autism,”
tradition of not identifying members by their last or Kanner’s syndrome, for children who are not
names as a way to preserve their anonymity. interested in socializing but are not retarded or
emotionally disturbed. At about the same time,
1938: The German psychiatrist Franz Kallman, the Austrian pediatrician Hans Asperger identifies
working in the United States, is the first to suggest a similar syndrome in a group of child patients.
that there may be a genetic component to schizo- One distinction between Kanner’s and Asperger’s
phrenia. He establishes the first full-time genetics subjects is that all of Asperger’s subjects are able
department in a U.S. psychiatric hospital in part to speak; hence, the term Asperger’s syndrome is
to research this hypothesis. usually applied to autistic individuals with nor-
mal language development.
1938: In Canada, the Opium and Narcotics Act
is amended to define codeine as a substance pro- 1946: In the United States, the National Institute
hibited except when used by a physician to treat of Mental Health is created as part of the National
disorders other than addiction. Codeine was first Mental Health Act. It is allocated $7.5 million to
xl Chronology

provide technical assistance to the states, train 1950: The German American psychoanalyst and
personnel, and conduct research. psychologist Erik Erikson publishes his book
Childhood and Society, popularizing the term
1948: The American psychologist B. F. Skinner identity crisis and developing Freud’s concept of
publishes Walden Two, a novel describing a fic- infantile sexuality.
tional utopian community whose members adopt
an experimental approach to all aspects of their 1951: The American sociologist Talcott Parsons
life. Walden Two expresses Skinner’s beliefs that publishes The Social System, which includes his
free will does not exist and that human behav- concept of the “sick role” and the obligations and
ior is governed by a combination of genetics and rights of a sick person.
environment.
1952: In France, the antipsychotic drug chlor-
1948: Journalist Albert Deutsch publishes Shame promazine (Thorazine) is first used to successfully
of the States, exposing the terrible conditions in treat psychosis. This and other antipsychotics
state mental hospitals, which at the time are hous- provide breakthrough treatment for schizophre-
ing many mentally ill people. This report is influ- nia, with an estimated 70 percent of patients
ential in the deinstitutionalization movement in helped by antipsychotic drug therapy.
the United States.
1952: The first edition of the Diagnostic and Sta-
1948: The American zoologist Alfred Kinsey pub- tistical Manual of Mental Disorders (DSM-I) is
lishes Sexual Behavior in the Human Male, the published by the American Psychological Asso-
first of the so-called Kinsey Reports. This volume ciation. This classification of mental disorders
includes the Kinsey Scale, which ranks the sexual- becomes highly influential among mental health
ity of men from 0 (completely heterosexual) to 6 professionals. It has since been revised regularly,
(completely homosexual), as well as the conclu- with the fifth edition published in 2013.
sion that 10 percent of men were primary homo-
sexual for at least three years of their adult life. 1952: The psychiatrist Fantz Fanon, born in Mar-
Kinsey’s results have since been criticized on many tinique and educated in France, publishes “The
grounds, including the selection of his sample, but ‘North African Syndrome.’” This paper details
are groundbreaking in terms of presenting objec- Fanon’s observations about how the experience
tive data about the sexual practices of Americans. of colonialism shaped the consciousness of North
African migrant workers.
1949: John Frederick Joseph Cade, an Australian
psychiatrist, first uses lithium to treat psychosis. 1953: August B. Hollingshead and Frederick C.
It becomes a standard treatment, replacing bar- Redlich publish “Social Stratification and Psy-
biturates and bromides, to treat manic depressive chiatric Disorders” in the American Sociological
(bipolar) disease. Review, reporting that individuals in lower social
classes, as compared to those in higher classes, are
1949: The Portuguese neurologist Egas Moniz more likely to be treated for mental illness and
receives the Nobel Prize in Physiology or Medi- more likely to suffer from more severe forms of
cine for his work in developing lobotomy (which mental illness.
he calls “leucotomy”) as a tool for treating psy-
chotic patients. 1953: The American psychologist B. F. Skinner
publishes Science and Human Behavior, which
1949: The American psychologist Carl Rogers includes a description of his theory of operant
publishes “The Attitude and Orientation of the conditioning.
Counselor in Client-Centered Therapy” in the
Journal of Consulting Psychology, setting out his 1953: The American zoologist Alfred Kinsey pub-
ideas on humanistic psychology, which was origi- lishes Sexual Behavior in the Human Female, the
nally called “nondirective therapy.” second of two “Kinsey Reports.” Although women
 Chronology xli

in this study show a lower degree of homosexual- and attitudes. Festinger argues that people are
ity on Kinsey’s 0–6 scale of sexual orientation, the uncomfortable with cognitive dissonance and may
report still arrives at the surprising conclusion that change their attitudes to match their behavior.
1 to 3 percent of unmarried women aged 20 to 35
are rated 6 (exclusively homosexual). 1958: The South African physician Joseph Wolpe,
working in the United States, publishes reports
1954: P. K. Benedict and I. Jacks publish “Men- of his use of systematic desensitization to treat
tal Illness in Primitive Society” in the Journal for adults. The technique, which involves training a
the Study of Interpersonal Processes, reporting patient in relaxation techniques and then intro-
that people in all societies experience all of the ducing a feared stimulus or having the person
major psychoses identified in Western psychol- imagine a feared situation, works on the principle
ogy and psychiatry, thus refuting the Freud- that a person cannot be anxious and relaxed at
ian notion that neurosis is caused by conflict the same time.
between repressive Western civilization and a
person’s instinctual drives. 1958: In his doctoral dissertation at the Univer-
sity of Chicago, the American psychologist Law-
1955: The Joint Commission on Mental Illness rence Kohlberg outlines his theory of the stages
and Health, a task force created by the Ameri- of moral development. Inspired by the work of
can Medical Association and American Psychiat- Swiss developmental psychologist Jean Piaget,
ric Association, is created to make recommenda- this theory suggests that as children mature, they
tions to the U.S. Congress regarding creation of a are able to engage in more complex moral reason-
national mental health program. ing. Kohlberg’s theory becomes extremely influ-
ential but is also criticized on the grounds that
1955: The introduction of psychoactive drugs in it emphasizes a male, Western point of view and
the United States coincides with the beginning of a values justice to the exclusion of other important
rapid decline in the number of mentally ill people values such as caring for others.
held in mental hospitals. Some contend that it also
helps speed the deinstitutionalization process by 1959: The first methadone treatment program is
allowing some people with serious mental illness established in British Columbia, Canada. Run by
to function in assisted living facilities or with sup- Dr. Robert Halliday, the program does not have
port from community mental health organizations. the goal of abstinence but of maintenance; Hal-
liday likens the program to insulin treatment for
1956: The Hungarian physician Hans Selye, work- diabetics.
ing at McGill University in Canada, publishes
The Stress of Life. In this book, Selye explains 1959: E. Byrne studies patients in mental hos-
his theory of general adaptation syndrome, which pitals in Africa, Latin America, and the United
describes how stress affects mental and physical States and concludes that the major mental ill-
well-being. nesses such as schizophrenia manifest themselves
in the same way in widely different cultures.
1956: The American Bar Association and the
American Medical Association officially recog- 1960: The American physician and psychoana-
nize alcoholism as a disease. This decision influ- lyst Thomas Szasz publishes “The Myth of Men-
ences many areas of life, including insurance cov- tal Illness,” an essay outlining many of the ideas
erage for alcohol-related conditions and the legal of the antipsychiatry movement, beginning with
status of alcoholics. questioning whether such a thing as mental illness
exists at all.
1957: The American psychologist Leon Festinger
publishes his theory of cognitive dissonance, which 1961: Jum C. Nunnaly, Jr., publishes Popular
describes how people behave when they experi- Conceptions of Mental Health: Their Develop-
ence a conflict among their beliefs, behaviors, ment and Change, arguing that public education
xlii Chronology

is necessary to overcome the stigma of mental ill- reflexes, and no electrical activity in the brain—
ness. Nunnaly’s book is directed in part toward are proposed by a committee at Harvard Medi-
the deinstitutionalization taking place in the cal School to identify when “brain death” has
United States, in which care for mentally ill peo- occurred. The concept of brain death, which
ple is in the process of being shifted from large allows a physician to certify a patient as dead
institutions that isolate the mentally ill from most even if their heart and lungs may continue to
of the population to community mental health function with the assistance of life-support equip-
treatment that aims to achieve as much integra- ment, remains controversial but has been adopted
tion of the mentally ill with “normal” communi- by some countries and some U.S. states.
ties as possible.
1968: Thomas H. Holmes and Richard H. Rahe
1962: The German American psychoanalyst Hilde present a paper at the Royal Society of Medicine
Bruch publishes “Perceptual and Conceptual that includes their Life Change Rating Scale. This
Disturbances in Anorexia Nervosa.” This paper scale assigns a numerical value to different life
differentiates between self-starvation caused by events (for instance, 100 for the death of a spouse,
other psychiatric illness and primary anorexia, 45 for retirement, 20 for change in residence or
which is characterized by disturbed body image, a school) and instructs individuals to calculate their
sense of helpless, and misinterpretation of stimuli score by adding up the points for all the events
such as hunger sensations. that have happened to them in the past year. A
higher score indicates greater stress and increased
1962: American author Ken Kesey publishes One probability of illness in the upcoming year; for
Flew Over the Cuckoo’s Nest, based on his expe- instance, a score between 150 and 300 predicts
riences working in a Veterans Administration a 51 percent increase in the probability of illness.
hospital. Kesey’s best-selling novel is based on the
antipsychiatry position that mental patients are 1970: Gay rights activists disrupt the annual
simply nonconformists rather than people with meeting of the American Psychiatric Association
genuine illnesses. (APA), protesting the classification of homosexu-
ality as a disease in the APA’s Diagnostic and Sta-
1963: In October, the U.S. Congress passes the tistical Manual of Mental Disorders. Partly as a
Community Mental Health Centers Act, autho- result of this action, homosexuality is no longer
rizing federal funds to create mental health cen- listed as a disease in the 1974 printing of DSM-II.
ters in local communities to care for new mental
health patients as well as individuals formerly 1970: The American psychiatrist Aaron T. Beck
housed in state mental hospitals. publishes “Cognitive Therapy: Nature and Rela-
tion to Behavior Therapy,” a paper outlining his
1965: Michel Foucault’s Madness and Civiliza- theory that elaborate explorations of a patient’s
tion: A History of Insanity in the Age of Reason past are not necessary to help depressive patients
is published in English, translated from 1961 and that quicker results can be gained by sim-
French editions. ply challenging the truthfulness of their negative
thoughts.
1966: American sociologist Thomas J. Scheff pub-
lishes Being Mentally Ill: A Sociological Theory, 1975: The British secretary of state for social ser-
articulating his theory that labeling deviant behav- vices issues a white paper, “Better Services for the
ior as signs or results of mental illness stigma- Mentally Ill,” outlining the logic behind deinstitu-
tizes individuals who display such behavior, with tionalizing the mentally ill, along with a brief his-
potentially profound effects such as the adoption tory of how mentally ill people have been cared
of mental illness as part of the self-image. for in different historical periods.

1968: Four criteria—unresponsiveness to stim- 1975: The American cardiologist Dr. Herbert Ben-
uli, no movement or spontaneous breathing, no son publishes The Relaxation Response, describing
 Chronology xliii

the physiological response some people experience for people with mental illness, is founded in the
as a result of transcendental meditation. Benson United States.
writes that this response can help people manage
conditions such as high blood pressure, although 1980: For the first time, post-traumatic stress dis-
he cautions that it is not a substitute for medical order (PTSD) appears in the Diagnostic and Sta-
care and appropriate use of medication. tistical Manual of Mental Disorders (DSM) of the
American Psychiatric Association.
1975: Ken Kesey’s novel, One Flew Over the
Cuckoo’s Nest, is made into a film directed by 1980–85: The first Epidemiologic Catchment
Milos Forman and starring Jack Nicholson. The Area Survey of Mental Disorders is conducted in
film wins five Oscars, including Best Picture, and the United States. It is the largest and most com-
helps to popularize the antipsychiatry position prehensive survey of its type, conducted to deter-
that people in mental hospitals are nonconform- mine the overall prevalence of mental disorders—
ists who are inconvenient to society, rather than not just among those who sought treatment—and
people needing treatment for illnesses. the need for mental health services.

1976: The American journalist Norman Cousins 1983: The American singer Karen Carpenter dies
publishes the essay “Anatomy of an Illness as Per- of cardiomyopathy at age 32 after years of suffer-
ceived by the Patient,” describing his experience ing from anorexia and bulimia and abusing syrup
with the disease ankylosing spondylitis, a form of of ipecac to induce vomiting. Her death brings
arthritis. He claims that he was able to improve great publicity to the risks of anorexia and buli-
his condition by ending medical treatment, taking mia, particularly for young women.
large doses of vitamin C, and watching humorous
movies in a comfortable hotel room rather than 1986: The passage of the Consolidated Omnibus
the hospital. His case history is groundbreaking Budget Reconciliation Act (COBRA) increases
in its approach to the patient taking charge of the ability of U.S. employees to retain employer-
their own health, sparking the trend of patients sponsored health insurance for a period after they
working with their doctors and using humor for leave a job.
healing.
1988: Marti Loring and Brian Powell publish an
1977: At its annual meeting, the World Psychi- article in the Journal of Health and Social Behavior
atric Association (WPA) issues a proclamation that casts doubt on the objectivity of the psychiat-
condemning the use of psychiatric institutional- ric diagnosis process. After sending the description
ization of political dissidents in the Soviet Union. of symptoms to different psychiatrists, along with
The WPA also issues a code of ethics called the varying gender and racial characteristics, they find
Declaration of Hawaii, which specifies, among that the diagnoses vary by the gender and race of
other things, that patients must be informed of the hypothetical patient as well as the gender and
treatment options and must consent to treatment race of the psychiatrist making the diagnosis.
unless they lack the capacity to reason.
1989: In Japan, a study of employees of Chiyoda
1977: Edna Rawlings and Dianne Carter publish Fire and Marine Insurance, Ltd., popularizes the
Psychotherapy for Women, a book claiming that term karoshi, meaning death from overwork, and
social and external causes, rather than internal focuses attention on sources of stress for Japanese
and personal forces, are behind many women’s workers. These findings are later applied to work-
psychological problems and that society should ers in other countries, with the general conclusion
become more just rather than expecting women that workers who experience high levels of stress
to cheerfully adapt to the unjust state of society. from high work demands, coupled with low levels
of control and low social support, are at increased
1979: The National Alliance for the Mentally Ill, risk for many diseases and behaviors such as drug
a grassroots advocacy and support organization and alcohol abuse.
xliv Chronology

1989: Dennis E. Clayson and Michael L. Klassen Life. The book helps to popularize mindfulness
release the results of a study demonstrating that meditation, a type of meditation drawing on Bud-
many Caucasian American college students hold dhist traditions, to reduce stress and induce relax-
negative views of obese people, associating them ation, with claims that it also helps treat physical
with characteristics such as lazy, unhealthy, inse- disorders.
cure, and lacking in self-discipline.
1994: The Alzheimer’s diagnosis of former U.S.
1989: the U.S. Department of Veteran’s Affairs president Ronald Reagan is made public. This
creates the National Center for Posttraumatic announcement brings heightened awareness of
Stress Disorder to treat military veterans with the disease as well as speculation about how long
post-traumatic stress disorder (PTSD) and to Reagan might have been suffering from it.
advance research and clinical practice for indi-
viduals suffering from this condition. 1994: Results from the National Comorbidity
Study, the first study in the United States to esti-
1989: John Mirowsky and Catherine E. Ross mate the prevalence of psychiatric disorders using
publish an article in the Journal of Health and a national probability sample, is published. One
Social Behavior estimating that social conditions of the striking findings is the strong relationship
are a primary influence in depression. According between socioeconomic status (SES) and psychiat-
to their research, half of depressive symptoms ric disorders. Lower SES is associated with higher
could be explained by social conditions, and an probability of psychiatric disorder.
even higher proportion (almost three-quarters) of
those symptoms could be explained by positions 1996: A study from the Chinese University of
of low personal control and social position. Hong Kong reports that eating disorders and body
dissatisfaction have become common among Chi-
1990: The passage of the Americans with Dis- nese adolescent girls, suggesting that this is due to
abilities Act prohibits discrimination against the the increasing influence of Western cultures.
disabled in employment. The definition of “dis-
abled” includes those with mental illness and 1996: In the United States, the Mental Health Par-
requires employers to make “reasonable accom- ity Act (MHPA) becomes law. The MHPA requires
modations” if necessary to allow a person with a that group insurance plans covering more than 50
disability to perform a job. workers provide annual and lifetime medical ben-
efits limits for mental health at least as high as
1990: In the United States, the Consortium on those provided for medical and surgical benefits.
Child and Adolescent Research (C-CAR) is estab-
lished within the National Institute of Mental 1997: Jo Phelan and Ann Steuve present a paper at
Health. C-CAR works to facilitate research and the American Sociological Association in Toronto,
the exchange of knowledge on children and young showing that U.S. public opinion toward the men-
people with developmental, emotional, and brain tally ill has become more negative over the past
disorders. 50 years. This is a surprising result because it is
generally believed that deinstitutionalization and
1991: The Epidemiologic Catchment Study (ECA), community mental health treatment would have
a community mental health survey conducted reduced the stigma associated with mental illness.
between 1980 and 1983, is published in the United
States. Based on interviews with almost 20,000 1998: In Canada, constable Gil Puder, speaking
adults, the ECA is able to provide estimates of at the Fraser Institute Forum, calls for an end to
the incidence and prevalence of mental disorders, the Canadian War on Drugs and the creation of a
whether or not sufferers have sought treatment. harm reduction program in its place.

1993: The American psychologist Jon Kabat-Zinn 2001: A study published by Joshua Rubinstein,
publishes Mindfulness Meditation in Everyday Jeffrey Evans, and David Meyer in the Journal
 Chronology xlv

of Experimental Psychology declares that “mul- colleagues from the University of California, Riv-
titasking” does not exist and what looks like erside publish a literature review in School Psy-
multitasking is in fact switching attention rap- chology Quarterly showing that poor academic
idly from one task to another. They also report performance and poor problem-solving skills are
that, contrary to popular belief, rapid switch- highly predictive of which children would engage
ing between tasks may not be efficient because in bullying behavior.
people lose significant amounts of time as they
switch from one task to another and that this 2010: Psychologist Scott Huetell and colleagues
loss of time increases with the complexity of the publish a report in Psychology and Aging show-
tasks performed. ing that, after controlling for cognitive abilities
such as memory, the tendency to make risky deci-
2001: The World Health Organization dedicates sions does not increase with age, contrary to pop-
World Health Day (April 7) to mental health, and ular belief.
the “World Health Report 2001” is also dedi-
cated to mental health. According to the report, 2011: The New York Times reports that many
about 450 million people around the world suf- U.S. psychiatrists no longer provide talk therapy to
fer from a mental disorder and 25 percent will be their patients because of difficulties getting health
affected by a mental disorder at some point in his insurance companies to pay for the treatment, and
or her life. rely increasingly on drug therapies instead.

2005: In Vancouver, British Columbia, the North 2011: A study by Aaron T. Beck and colleagues,
American Opiate Medication Initiative clinical published in the Archives of General Psychia-
trials test whether people who are suffering from try, finds that patients with severe schizophrenia
chronic opiate addictions (and have not been respond well to a type of cognitive behavior ther-
helped by other treatments) might be aided by apy originally developed to treat depression.
heroin-assisted therapy.
2012: A report from the Substance Abuse and
2008: A report by the American Psychoanalytic Mental Health Services Administration states
Association finds that while psychoanalysis is that about 20 percent of Americans experienced
frequently discussed in U.S. college classes in the mental illness in 2010 and about 5 percent had
humanities, including history, literature, and film, mental illness sufficiently severe to interfere with
it is not customarily taught in university classes in daily life.
psychology departments.
2012: The American Psychiatric Association
2008: A bill decriminalizing adult use of mari- announces that the fifth edition of the Diagnostic
juana is introduced in the U.S. Congress but does and Statistical Manual of Mental Disorders has
not pass. It is reintroduced in 2009 but, again, it been completed and will be published in 2013.
does not pass. Among the changes in the new edition: classifi-
cation of hoarding, binge eating, and severe pre-
2010: The U.S. Centers for Disease Control and menstrual syndrome as disorders; stricter defini-
Prevention (CDC) report that the diagnosis of tions of autism spectrum disorder; and lumping
attention deficit hyperactivity disorder (ADHD) in the term Asperger’s syndrome under autism spec-
the United States increased by an average of 3 per- trum disorder rather than listing it as a separate
cent per year from 1997 to 2006. The CDC also diagnosis.
reports that several studies found a link between
blood lead levels and symptoms of hyperactivity 2012: In the United Kingdom, mental health
and impulsivity. patients are granted the right to choose the con-
sultant psychiatrist who treats them, increasing
2010: Clayton R. Cook of the College of Edu- parity between mental and physical illness treat-
cation at the University of Washington and ments. The change will go into effect in 2014.
xlvi Chronology

2012: American psychologist Lena Brundin, from 2013: In September, Statistics Canada releases
Michigan State University, and an international results from a national population health survey
team of colleagues publish an article in Neuropsy- which found that 17 percent of Canadians aged
chopharmacology offering proof that the chemi- 15 or older felt they had an unmet need for men-
cal glutamate is linked to suicidal behavior. This tal health care in the previous 12 months.
means that glutamate levels should be monitored
in those deemed potentially suicidal and that anti- 2013: On October 10, National Football League
glutamate drugs may help prevent suicide. player Brandon Marshall wears green cleats dur-
ing a game between the Chicago Bears and the
2012: A report by the World Health Organization New York Giants. This occurs during Mental
calls conversion therapy, which claims to be able Health Awareness Week to raise awareness about
to “cure” gay men and lesbians and make them mental health.
heterosexual, a threat to the lives and well-being
of those subjected to it. 2013: In November, the National Alliance on
Mental Illness announces a new national pro-
2013: In California, the Investment in Mental gram, “Ending the Silence,” which educates high
Health Awareness Act of 2013 creates a grant school students about mental illness.
program to help counties, public agencies, and
nonprofit agencies develop mental health crisis 2013: In November, Kathleen Sebelius, Secretary
support systems. of Health and Human Services, announces new
regulations that require health insurers to cover
2013: May 2013 sees the publication of the fifth mental health care on the same basis that they
edition of the American Psychiatric Association’s cover physical health care. Although theoreti-
Diagnostic and Statistical Manual of Mental Dis- cally, mental health care parity has been required
orders, DSM-5. A week before it appears, Thomas by law since 2008, the new regulations make it
Insel, director of National Institute of Mental more difficult for insurers to evade the law.
Health (NIMH), objected to “its lack of validity”
and reliance upon the outmoded idea of defining Sarah Boslaugh
and diagnosing illnesses o the basis of symptoms. Kennesaw State University
“Mental patients deserve better,” he proclaimed,
and he indicated that NIMH would “be reorient-
ing its research away from DSM categories.”
 A
Acculturation immigrants have moved to this nation and expe-
rienced a fairly orderly, controlled moving expe-
Acculturation, or the process of adaptation to the rience; but others have been pushed from their
dominant culture, is an important topic in the homelands by wars, famines, or other hardships,
contemporary migratory world, especially from and for these new residents, their resettlement pro-
the perspective of U.S. residents. The American cess may be considerably more stressful, with past
ethnoscape was formed by immigrants, first by trauma complicating their mental well-being. For
aboriginal peoples, who spread across the land- all new residents, acculturation has mental health
scape many thousands of years ago, followed implications, and mental health plays a role in suc-
by historically documented European explorers cessful adaptation to a new setting, so considering
and settlers and, more recently, immigrants from how these processes connect is important. Linguis-
every region of the world. In all these cases, peo- tic skills often play a mediating role.
ple had to adapt to others, but the size of contem-
porary population movements and their diversity Learning a New Language
contributes an additional level of challenge and The experience of acculturation interests many dif-
opportunity for new immigrants and their desti- ferent types of social scientists and mental health
nation populations. providers. Although each practitioner may inves-
While the term acculturation is often used to tigate the phenomenon slightly differently, they all
describe how new citizens adjust to the beliefs and recognize the centrality of language in a successful
behaviors espoused in their adopted homes, it may social integration. Linguistic prowess eases transi-
also be applied in situations involving aboriginal tions into school, employment, and other social
inhabitants, rural citizens, or members of ethnic situations, and it allows people to access health
minority groups, who may also deal with accul- services with greater ease, allowing for commu-
turation when they move to a new urban center nication with specialists. This is especially the
or a different region of their home country. The case in a nation such as the United States, where
United States is a land of immigrants, spread across many long-term residents have low tolerance for
a geographically diverse territory, with a number non-English-speaking populations, demonstrated
of regional cultures. In addition to regional dif- most recently by many states attempting to pass
ferences, immigrants vary, and their reasons for “English only” legislation, penalizing non-native
migration shape their acculturation process. Some speakers who struggle with English.

1
2 Acculturation

While “English only” legislation may be viewed pattern, hoping that their offspring will succeed
as institutional discrimination (when a social in school and employment. Many other immi-
institution is organized in such a manner that it grants maintain a middle position between these
creates inequity for specific community groups), two extremes and strive to integrate both sets of
challenges for non-English-speaking populations social norms, creating something new, such as the
may occur at a variety of levels. Stereotypes (ideas Tongan American community in Salt Lake City,
about a group of people, based on limited evi- Utah. This typology idealizes people’s accultura-
dence), and discrimination (actions against people tion experience; there are also individuals who do
viewed as different) may make it truly challenging not fit these patterns and may end up marginalized
for non-native speakers of English to acculturate from both their birth community and their new
successfully to a new location. home, with a degree of discomfort in functioning
in either. While each of these processes has differ-
Adapting to Change ent sets of stressors that may affect mental health,
Moving and assimilating to a new location is stress- there are also individual and environmental fac-
ful because of its novelty, because people tend to tors influencing well-being.
like order in their world and may not respond well The process of acculturation can be consider-
to unexpected change. Relocation may be the result ably aided by moving to a region where other
of personal or family decisions, or external circum- members of the home community have previously
stances such as wars or famines. Forced moves are moved, which allows for a more gradual, easier
more difficult and stressful. For all of these cases, integration experience. In addition, people bring
acculturation may be considered at several differ- resources with them to a new location, includ-
ent levels of analysis, each with a different set of ing their ideas about physical health and men-
new experiences, requiring some response. Reloca- tal illness, and these beliefs may contribute to or
tion may involve adapting to a new region, with detract from their acculturation experience.
different geographic features, climate, and residen-
tial norms. Even a slight adjustment to living in a Acculturation and Mental Health
colder, damper place involves new household fur- In many regions of the world, there are folk tax-
nishings, clothes, and transportation modes. onomies of mental illness that may differ from
Additional changes occur as people meet new American mental health specialists’ ideas about
neighbors, children are placed in schools, and diagnosis, recorded in the Diagnostic and Sta-
adults find employment. All of these interactions tistical Manual of Mental Disorders (DSM). The
expose newcomers to different types of food, and DSM, produced by the American Psychiatric
other alternatives to their typical social norms. Association, is used by American mental health
After some time, new residents may marry mem- specialists for diagnosis and treatment. In con-
bers of the host populations, learn their languages, trast to the DSM labels, immigrants, members of
or adopt their political and religious ideas. For minority populations, and American Indians or
many individuals, this process occurs slowly, other aboriginal peoples may have different ideas
over a lengthy period of time. Family members, of causation, symptoms, and curing techniques.
depending on their gender, age, or personality, For example, Spanish speakers may suffer from
may adapt more quickly or may respond differ- attaque de nervios (nervous attacks), an extreme
ently than others. reaction to stress that may involve hysterical weep-
Some newcomers may reject markers of the ing, screaming, and other wild-seeming behavior.
novel culture, striving to maintain their home This is now understood, according to the most
country norms despite living in a new place, recent edition of the DSM, as a “culture-bound
which is easier for members of larger, established syndrome,” although previously, it was challeng-
immigrant communities such as Chinatown in ing for American-trained mental health specialists
San Francisco, California. Another possibility is to understand this set of symptoms and provide
to assimilate fully to the new location, paying meaningful assistance.
little heed to former traditions and ideas, and While some new immigrants may bring ideas
parents of young children often adhere to this about mental illness with them and manifest
 Acculturation 3

A vendor in Chinatown, San Francisco, California, September 2009. Many immigrants to the United States strive to maintain the
familiar norms from their home country, which is easier to do in larger, established immigrant communities such as Chinatown. The
taxonomies of mental illness that are used by these immigrants may differ sharply from those espoused by the American Psychiatric
Association’s Diagnostic and Statistical Manual of Mental Disorders, which refers to these as “culture-bound syndromes.”

folk ailments, the majority of new residents have may change with acculturation challenges such as
good mental health prior to departure from their experiencing discrimination, possibly resulting in
homeland, during their move, and after they are depression, requiring treatment. Individuals may
well established in their new home. Other people be challenged or excited by the process of accul-
may arrive in the host location with a diagnosed turation, but there are also implications for host
mental illness such as schizophrenia, which may communities.
be exacerbated by the relocation. Lacking sup-
ports available in their former homes, people may Acculturation and the Future
experiment with new strategies for feeling better; The United States is considered a peaceful, demo-
one response is to use alcohol or drugs to dull cratic, wealthy nation and will continue to be a
unpleasant symptoms. desired new home for immigrants escaping hard-
It is also possible that as a result of trauma, ship in their homelands, or merely hoping for a
age, the challenges of living in a new place, or better life for themselves and their children. Eas-
some other event, individuals may develop a men- ing people into productive, mentally healthy lives
tal illness, which is diagnosed for the first time in their new homes will result in a better function-
in their new home. Each of these situations may ing society. This process will be aided by a more
present difficulties from the perspective of both multilingual, multicultural mental health special-
newcomers and mental health specialists. For ist body, which is happening as new residents
some new residents, a mentally healthy arrival access educational opportunities. It will also be
4 Adolescence

assisted by a more informed American citizenry, socioeconomic status (SES), without insurance,
which understands the challenges of accultura- living in rural areas, and living in less developed
tion and works to assist new citizens, rather than countries.
reacting fearfully to difference. Clinical diagnoses for mental illness reveal dif-
ferences by sex and age, with a gradual increase
Susan J. Wurtzburg from 6 to 7 years of age, when children first enter
Shayna Vi school, until the trend peaks at about 14 to 15
University of Hawai‘i, Manoa years of age, when normal adolescent transitional
issues (rapid cognitive and emotional growth)
See Also: Cultural Prevalence; Diagnosis; Diagnosis may exacerbate problems that previously existed.
in Cross-National Context; Ethnopsychiatry; For example, adolescents who display some prob-
Migration; Peer Identification; Treatment. lems with mild anxiety or other psychological
distress in childhood are more likely to suffer
Further Readings from depression as they enter into adolescence.
American Psychiatric Association (APA). Diagnostic Although there are competing explanations, there
and Statistical Manual of Mental Disorders. is some evidence that the rise in diagnoses of men-
Washington, DC: APA, 1952. tal illness in adolescents has been influenced by
Healey, Joseph F. Race, Ethnicity, Gender, and Class: the availability of new drugs and societal pres-
The Sociology of Group Conflict and Change. 6th sure to medicate. Prevention and treatments vary
ed. Thousand Oaks, CA: Sage, 2012. depending on risk factors and diagnosis.
Lara, Marielana, Cristina Gamboa, M. Iya
Kahramanian, Leo S. Morales, and David E. Hayes Risk Factors
Bautista. “Acculturation and Latino Health in the Risk factors for social and mental problems in
United States: A Review of the Literature and its adolescence are of two types, internal/individual
Sociopolitical Context.” Annual Review of Public characteristics and external/social factors. Inter-
Health, v.26 (2005). nal characteristics include first-degree relatives
Takaki, Ronald. A Different Mirror: A History of with a history of mental illness, undetected anxi-
Multicultural America. New York: Back Bay ety early in life, low self-esteem, poor body image,
Books, 2008. difficulty regulating emotions, extensive use of
emotion-based coping (e.g., fear), perfectionism,
and lower cognitive abilities. Additionally, growth
factors related to the adolescent’s immature brain
may lead to increased risk-taking behavior or
Adolescence acting out before rational decision-making areas
of the brain such as the prefrontal cortex have a
Adolescence is a period of experimentation that chance to activate.
may result in violations of social norms. How- External factors such as lower socioeconomic
ever, the majority of adolescents do not develop status, inadequate schools, stressful neighbor-
a serious social problem or mental illness. Risk hoods, and exposure to violence or disasters
factors for mental illness in adolescence include contribute to socially based mental problems.
both internal and individual characteristics and Exposure to violence during adolescence is asso-
external factors. There has been an upward trend ciated with anxiety, post-traumatic stress disorder
in mental illness, with approximately 21 percent (PTSD), and depression, which may continue into
of adolescents exhibiting some symptoms of men- adulthood. A number of family conditions such
tal illness and about 10 percent of adolescents as insecure attachment, poor family cohesion, and
showing symptoms serious enough to be diag- poor parenting (especially long-term parent-ado-
nosed as emotionally impaired. Of those show- lescent conflict) increase risk for problems. Ado-
ing any symptoms, about half have access to pro- lescents spend less time with parents and more
fessional help, with an even smaller proportion time with peers; thus, peer relationships, positive
among those from racial/ethnic minorities, lower or negative, have a critical effect. Adolescents who
 Adolescence 5

have difficulty connecting with society through Sex Differences

friendships and romantic relationships are at risk, Diagnoses for most mental disorders differ by
and those rejected by peers are especially prone to sex. In adolescence, males are three times more
developing problems. likely to be diagnosed with ADHD, even though
Internal characteristics often interact with recent research indicates that the real incidence of
external risk factors. For example, adolescents ADHD in males and females is equal. Males are
who are exposed to a disaster (e.g., 9/11) are also two to four times more likely to be diagnosed
at risk for PTSD. However, those who charac- with conduct disorder, up to seven times more
teristically use problem-based coping (tackle the likely to exhibit any type of autism, and are more
problem) have a better immediate outcome, with likely to be diagnosed with anxiety disorder. High
long-term results depending upon family support rates of ADHD, anxiety, and autism mean that
and society’s reaction to the event. Thus, ado- males are more likely to be academically affected
lescents with few individual risk factors, caring and are more at risk for multiple diagnoses (e.g.,
parents, and strong bonds outside the family are ADHD or anxiety with disruptive disorder or
more resilient. criminal behavior).
Eating disorders, such as anorexia nervosa
Incidence Rates (fear of being overweight with disrupted body
While incidence rates are not available for all image) and bulimia (binge eating with purging)
mental illnesses, adolescents suffer from diagno- are more common in females. Because bulimia is
ses similar to many adult diagnoses. About half rare in males, it is often misdiagnosed or under-
of all lifetime mental health disorders appear by diagnosed. Generally, adolescents diagnosed with
age 14, while three-quarters emerge by age 24. eating disorders are dissatisfied with their bodies,
Most common in adolescence are depression and with males wanting to increase their upper bod-
suicide, anxiety disorders, and substance-related ies and females wanting to decrease their over-
disorders. Other disorders common in adoles- all body size. There are additional factors related
cence are attention deficit hyperactivity disorder to female adolescents with eating disorders. For
(ADHD), autism spectrum disorders, and dis- example, girls who are sexually active during the
ruptive behavior disorders (conduct and delin- transition into adolescence are at greater risk for
quency). Eating disorders are generally on the an eating disorder. In addition, adolescent girls
rise but vary depending on the specific diagnosis; are more likely to go on a diet in response to a
for example, research indicates that the rate of negative parent-adolescent relationship. There is
anorexia has held steady since 1931, while rates also considerable criticism directed toward mass
of bulimia nervosa have risen since the 1970s, media since adolescent girls are highly motivated
with a threefold increase between 1988 and 1996. to look like same-sex media figures, even though
Deliberate self-injury is also common, espe- images are often unrealistic or digitally distorted.
cially cutting, which has generally been on the Approximately 15 to 20 percent of adolescents
rise over the past decade. Incidence rates of self- show symptoms of depression, with female adoles-
injury peak during early to mid-adolescence, with cents presenting at double the rate of males. This
a steady decline from college into adulthood. 2:1 ratio continues into adulthood. Perhaps there
This trend indicates a specific vulnerability dur- are more risk factors for adolescent girls, such as
ing adolescence. Incidence rates for adolescent pressures of body image and societal pressure for
mental disorders are complicated by common females to display specific emotions (e.g., empa-
co-occurrence of disorders, for example, disor- thy), which result in additional stress. Addition-
ders of depression and borderline personality ally, there could be a difference in the developing
often occur with self-injury. Likewise, substance brain and hormones that render adolescent girls
abuse commonly co-occurs with numerous dis- more vulnerable. Depression is the most significant
orders and may mask, exacerbate, or reinforce risk factor for suicide attempts, which are on the
disorders such as manic disorder, which is com- rise. However, actual rates of adolescent suicide
monly associated with both ADHD and sub- are difficult to quantify because it is possible that
stance abuse disorder. some adolescents die in automobile accidents that
6 Adolescence

are actually intentional suicides. Similar to the pat- as an easy alternative to talk therapies. Critics add
terns among adults, because of the gendered mech- that primary care physicians, who write as many
anisms used (e.g., pharmaceuticals for females, and as four out of five psychotropic prescriptions, have
guns for males) adolescent females are more likely limited mental health training and are too eager
to attempt suicide, whereas males are more likely to prescribe medications for milder forms of inat-
to succeed in killing themselves. tention and emotional self-regulation, which may
be from normal differences in adolescent brain
Ongoing Trends development or lack of parental reinforcement of
There has been a dramatic upward trend in the behavioral norms.
diagnosis of adolescents with social problems and
mental illness over the past 50 years. The dra- Prevention and Treatment
matic rise in diagnoses could be because of an Prevention, before onset of illness, is seen by
actual rise in adolescent mental illness. However, many clinicians as important because early epi-
the trend is complex and difficult to understand sodes are a risk factor for later episodes (e.g.,
for several reasons. First, trends within a cate- depression). Preventive measures vary depend-
gory are sometimes contradictory. For example, ing upon common age-specific stressors. For
within substance-related use disorders, marijuana example, at-risk adolescents leaving home for
use has risen for four straight years from 2008 to college are more likely to suffer from depression,
2011, and is at a 30-year high among high school perhaps because of the stress of leaving family
seniors. However, alcohol use, including binge- and peers and because of increased responsibili-
drinking episodes, continues a long-term gradual ties. However, adolescents exposed to stressors
decline, along with smoking of tobacco, which can be resilient when they have support, such as
fell significantly from 2011 to 2012. high-achieving personalities, healthy stable rela-
Second, it is difficult to compare across stud- tionships (inside and outside the family), good
ies because classifications of some mental illnesses schools, effective parenting, supportive commu-
have changed over time. For example, there has nity policies, and when understanding mental ill-
been a dramatic increase in autism spectrum diag- ness and its affects.
noses, but this increase is associated with a simul- After onset, mental health services are important
taneous increase in greater numbers included in because going without treatment can lead to seri-
the spectrum, such as Asperger’s. Next, it is possi- ous negative consequences; for example, additional
ble that mental illness, such as ADHD, was previ- low self-esteem and academic and social failures
ously underdiagnosed because it was not listed in that remain or worsen into adulthood. Estimates
the American Psychological Association’s Diag- suggest that just over 20 percent of adolescents in
nostic and Statistical Manual of Mental Disorders the United States, aged 12 to 17, received some
(DSM-I) prior to 1968, when students were more form of treatment from a mental health care spe-
likely identified as “poor learners” or “lazy.” cialist in the school, home, or community setting.
The DSM-IV-TR includes expanded guidelines Of those adolescents, 40 percent reported depres-
for reaching the diagnosis of ADHD, but these sion as the reason for seeking treatment.
more specific criteria may also lead to an increas- Studies consistently find that adolescents with
ing number of cases. Finally, there is a positive substantial emotional distress remain untreated,
relationship between the increasing number of with older adolescent males the least likely to
diagnoses and the exploding availability of new receive treatment. Additionally, primary care pro-
psychiatric drugs. For example, in the United viders and pediatricians report that mental health
States, use of methylphenidate (Ritalin) has steadily care is a sizable part of their practice, suggesting a
increased, along with the number of adolescents need for additional mental health services that are
diagnosed with ADHD. These numbers lead some specific to adolescents. When seeking treatment,
to conclude that ADHD is increasingly overdiag- a recent survey found that adolescents are more
nosed because of pressures from pharmaceutical likely to ask peers for information about mental
companies and direct marketing, increased avail- illness than to trust professionals, which may be
ability of drugs, and social pressure to medicate one reason many adolescents go untreated.
 Afghanistan 7

Treatments fall into two general categories, of health for Afghans and left Afghanistan with
psychotherapies (talk therapy) or biotherapies a shattered health care infrastructure, difficulties
(medication), with more effective treatments a in effective service coordination, and severe staff-
combination of the two. For example, antide- ing and supply shortages. Afghans have endured
pressants (e.g., Prozac) are effective for treating incessant violence, continued poverty, and insta-
major depressive episodes, while cognitive behav- bility in a fragile, conflict-ridden environment.
ioral therapies (making changes in thinking and According to several epidemiological surveys,
coping style) are more effective in lowering the Afghans report high rates of symptoms of depres-
frequency, duration, and intensity of future epi- sion, anxiety, and post-traumatic stress disorder.
sodes. Family and group therapies can be about These numbers increase for women and girls.
as effective as individual treatment; for example, In the face of traumatic emergencies and failing
attachment family therapies are especially effec- infrastructures, family and community remain
tive for adolescents who self-injure, while group of critical importance to the mental well-being
programs focusing on both the individual charac- of Afghans. A combined approach that builds
teristics and social environment (peers and par- community capacity and integrates mental health
ents) are most effective for adolescent substance treatment at the primary care level with effective
abusers. Self-help groups are also effective and government policy is required for much-needed
can be accomplished in person or online. supports and services.
Afghanistan has 35 provinces and is located
Debra L. Frame in central Asia bordering China, Iran, Tajikistan,
University of Cincinnati the former Soviet Union, and Pakistan. Approxi-
mately 46 percent of its population are under
See Also: Age; Eating Disorders; Family Support; 15 years of age and life expectancy is 48 years.
Peer Identification; Self-Injury; Suicide: Patient’s Maternal mortality and morbidity are devastat-
View. ingly high; every two hours a woman dies from
a maternity-related problem. The main faith of
Further Readings Afghanistan is Islam. The two official languages
Knopf, David, M. Jane Park, and Tina Paul Mulye. are Dari and Pashto, but numerous other lan-
“The Mental Health of Adolescents: A National guages are also spoken in parts of this ethnically
Profile, 2008.” http://nahic.ucsf.edu/downloads/ diverse country.
MentalHealthBrief.pdf (Accessed July 2012).
University of Michigan Institute for Social Research. Mental Illness: Rates, Risk, and Treatment
“Monitoring the Future: National Results on There is a paucity of data on the prevalence of
Adolescent Drug Use, Overview of Key Findings severe mental disorders (such as psychosis); how-
2011.” http://www.monitoringthefuture.org/pubs/ ever, reports indicate that over half of the Afghan
monographs/mtf-overview2011.pdf (Accessed July population aged 15 years and above have been
2012). affected by anxiety, depression, or post-traumatic
Whitaker, Robert. Anatomy of an Epidemic: Magic stress disorder. Day-to-day stressors of inequita-
Bullets, Psychiatric Drugs, and the Astonishing ble access and domestic violence are reported to
Rise of Mental Illness in America. New York: contribute to mental health problems. Sufferers of
Crown Publishers, 2010. mental illness are said to have baymaree ruhi wa
rawanee, or spiritual and mental illness. A 2004
World Bank discussion paper reported 72 percent
of survey respondents had anxiety, 68 percent suf-
fered from depression, and an additional 44 per-
Afghanistan cent reported four or more traumatic experiences
in the last 10 years. These figures were found to be
Thirty years of instability—first invasion, then higher in women and children. Those with mental
internal discord, then the multinational military illness report praying and reading the Qur’an as
presence—have challenged the social determinants the most common coping methods.
8 Afghanistan

In 2001, there were only two psychiatrists for a are fundamentally important to the well-being
population of 25 million and no qualified mental of any healthy society. The mental well-being of
health nursing staff. In 2001, after the fall of the Afghans cannot be achieved without peace and
Taliban, the government outsourced all mental stability in the war-ravaged region. Safety and
health services to nongovernmental organizations security of all peoples (nationals and foreign aid
(NGOs) in the region. In a pilot project by the health workers) must be promoted through coor-
NGO HealthNet TPO, residents of Nangarhar dinated and deliberate local, national, and global
province were encouraged to mobilize through responses that protect Afghan mental health and
community development. This project was well well-being through peace.
received and has now been rolled out across 12
provinces. Mental health services were also out- Wajma Soroor
lined in the Basic Package of Health Services, a Nazilla Khanlou
government-approved national health care plan York University
within reach of about 85 percent of the popula-
tion. However, the terms of the arrangement were See Also: Anxiety, Chronic; Depression; Military
not clear. Psychiatry; Pakistan; Post-Traumatic Stress Disorder;
Today, mental health services are among the War; Women.
first tier of priorities for the Afghan Ministry of
Public Health (MOPH). Among the challenges of Further Readings
understanding the current mental health and ill- Cardozo, B. L., et al. “Mental Health, Social
ness outcomes of Afghans is the paucity of research Functioning, and Disability in Postwar
in the country, its outdated surveys, and the ongo- Afghanistan.” Journal of the American Medical
ing instability due to war-related trauma. As more Association, v.292/5 (2004).
acute aspects of mental illness are addressed, over Dastagir, G. S. “Mental Health in Afghanistan:
time and with improvements in the social deter- Burden, Challenges, and the Way Forward.”
minants of health, research is needed to address Health Nutrition and Population Discussion
the mental well-being of the population. Paper for the World Bank (2011). http://
Children report high levels of mental distress siteresources.worldbank.org/healthnutrition
from non-war-related events. Those with five or andpopulationResources/281627-10956981
more war-related experiences report more health 40167/MHinAfghanistan.pdf (Accessed
problems. School-based programs to address December 2012).
mental health for children have been imple- Dawes, A. “Children’s Mental Health in Afghanistan.”
mented; however, program evaluation data are Lancet, v.374/9692 (September 5, 2009).
not available. deJong, J. T., I. H. Komproe, and M. van
Important challenges lie ahead. There are no Ommeren. “Common Mental Disorders in
mental health services for children and adoles- Post-Conflict Settings.” Lancet, v.361/9375
cents; hospitals do not have formal protocol to (June 21, 2003).
report statistics to MOPH; patients receiving Eggerman, M. and C. Panter-Brick. “Suffering, Hope,
treatment typically have no aftercare services; and and Entrapment: Resilience and Cultural Values in
community contact is lost after treatment. Sug- Afghanistan.” Social Science & Medicine, v.71/1–2
gestions for sustainable mental health services in (July 2010).
Afghanistan include the ongoing training of com- Panter-Brick, C., M. Eggerman, A. Mojadidi, and T.
munity actors and support through group discus- McDade. “Social Stressors, Mental Health, and
sions and case management. Health professionals Physiological Stress in an Urban Elite of Young
at the primary care level must continue to receive Afghans in Kabul.” American Journal of Human
psychiatric training, and better coordination is Biology, v.20/6 (2008).
needed with MOPH for efficient prioritization Scholte, W. F., et al. “Mental Health Symptoms
and organization of services. Following War and Repression in Eastern
According to the World Health Organization’s Afghanistan.” Journal of the American Medical
social determinants of health, safety and security Association, v.292/5 (2004).
 Age 9

VanOmmeren, M., S. Saxena, and B. Saraceno. “Aid teens and early 20s. About half of all lifetime
After Disasters.” BMJ, v.330 (2005). mental disorders start by the mid-teens and three-
Ventevogel, P., W. van de Put, F. Hafizullah, B. van quarters by the mid-20s. Later onsets tend to be
Mierlo, M. Suddique, and I. Kompore. “Improving secondary conditions, and severe disorders are
Access to Mental Health Care and Psychosocial nearly always preceded by less severe disorders.
Support Within a Fragile Context: A Case Study
From Afghanistan.” PLoS Medicine, v.9/5 (May Life Stages and Types of Mental Illness
2012). Different mental disorders exhibit different pat-
World Bank. “Afghanistan Overview” (October terns of association with age. Some, such as tic
2012). http://www.worldbank.org/en/country/ disorders and attention deficit hyperactivity dis-
afghanistan/overview (Accessed December 2012). order (ADHD), have childhood onset as part of
World Health Organization. “World Health their definition. The presence of conduct disor-
Statistics 2012.” (2012). http://www.who.int/ der in childhood is a requirement for a diagnosis
gho/publications/world_health_statistics/EN_ of antisocial personality disorder in adulthood.
WHS2012_Full.pdf (Accessed December 2012). Autism and personality disorders are defined as
lifelong and so should not be associated with
age in adulthood. In practice, many do show an
association with age, either because people learn
to manage the symptoms of their condition, the
Age prevalence of the disorder is changing between
birth cohorts, or because of “healthy survivor”
In high-income countries, mental illness tends to effects (i.e., people without the condition tend to
be more common among people under the age of live longer than those with it). Different stages
65 than those who are older. This pattern of asso- of life are associated with vulnerabilities to dif-
ciation with age varies with country, birth cohort, ferent types of mental illness. Furthermore, what
and type of mental disorder. In most high-income might be considered normal behavior at one life
countries, including the United States, Canada, stage could be considered illness at another stage.
Australia, and European countries such as Bel- For example, symptoms of separation anxiety
gium, rates of mental illness are highest among are regarded as normal in early childhood, but as
young people (18–24 years old), and decrease signs of distress if present in older childhood or
with age. However, this pattern is not always evi- beyond.
dent. For example, in Iran and the Ukraine, men- As people transition into early adulthood,
tal illness is most prevalent among older people important developmental changes take place.
(aged more than 40 and 50, respectively). Data These include leaving school and entering
from the World Health Organization’s (WHO) employment or further training; developing inti-
World Mental Health Surveys show that major macy, personal relationships, and self-confidence;
depressive episode was less prevalent among and finding a place within the community. The
respondents older than 65 than among younger enormity of the changes associated with this life
respondents in developed countries, but not in stage can contribute to the development of mental
developing countries. illness and substance dependence among young
The WHO World Mental Health Survey data adults who are predisposed to mental illness.
also show that first onset of mental disorder usu- Anxiety, depression, and psychosis, in particular,
ally occurs in childhood or adolescence. Average are mental disorders that present special prob-
age of onset is earliest for phobias (7–14 years old) lems at this life stage. The first episode of psycho-
and impulse-control disorders (7–15 years old), sis tends to be experienced at this point. It is the
and later for anxiety disorders (25–53 years old), most persistently disabling condition, especially
mood disorders (25–45 years old), and substance for young adults, in spite of recovery of function
abuse disorders (18–29 years old ). Although less by some individuals in mid- to late life. Eating
is known about nonaffective psychosis, it appears disorders are most prevalent in early adulthood,
that average age of onset may be between late as well as several impulse control and substance
10 Age

disorders. In Britain, alcohol and drug misuse and that the association between completed suicide
dependence peaks among women in their 20s and and age varies from country to country and has
men in their 30s. The lower prevalence in later changed over time. In many high-income coun-
life may be because substance-dependent peo- tries, rates were highest among young men in
ple either recover from their addiction, become the 1980s and 1990s. Most countries have since
homeless or institutionalized (so are not included experienced an overall decline in suicide rates
in the survey samples from which these age-asso- and a more even spread across age groups. Some
ciations are derived), or have heightened mortal- countries have prominent rates among older men.
ity. Young people are more likely to experience In Britain, rates of mental illness have been
violent trauma (from experience of active armed found to peak among people in their middle years
service or violent crime), and as a result may be (40s and 50s), and are least likely among those
more likely to develop post-traumatic stress dis- in their 60s and 70s. This pattern of association
order (PTSD). between age and mental illness is a neat reversal
Anxiety and depression contribute to the of the widely reported U-curve in positive mental
high rates of self-harming behavior reported by well-being that has been identified in many parts
younger adults, including acts such as cutting, of the world. The U-curve theory finds that posi-
burning, and swallowing poison without suicidal tive mental well-being is lowest among people in
intent. However, suicidal attempts have a weaker midlife. Various explanations have been proposed
association with age. Mortality statistics suggest for the excess of (often subthreshold) neurotic

Army Spc. Karla Tyson helps an injured Afghan child with some toys at the American Hospital at Bagram Air Base, Afghanistan, in March
2008. While they come from vastly different worlds, this young soldier and child share something significant: They are both more at risk
of having post-traumatic stress disorder (PTSD) than the general population. Young people are more likely to experience violent trauma,
such as from actively participating in the armed services or as a result of violent crime, and may be more likely to develop PTSD.
 Age 11

symptoms at this life stage. These include the care hospitals where mental illness is common.
realization of limited achievement while people They often do not include assessment of demen-
are still aspirational, the squeeze resulting from tia, or people with dementia may not be able to
a combination of caring responsibilities to chil- take part. In addition, older people may be less
dren and to ailing parents, work-related stress, likely to remember past episodes, or the survey
and menopause. Traumatic life events that can questions may not have been sensitive enough
be damaging to mental health, such as marital to identify symptoms of mental illness as they
breakdown, become more likely at this life stage. manifest among older people.
There is a stage, around the time of transition- Using a general population survey sample is
ing to retirement, when rates of mental illness are preferable to using a sample drawn from patients in
particularly low. However, there is evidence that contact with health services because many people
rates increase somewhat in late older age. Stress- with mental illness are not in contact with health
ful life events, such as declining health and/or the services, and the likelihood and extent of health
loss of mates, family members, or friends, often service contact varies with age. Survey interviews
increase with age. These are coupled with increas- include structured schedules that assess the pres-
ing social isolation, experience of pain, and loss ence of symptoms and screen for disorders, which
of status. It may be difficult to diagnose mental is preferable to asking whether people have been
illness among older people because their mul- diagnosed with or treated for mental illness, in
tiple physical health problems may be confused part because people are not always aware of what
with or masked by an underlying mental illness. they have been diagnosed with. Some conditions
Symptoms of mental illness among older people are more prominent at particular life stages, so
may differ from those experienced by younger when looking at overall association with age, the
people, which can make accurate identification in definition of mental illness used will be key.
research and in diagnosis and treatment difficult.
In addition, symptoms of anxiety or depression Sally McManus
may incorrectly be considered part of the aging National Center for Social Research
process and not be recognized as a treatable con-
dition among older people. Dementia also makes See Also: Ageism; Children; Cultural Prevalence; Life
it difficult to identify underlying mental illness. Course; Measuring Mental Health.
Dementia is prominent as a chronic or progres-
sive neurological condition that overwhelmingly Further Readings
onsets in older age. With an aging society, the Cooper, C., P. Bebbington, S. McManus, H. Meltzer,
number, although not necessarily the proportion, R. Stewart, King M. Farrell, R. Jenkins, and G.
of people in later life with mental health problems Livingston. “The Treatment of Common Mental
is increasing. Mental health among older people Disorders Across Age Groups: Results From the
should therefore become a greater public health 2007 Adult Psychiatric Morbidity Survey.” Journal
priority than it currently is in most countries. of Affective Disorders, v.127/1–3 (2010).
Kessler, R. C., G. P. Amminger, S. Aguilar-Gaxiola, J.
Methodological Issues Alonso, S. Lee, and T. B. Ustun. “Age of Onset of
The best way to examine how the prevalence Mental Disorders: A Review of Recent Literature.”
of mental illness varies across the life course Current Opinions in Psychiatry, v.20/4 (2007).
is by analyzing data from epidemiological sur- Office of the Surgeon General. Mental Health: A
veys of people in the general population. How- Report of the Surgeon General. Washington, DC:
ever, general population surveys often exclude National Institute of Mental Health, 1999.
people above a certain age; or, where there is no Spiers, N., P. Bebbington, S. McManus, T. S. Brugha,
upper age limit to participation, the data repre- R. Jenkins, and H. Meltzer. “Age and Birth
sent an underestimate of the actual prevalence Cohort Differences in the Prevalence of Common
of mental illness among older people. Surveys Mental Disorder in England: National Psychiatric
tend not to include those individuals living in Morbidity Surveys 1993 to 2007.” British Journal
nursing homes, retirement homes, or chronic of Psychiatry, v.198/6 (2011).
12 Ageism

Ageism work, family, and society that are important to

personal identity, increasing psychological dis-
The President’s New Freedom Commission on tress and mental health problems.
Mental Health indicated that as many as one
in four older adults have a clinically significant Double Stigma of Mental Illness and Age
mental disorder. It is estimated that older adults In addition to ageism, older adults with mental ill-
with serious mental illness will double by 2030, ness face stigma toward mental illness, leading to
reaching 15 million. Many older adults with double stigma. Double stigma among older adults
mental illness face double levels of stigma related with mental illness is associated with reductions
to age and mental illness. Stigma toward older in quality of life, self-esteem, and psychological
adults with mental illness is a topic that is often well-being. Double stigma in this population has
overlooked, despite high rates of prevalence. In also been associated with social withdrawal and
a study of older adults with serious mental ill- reduced help seeking. Older adults often internal-
ness, 57 percent reported experiences of stigma- ize negative beliefs about individuals with mental
tization. One’s family, community, culture, or the illness with regard to social functioning in par-
general public may perpetuate stigma. An older ticular, leading to low utilization of mental health
adult with mental illness may also internalize this services among this group.
stigma, or encounter stigma in the institutions Vulnerability to stigma further contributes to
with which they interface (e.g., in employment, risk factors among older adults with mental ill-
government, or service settings). Stigma toward ness. For example, older adults with mental illness
mental illness and age is known to diminish men- experience a higher risk of institutionalization and
tal health, social functioning, and quality of life. increased use of other intensive services, impair-
Age-related stigma faced by older adults with ment in independent living skills, and nursing
mental illness is termed “ageism.” Robert Butler home placement. Older adults are more likely to
coined this term in 1969, to refer to prejudice and experience financial inequity, and those with men-
discriminatory practices or policies based upon tal illness are at increased risk of poverty. Stigma
the chronological age of a person or group. Age- may factor into elevated incidences of elder abuse
ism may consist of negative attitudes, beliefs, and among this group, such as neglect, financial and
biases toward the aging process and older people. sexual exploitation, and victimization.
Negative attitudes toward older adults perpetuate The literature suggests that older adults with
stereotypes that elders are helpless, dependent, mental illness often experience impairment in
incapable, or demented. Ageism may take the social skills. These specific social skill deficits have
form of discriminatory policies and practices that included initiating and receiving social contact,
marginalize older adults at the institutional level. communication skills, and social activity engage-
Ageist discrimination may reduce the availability ment. Social withdrawal is often a consequence of
of opportunities necessary for a satisfactory life social skill impairment, and is worsened by trans-
and undermine personal dignity. portation problems among this group. As a result
Research has identified ageist attitudes among of social withdrawal, older adults with mental ill-
individuals across the age spectrum, from children ness encounter risk of depression and substance
as young as 6 years of age to elders. Older adults abuse. This relationship demonstrates that unmet
can be persuaded by ageist attitudes that physi- needs can compound preexisting mental health
cal and cognitive decline is inevitable. Referred to problems.
as “internalized ageism,” these beliefs can have
a significant impact on the elderly. For example, Barriers to Care
one study examined elders who attribute prob- Older adults with mental illness experience barri-
lems in behavior and symptoms to age-related ers to mental health care at both intrinsic (inter-
decline rather than to plausible environmental nal) levels and extrinsic (external) levels. With
causes. This group had poorer functioning, group regard to intrinsic barriers, research has indicated
participation, and general sociability. Ageist prac- that many older adults with mental disorders
tices and prejudices can threaten social roles in tend to be less likely to perceive a need for mental
 Ageism 13

health care. Older adults have also been found increase of psychotic symptoms, housing instabil-
to view depression as a normal part of aging ity, and poor treatment compliance.
and avoid reporting these symptoms. Feelings The degree to which inadequate health care is
of responsibility for causing and resolving their the result of patient follow-up or physician fol-
mental health problems also pose intrinsic barri- low-up is unclear. However, researchers agree on
ers to care. Older adults tend to report feeling less the need to better tailor services to this popula-
knowledgeable and confident about when to seek tion to address this problem. Health care received
mental health services. Questions and concerns by older adults with mental illness is often of poor
about costs of Medicare insurance coverage for quality. Services may be inaccessible because of
mental health service coverage further interfere such factors as geographic location and avail-
with service access. ability of specialized providers. In addition, older
Extrinsic barriers to mental health care are adults with mental illness often receive inap-
encountered by older adults with mental illness propriate prescriptions and a lower intensity of
because of a lack of availability of qualified men- care, despite the need for more intensive services.
tal health providers who specialize in the needs of Moreover, this group experiences an increased
this group. Older adults with mental illness are rate of mortality following acute symptoms. One
also less likely to receive specialized mental health study found that after adjusting for poor health
care, or get screened or referred by a physician care, mental disorders failed to be associated
for mental health care. While older adults with with increased mortality among older adults with
mental illness are most likely to be insured than mental illness as compared to those without. This
other age groups, many still encounter insurance finding indicates that mortality of this population
and payment barriers to mental health services. can be reduced through improvements in the pro-
Transportation problems are reported to further vision of health care.
hinder attendance of mental health appointments The consensus statement of the practice of old
among this group. age psychiatry by the World Psychiatric Associa-
tion on stigma toward older adults with mental dis-
Problems With Health and Health Care orders describes the impact of stigma on quality of
Both older adults and people with mental illness health care. Double stigma in institutional settings
tend to have high rates of medical comorbidity, can reduce accessibility, diminish the status of pro-
leading to a double jeopardy to health. Schizo- fessionals providing care to this group, and pose
phrenia in particular accounts for a 20 percent problems to staff recruitment and retention. Dou-
shorter life span. Health problems among older ble stigma toward older adults with mental illness
adults with mental illnesses have been attributed to may lead to exclusion of this group from research,
unhealthy lifestyle choices, metabolic side effects of policy, and government funding. The consensus
antipsychotic medication, and inadequate health statement cautions against the consequences of
care. Older adults with schizophrenia in particular double stigma, which can lead to alarmist attitudes
are more likely to encounter cardiovascular risks, about the need, burden, and cost of care.
respiratory illnesses, and endocrine disorders. As
a result of metabolic side effects of medications, Future Clinical, Health Care, and
hyperlipidimia, weight gain, obesity, glucose intol- Research Needs
erance, and diabetes mellitus may occur. Both The consensus statement also includes a pro-
younger and older adults with mental illness are posal for stigma reduction strategies. This state-
more likely to have problems with smoking, alco- ment emphasizes counteracting stigma through
holism, poor diet, and lack of exercise. While sub- respect for the autonomy, dignity, safety, and care
stance and alcohol abuse decrease among people of older adults with mental illness. Public and
with mental illness in older age, older adults with professional education, awareness promotion,
mental illness and substance abuse problems tend and advocacy are encouraged to reduce stigma.
to have more psychiatric outpatient visits than Specific implementation of antistigma efforts can
individuals with either disorder alone. This dually occur through the creation of policies and laws
diagnosed elder population often experiences an related to stigma and discrimination to provide
14 Agoraphobia

additional protection in national and local justice in the Quality of Life of Older Adults With Severe
systems. Equitable research, welfare, and health Mental Illness.” International Journal of Geriatric
care budgets, as well as provision of resources Psychiatry, v.20 (2005).
such as pensions, facilities, activities, and trans- McCarthy, John F. and Frederic C. Blow. “Older
portation are needed. Patients With Serious Mental Illness: Sensitivity to
Older adults with mental illness rank improv- Distance Barriers for Outpatient.” Medical Care,
ing health as a high priority. Moreover, older v.42/11 (2004).
adults respond similarly and as effectively as Palinkas, Lawrence A., Viviana Criado, Dahlia
younger populations to standard practices of Fuentes, Sally Shepherd, Hans Milian, David
care. Physicians and mental health practitioners Folsom, and Dilip V. Jeste. “Unmet Needs for
can be better trained to meet the needs of this Services for Older Adults With Mental Illness:
population. Collaborative care models are espe- Comparison of Views of Different Stakeholder
cially effective at integrating physical and men- Groups.” American Journal of Geriatric
tal health through interdisciplinary care teams, Psychiatry, v.15/6 (2007).
leading to better clinical outcomes. Older adults Pepin, Renee, Daniel L. Segal, and Frederick L.
with mental illness can be provided with outreach Coolidge. “Intrinsic and Extrinsic Barriers to
and in-home services, as well as travel reimburse- Mental Health Care Among Community-Dwelling
ments to reduce geographic barriers to care. The Younger and Older Adults.” Aging and Mental
use of trained peers has also been recommended Health, v.13/5 (2009).
to help monitor and assist older adults with men- Segal, Daniel L., Frederick L. Coolidge, M. S. Mincic,
tal illness to increase access and social support, and A. O’Riley. “Beliefs About Mental Illness
while reducing risks and enhancing prevention. and Willingness to Seek Help: A Cross-Sectional
Skills training and health management interven- Study.” Aging & Mental Health, v.9/4 (2005).
tions have also demonstrated empirical support,
specifically with regard to social functioning and
independent living skills.
Researchers have indicated that older adults
with mental illness are often excluded from Agoraphobia
research trials, contributing to research bias and
a lack of generalizability. It is recommended that Agoraphobia is an anxiety disorder that is often
additional funding be allotted to research on associated with panic disorder and can be char-
older adults with mental illness to conduct fur- acterized by panic symptoms, anxiety regarding
ther clinical research on psychiatric rehabilitation circumstances where escape seems difficult, and
and antistigma interventions for this population. intense fear of places. Agoraphobia symptoms
Moreover, additional research is needed to exam- can develop with or without history of panic dis-
ine the strengths, coping, and protective factors of order. The presence of recurring panic attacks
older adults with mental illness in order to better and concern regarding future panic attacks are
understand resilience. features of agoraphobia with panic disorder. In
agoraphobia without history of panic disorder,
Lauren Mizock the individual’s fear is focused on debilitating
Boston University symptoms that mimic panic and can be embar-
Kathleen Harrison rassing (e.g., public incontinence). Approximately
Emmanuel College 95 percent of individuals with agoraphobia also
have an accompanying panic disorder diagnosis.
See Also: Age; Alzheimer’s Disease; Nursing Homes; Occasionally, differential diagnostic questions
Stereotypes; Stigma; Stigma: Patient’s View. can arise between agoraphobia and social pho-
bia. In social phobia, a fear of negative evaluation
Further Readings from others is present, whereas fear of situations
Depla, Marja F. I. A., Ron de Graaf, Jaap van associated with panic or difficulty escaping is
Weeghel, and Thea J. Heeren. “The Role of Stigma present with agoraphobia. Diagnostic criteria for
 Agoraphobia 15

agoraphobia take into account the complex rela- environmental situations in which they believe
tionship between biological, cultural, and psycho- panic attacks will be triggered. Excessive fear in
logical processes and how they affect experiences the absence of actual danger is the primary pathol-
of panic and fear. Elimination of other contribut- ogy of the disorder, and it can be compounded
ing factors, such as the effects of a substance or by the sufferer’s fear of being socially humili-
other underlying medical conditions, is necessary ated in public by showing distress. Often, when
for an accurate agoraphobia diagnosis. The Diag- individuals with agoraphobia are distanced from
nostic and Statistical Manual of Mental Disorders surroundings where they feel safe, their fear and
(DSM) describes agoraphobia and notes a variety anxiety increase. Traveling, places where there are
of factors such as individual traits, cultural con- crowds, or open spaces where it can be perceived
text, gender features, and other associated disor- that help is unavailable, and the sufferer’s feel-
ders that can influence the diagnosis. ings of helplessness are generally how anxiety and
Globally, the lifetime prevalence of agorapho- panic attacks are generated in those with panic–
bia is approximately 12 percent. Over half of related agoraphobia.
these individuals seek treatment at some point in Individuals with agoraphobia experience pow-
their lives, and these treatment seekers indicate erful responses that are often described as involv-
that agoraphobia affects them over long periods ing three systems: cognitive, psychophysiologi-
of time. Agoraphobia primarily develops during cal, and behavioral. The cognitive system evokes
adolescence and has become more prevalent in apprehension and feelings of fear. These feelings
recent decades. Many of the diagnostic criteria in can significantly impair functioning and create
the DSM have only appeared within the last 30 anxiety. Self-defeating thinking can also impair
years, suggesting that either the frequency of the functioning for a sufferer, unsettling them and
disorder has increased in recent generations or negatively affecting their self-esteem. A prolonged
that identification of the disorder has improved. state of arousal greatly affects the psychophysio-
Cultural socialization influences the level of logical system, activating the sympathetic nervous
functional impairment caused by agoraphobic system that can lead to increased heart rate and
symptomology. The degree to which symptoms blood pressure, muscle tension, and feeling faint.
related to agoraphobia are a hindrance to one’s There are several medical problems that can
life may be related to factors such as physical be mistaken for panic disorder that must be ruled
location. Cultures in which survival does not out to effectively treat agoraphobia. Agorapho-
require interaction with others on a regular basis bia often results in persistent, maladaptive, and
are associated with less functional impairment excessive behavioral responses; thus, agorapho-
than cultures that require more interpersonal bia typically has the greatest effect on the behav-
interaction. In Western cultures, agoraphobia ioral system. Sufferers tend to isolate themselves
can be debilitating because social and interper- and avoid certain situations. This avoidance gen-
sonal skills are the primary traits that allow the erally makes the disorder worse over time. Nau-
acquisition of resources. sea, sweating, and feelings of paralysis are other
physical symptoms that may be present with
Definitions and Characteristics agoraphobia.
As described by the DSM, agoraphobia is an anx-
iety-related disorder characterized by anxiety sur- Variations in Culture
rounding environments where the sufferer feels There is currently widespread use of the term ago-
helpless, trapped, and unable to escape. Some of raphobia. First termed “agoraphobic syndrome”
the criteria for a diagnosis of agoraphobia include by Carl F. O. Westphal in 1871, the disorder has
feeling detached or dependent on others, fear of also been described as anxiety hysteria, street fear,
being alone, disconnection from a surrounding locomotor anxiety, anxiety syndrome, phobic
environment, and several panic attack–related anxious state, phobic-anxiety-depersonalization
symptoms such as shortness of breath, chest pain, syndrome, and nonspecific insecurity fears. Cur-
numbness, and trembling. Individuals often go rently, the German term platzangst and French
to extremes to avoid uncontrollable social and terms peur des escapes and horreur du vide share
16 Agoraphobia

general meanings with the English term agora- a higher emotional sensitivity are at greater risk
phobia, and though their meanings may be simi- to develop agoraphobia, and children of parents
lar, they are not representative of all cultural with the same sensitivity are more likely to expe-
contexts and meanings. A fundamental problem rience agoraphobic symptoms.
in generalizability arises when comparing agora- From a biological perspective, people diag-
phobia among different cultures, while still taking nosed with agoraphobia often have difficulties
into account the differences in socially governed with spatial orientation because of deficits in the
behavior. Modern researchers theorize that spe- vestibular and visual systems. If these two systems
cific stimuli are typically linked with agoraphobia are weak, sensory signals can cause disorientation
symptomology. Across cultures, there are similar when cues are sparse (no stimuli) or overwhelm-
symptoms, experiences, and behaviors that are ing (abundance of stimuli). Some brain scan stud-
associated with agoraphobia. ies show that individuals with agoraphobia have
Women are nearly four times more likely to delayed processing speed with continually chang-
be diagnosed with agoraphobia than men. This ing audiovisual data, suggesting that they process
gender difference could be because of several bio- information too slowly to keep up with other
logical and behavioral factors, such as hormones, response systems. There is evidence that agora-
socialization, and other learned behaviors. It is phobia is associated with genetic factors, but
important to consider cultural perspectives on most understand it to be triggered by events, his-
female involvement in community life and sepa- tory, trauma, and irrational thinking. The genetic
rate that from agoraphobia. Women are also studies that provide this link suggest that there
more likely than men to seek professional help, are two loci in DNA that govern an individual’s
which may distort statistical reporting that agora- risk for developing agoraphobia.
phobia is a female-dominant disorder. Men with There are several treatments that are largely
agoraphobic symptomology who seek treatment effective in the treatment of agoraphobia. There is
are more likely than women who seek treatment an abundance of evidence supporting the efficacy
to be diagnosed with a comorbid substance use of cognitive behavioral therapy (CBT) in the treat-
disorder because men are more likely than women ment of agoraphobia. Pharmacological treatments
to use alcohol as a way to cope with their agora- start with nonaddictive drugs such as antidepres-
phobia symptoms. sants (selective serotonin reuptake inhibitors and
serotonin norepinephrine reuptake inhibitors) to
Etiology, Epidemiology, and Treatment modify neurotransmitter levels. If antidepressants
The cause of agoraphobia is unknown, but there are ineffective on their own, augmentation with
are several theories about the contributing factors. other drugs such as benzodiazepines (only tem-
One theory explains that agoraphobia is a learned porary use, to be eliminated after the initial regi-
behavior in which an individual may originally men), buspirone, pregabalin, or adrenergic block-
experience agoraphobic symptoms with a specific ades may also be considered. CBT, specifically
situation, and then associate further symptoms exposure therapy, relaxation/meditation, recogni-
with situations similar to the first. Other research tion and replacement of panic thoughts, and sup-
suggests that agoraphobia is associated with inse- port groups, in combination with antidepressant
cure or avoidant attachment, where individuals medications, have been empirically validated as
fear leaving spaces in which they feel secure, or effective treatments for agoraphobia.
have previously been separated from individu-
als to whom they were attached, such as parents Shannon Bierma
during childhood. Individuals with a history of Ryan Shorey
respiratory disease report higher rates of agora- Hope Brasfield
phobia. Difficulty breathing and feeling suffo- Gregory L. Stuart
cated may be contributing factors in associating University of Tennessee, Knoxville
fear with physiological symptoms. Researchers
have also theorized that temperament can factor See Also: Cognitive Behavioral Therapy; Panic
into the development of agoraphobia. Those with Disorder; Serotonin Reuptake Inhibitors.
 Alcoholism 17

Further Readings spirituous liquors in particular, the excessive con-

Hinton, D. E., and B. J. Good. Culture and Panic sumption of which they claimed would lead to
Disorders. Palo Alto, CA: Stanford University destructive behaviors including madness, despair,
Press, 2009. murder, and suicide. These visions were expanded
Linden, D. The Biology of Psychological Disorders. by other campaigners throughout the 19th cen-
New York: St. Martin’s Press, 2012. tury to include alcoholic beverages in general, but
Tsuang, M. T., M. Tohen, and P. B. Jones. Textbook there continued to be a level of confusion associ-
in Psychiatric Epidemiology. 3rd ed. Hoboken, NJ: ated with the level of responsibility on the part of
John Wiley & Sons, 2011. the inebriate or alcoholic. Removing responsibil-
ity from the individual, and assigning it to uncon-
trollable biological features induced by the drug
ethanol, was linked to increased medical defini-
tions of addiction.
Alcoholism The term alcoholism was not introduced until
the mid-19th century, although medical links to
Making cultural comparisons concerning alco- alcohol-related abuses and other mental health
holism is, contrary to popular belief, neither a considerations date back to the previous century.
straightforward nor a simple exercise. Linking Dr. Magnus Huss of Stockholm is accredited with
mental illness to alcohol abuse has an extremely introducing the term alcoholism in 1852, which
long history, although the term only dates back he said referred to a special chronic condition of
to the 19th century and has been vigorously con- “inebriates,” the preferred medical term used for
tested, almost since its inception. For many indi- alcohol-related abuses throughout the 19th cen-
viduals and their families around the world, alco- tury. Later medical users of Huss’s term alcohol-
hol has formed part of a sequence of traumatic ism recognized that it did not capture all possible
events, with sometimes lethal results. Specifically, cases of alcohol abuse but was specific to the most
the term alcoholism is used to capture the mental, severe form, and the one involving toxicity. Popu-
physical, and social problems that can occur with lar media began to use the term shortly after it
the problematic consumption of alcohol. It is gen- entered anglophone medical circles.
erally linked to uncontrollable, addictive alcohol The latter part of the 19th century and the
consumption. beginning of the 20th century witnessed a rever-
sion toward the concept of individual responsi-
Constructions of Alcohol-Related Disorders bility governing alcohol-related problems. Such
In the course of the 20th century, the term alco- punitive conceptions culminated, in a number
holism became a popular global means of describ- of countries, with the government policy of total
ing alcohol-related problems, while researchers prohibition (most famously in the United States
increasingly recognized the cultural variations from 1920 to 1933), inspired by the belief that
associated with alcoholic behaviors. Global con- such moves would completely eliminate alcohol-
siderations regarding mental, physical, and social related problems, along with its consumption.
problems linked to alcohol have been expanding The failure of Prohibition led to a recognition of
through the leadership of the World Health Orga- greater complexity associated with alcohol abuse
nization (WHO), which has been a significant and also witnessed a resurgence in interdisciplin-
stakeholder in the cultural comparisons of alco- ary academic study of alcohol-related issues and
holism for over half of a century. problems, culminating in the United States with
Medicalized constructions of alcohol-related the establishment of the Centre for Alcohol Stud-
problems date back centuries, although the end ies in the early 1930s, originally housed at Yale
of the 18th century marks a period of increasing University but now located at Rutgers. From its
linkages with mental illness in both the United earliest days, these researchers were interested
States and Great Britain. Physicians Benjamin in social and cross-cultural variations regarding
Rush and William Coakley Lettsom campaigned alcohol consumption and problems. Research-
aggressively on either side of the Atlantic against ers were increasingly inclined to question, if not
18 Alcoholism

reject, all monocausal explanations for alcohol’s Causes and Diagnoses

social and medical discontents. A significant challenge for those who study alco-
Also in the United States, the early 1930s hol (alcohologists) lies in the fact that alcohol
marked the beginning of the self-help group plays an important part of many societies and cul-
Alcoholics Anonymous (AA). AA spread quickly tures around the world. In many cultures, alco-
around the world, establishing its first overseas hol is used in a myriad of ways, such as a relax-
organization in Ireland, a nation long associated ant, a social icebreaker, for business exchanges,
with both excessive alcohol consumption and and other celebrations throughout the life cycle.
problems. Although AA does not subscribe to In short, heavy recorded rates of consumption
any one medical model of alcohol-related prob- within some ethnic and national communities do
lems, it does accept an underlying disease model. not necessarily present the same range and extent
At the same time, the term alcoholism became of medical and behavioral problems as in oth-
part of popular parlance in the early part of the ers. In addition, the problematics of drinking are
20th century with the global expansion of similar generally associated with larger societal and eco-
and related self-help groups. Organizations such nomic stressors.
Gamblers Anonymous recognized within the par- Problematic drinking is, on the other hand,
adigm of the recovering alcoholic a template for often defined in terms of a more asocial sense of
alternate forms of reformative self-actualization. need. Some people confess to consuming alcohol
The total abstinence self-help organizational to feel better in some way, while others use alco-
model of AA rejected specific medical classifica- hol because they feel they need it, and believe that
tions while still accepting an addictive “lack of they are unable to stop consuming once they have
control” paradigm. At the same time, drinking started. Alcohol has an acknowledged role as a
alone, that is, without the sanction and the con- coping mechanism, helping some individuals to
text of sociability, became another key indicator alter their emotions, and creating a sense of being
of medical concern. The extremely social level able to manage circumstances they might other-
of convivial Irish drinking marketed by global wise find difficult. There is increasing (if contra-
drinks companies was also traditionally linked to dictory) evidence regarding the links between the
violent behavior. Accordingly, recent internation- consumption of alcohol and the altering of mental
ally funded drink gene research has concentrated states in a number of cultures around the world.
on the Irish example. In many cultures, alcohol has been used to reduce
Popular psychological constructions increas- feelings of anxiety or depression, although in
ingly formed part of media discussions, and the large quantities, alcohol (as a natural depressant)
term alcoholism became increasingly central to may well have the opposite physiological effect.
global thinking. In the 1950s, E. M. Jellinek was Comorbidity between major depressive disorders
a major contributor to the alcoholism subcom- and alcoholism is well documented, with a dis-
mittee of the WHO’s Expert Committee on Men- tinction between depressive episodes that involve
tal Health. Jellinek’s complex, cross-culturally alcohol (substance induced) and those that do not
informed visions of alcohol and mental health (independent). In addition, there may be codepen-
resulted in over 60 definitions that he outlined dence with other drugs.
in his seminal treatise, The Disease Concept of The diagnostics of alcohol-use disorders show
Alcoholism, in 1960. The cross-cultural complex- gendered patterns. Women diagnosed as hav-
ity of these definitions of alcoholism was directly ing a problem with alcohol are more likely to be
responsible for rejection of the term by medical recorded as having cognate symptoms including
officials internationally by the end of the 1970s depression, bulimia, anxiety, borderline personal-
and the beginning of the 1980s, in favor of other ity disorder, and post-traumatic stress disorder.
terms, including alcohol abuse, alcohol depen- Men diagnosed with similar problems tend to
dency, and alcohol dependency syndrome. How- be recorded as having cognate symptoms includ-
ever, the term alcoholism is still used by the Amer- ing antisocial or narcissistic personality disorder,
ican Medical Association to refer to a particularly as being bipolar or schizophrenic, or suffering
chronic primary disease. from attention deficit/hyperactivity disorder. The
 Alcoholism 19

An alcoholic sprawls on a sidewalk in Spain, August 2012. For many people around the world, alcohol is part of a sequence of
traumatic events. Making cultural comparisons concerning alcoholism is complex. A 1969 study argued that drunken comportment is
culturally rather than pharmacologically determined. In addition, although the link between mental illness and alcohol abuse is long-
standing, the idea of alcoholism as a disease has been debated for over a century.

extent to which these diagnoses are informed (or being labeled as “unnatural.” For mothers and
misinformed) by the gender-stereotyped assump- pregnant women, the stigma of “unnaturalness”
tions and expectations of medical practitioners is is heightened, with the result that it can be dif-
difficult to ascertain. There is, however, a correla- ficult for such women to acknowledge a problem
tion between women who have suffered any kind and then seek a course of treatment. Meanwhile,
of abuse or assault and women who subsequently the traditional social contexts for male drinking
develop alcohol problems. render problematic male drinkers socially visible,
One cross-cultural universal in nations where creating a pool of friends and family available to
alcohol is openly consumed is that men consis- prompt medical or support-group interventions.
tently have higher alcohol consumption rates Similarly, research has demonstrated in a num-
than women, as is evidenced by the GENACIS ber of cultures that increased consumption may
project, an international study of gender, alco- be related to life cycle features, with young males
hol, and culture. This is related to cross-cultural drinking in the largest quantities, while women of
biological and maternal roles. This gendered childbearing age often consuming less. There has
feature also connects with the associated cross- been increasing cross-cultural research on alcohol
cultural figure that males are far more frequently consumption by pregnant women, which can lead
diagnosed with alcoholic-related diseases. How- to fetal alcohol syndrome, an incurable and dam-
ever, there is a tendency for women to be diag- aging condition. Research on familial drinking
nosed with comparable or cognate diseases such cultures has found that maternal drinking, which
as depression. is often more hidden, offers a far more disrup-
There is considerable evidence that alcohol tive and influential image of the intergenerational
abuse, while more prevalent among men, is more problem consumption of alcohol. Ever since Wil-
stigmatized among women—a logical develop- liam Hogarth’s 1751 depiction of the gin-soaked
ment because if heavy drinking is less “natural” abusive mother, there continues to be a particular
for women, then women who drink heavily risk stigma associated with female alcoholism. Female
20 Alcoholism

alcoholism from Hogarth onward has been asso- to accurately estimate illegal or hidden consump-
ciated with solitary, asocial consumption. The tion of alternative alcoholic products, a problem
“bottle in the cupboard” is deemed a greater that has always been a feature of national con-
threat to the socially venerated role of mother sumption statistics, making direct comparisons of
than the public consumption of alcohol is to roles consumption figures a problem. Such figures rely
and responsibilities associated with men. either on retail sales or self-reporting, either of
Not only do national levels of consumption which are problematic as indicators.
vary cross-culturally, specific behaviors while Behavioral concerns associated with both alco-
consuming alcohol have also been shown to hol and alcoholism are dominated by discussions
vary across cultures. In their 1969 classic study, of violence, as well as violence directed toward
C. MacAndrew and R. B. Edgerton argued that the self, culminating with suicide. Of particular
drunken comportment is culturally determined, concern has been intimate partner violence (IPV),
rather than pharmacologically decided. They within which the more familiar term spousal
argued that in all cultures, there are culturally abuse is a dominant subset. When controlling
determined behaviors for those who are sober, for other variables, heavy alcohol consumption
which are different from the prescribed cultural appears as an accurate predictor for IPV (both
behaviors for being drunk. They also discuss cul- perpetrated and received) among black males and
tural instances where the fact that bad behavior females, and among white females, but not among
may be excused while drunk leads to the feigning white and Hispanic males. Among white females,
of drunkenness in order to avail of such cultural heavy consumption serves as an IPV predictor of
excuses. Experimental psychology studies have violence perpetrated but not received. Diagnosed
found similar placebo effects of expected con- schizophrenics are documented as three times as
sumption, rather than actual alcohol intake. likely to be heavy drinkers, but causal linkages
At the same time, historians have argued that are harder to establish.
this link between alcohol and disinhibition is
linked to late-18th- and 19th-century anti-alcohol Treatment and Considerations
social movements. However, more recent research for the Future
has shown excessive alcohol consumption to be Members of various ethnic and cultural groups
proportionally linked to increased interpersonal are less likely to seek and complete alcohol treat-
violence, as well as to increased suicide rates, ment compared to other groups. Those who do,
which, as the seminal sociologist/alcohologist often enter treatment for alcohol abuse as a result
Robin Room has argued, is not in conflict with of seeking treatment for some other problem,
MacAndrew and Edgerton because the cultural such as depression or another potential alcohol-
construction is no less lethal in its consequences. related or alcohol-exacerbated condition. Socio-
International cultural comparisons of recorded logical and anthropological perspectives on alco-
alcoholism are therefore complicated by a num- hol-related interventions prove invaluable, given
ber of sociodemographic factors, including gen- that no single biomedical template for behavioral
der, income, education, age, religion, and famil- change appears to cross-culturally apply. Inter-
ial drinking culture. Furthermore, cross-cultural ventions prove unsuccessful when they fail to
research has indicated that alcohol consumption acknowledge the larger social context of a sub-
is income elastic. In other words, individuals or ject’s lifestyle and cultural matrix. “Best practice”
societies with higher disposable income are more would therefore dictate that research experiments
likely to consume larger amounts of alcohol. How- consider the effectiveness of different forms of
ever, it is not demonstrated that those with the intervention applied to a variety of social and eth-
most disposable income within any defined soci- nic contexts.
ety are most likely to have a problematic relation- This social and cultural sensitivity becomes all
ship with alcohol. Furthermore, income-related the more necessary when models of intervention
increased consumption does not necessarily trans- are proposed for social or ethnic communities
late into problem drinking or alcoholism. These that may have traditionally encountered pervasive
data are, however, complicated by the inability cultural and/or institutional forms of oppression
 Alcoholism 21

or discrimination. In such cases, the relationship with severe mental health problems are more
between an individual and a representative of any likely to abuse alcohol through self-medication.
form of official authority, medical or otherwise, Given the definitional difficulties with alcoholism
may ignite tense conflicts regarding real or per- as a concept alongside a unanimous recognition
ceived inequities of power and agency. Alcohol of alcohol-related medical, behavioral, and soci-
interventions need to engage issues beyond the etal problems, such an initiative should help more
recuperative self-actualization of particular indi- specifically and constructively target and custom-
viduals and assess the broader social and eco- ize health policies.
nomic determinants that govern any individual’s A policy-oriented aim of any sociologically
life chances. informed perspective on alcoholism or alco-
Governments have long been looking for ways hol use disorder should be the removal of indi-
to easily solve the alcohol problem. Despite the viduated personal stigma from such conditions.
problems associated with total prohibition, By engaging a larger community, professional
governments continue to seek control over the interventions may lose the aura of hostile judg-
amount that individuals consume. This social con- ment that inhibits many people from seeking and
trol is accomplished in a variety of ways, includ- obtaining medical help. The WHO has recently
ing attempts to reduce consumption by increas- endorsed the principle that drinking descriptors
ing costs via taxation. In addition, there are many are limited in their adaptability and applicability
countries that restrict the times and places where by significant cultural and ethnic variations. Such
alcohol may be purchased. Many countries also is the variety of drinking practices and attitudinal
control the drinking age in attempts to deal with and behavioral responses associated with alcohol
youth alcohol consumption problems. transnationally that a global definition of alco-
French statistician Sully Lederman, in the late holism may well be impossible. A cross-cultural
1950s and 1960s, argued that there was a simple, model for best practice in alcohol abuse diagnosis
comparable cross-cultural relationship between and treatment remains ever more urgently sought
rates of national cirrhosis of the liver and rates and tantalizingly elusive.
of overall alcohol consumption within any given
population. However, this hypothesis has since Tanya M. Cassidy
been largely discredited, although there continues University of Windsor
to be a school of researchers in favor of the con-
sumption distribution model or theory (CDT)— See Also: Depression; Drug Abuse; Medicalization,
the policy belief that if national consumption rates History of; Peer Identification; Stereotypes; Stigma.
are lowered, alcohol-related problems will also
decrease. CDT-based policies continue to domi- Further Readings
nate a number of countries around the world and Obot, Isidore and Robin Room. Alcohol, Gender and
underlie many global initiatives. Drinking Problems: Perspectives From Low and
The WHO recently launched an initiative to Middle Income Countries. Geneva: World Health
assess and monitor cultural comparisons of alco- Organization, 2005.
hol and health issues. According to the WHO, Room, Robin. “Intoxication and Bad Behaviour:
global consumption of alcohol and commensu- Understanding Cultural Differences in the Link.”
rate problems have been increasing around the Social Science & Medicine, v.53 (2001).
world, and it estimates that the economic costs Schomerus, G., M. Lucht, A. Holzinger, H.
of alcohol abuse may vary from 1 to 6 percent of Matschinger, M. G. Carta, and M. C. Angermeyer.
a country’s gross domestic product. As a result, “The Stigma of Alcohol Dependence Compared
growing numbers of countries are instituting With Other Mental Disorders: A Review of
national alcohol policies, especially in light of the Population Studies.” Alcohol and Alcoholism,
increasing amount of research that has argued that v.46/2 (2011).
high consumption levels are linked to increased Tracey, Sarah W. Alcoholism in America: From
alcohol-related problems, including mental health Reconstruction to Prohibition. Baltimore, MD:
issues, although there is evidence that individuals Johns Hopkins University Press, 2007.
22 Algeria

Algeria among Algerians. Psychiatric services are usually

offered in emergency situations; however, during
Mental illness and its treatment in Algeria include Ramadan, this is least likely to occur. Mental ill-
aspects of traditional, religious, and Western influ- ness is called jinnoon (from the Arabic word for
ences. Algeria is the second-largest country on the demon, jinn); a mentally ill person may be said
continent of Africa. However, mental health jour- to have been possessed. Some behaviors may
nals generated by Algeria only accounted for 1.2 be considered abnormal among Algerians, such
percent of all mental health journals produced by as tankir (denial), the word given to those who
Arab countries between 1987 and 2002. Although voluntarily isolate themselves or are indifferent
the official language is Arabic (Berber and French to their social environments. However, waswas
are also spoken), M. M. Afifi found in 2005 that (obsessive-compulsive behavior) is not considered
for every French citation, an English citation also a mental health issue.
existed among these publications. Algeria strad-
dles the fence between its identity as both an Arab Diagnoses, Epidemiology, and Treatments
and African country. Because the Diagnostic and Statistical Manual
Algeria’s history has been marked by a series of of Mental Disorders (DSM) is based on Anglo
invasions and struggles to enhance the well-being notions of psychiatry, a manual was developed
of the population. Islam was imposed by Arabs to address French-related mental disorders. For
in the 7th century, the Ottoman Empire ruled in instance, bouffees delirantes (short-lived psy-
the 16th century, and France took over after the chosis) is not listed in the DSM, but is listed
Berlin Conference to partition Africa in the 19th in the Manual for North African Practitioners.
century. Algerians fought for their independence Its symptoms include hallucinations, delusions,
from France between 1954 and 1962. During and mood changes, usually because of marriage
the 1990s, the country was engaged in a conflict (stressors affiliated with its arrangement), incest,
between the FIS (Islamic Salvation Front) and the sudden death, or migration.
army-backed government, which saw the death of Although rates of depression are low, some
up to 200,000 people, 10,000 missing, and almost groups are more susceptible to it, including older
half a million refugees relocated to other coun- freedom fighters from the FLN (mujahideen),
tries. An earthquake in 2003 caused the death of young adults, and middle-aged women. The inci-
more than 2,200 people, and injuries among over dence of suicide, as a result, is low also; however,
11,400 people. Additionally, two-thirds of Alge- rates were increasing among teenage girls caught
rians are under the age of 30. These macro and between paternalistic worldviews and secularism,
micro forces have impacted their mental health. especially during the 1980s.
Frantz Fanon, a psychiatrist who recognized Joop T. V. M. de Jong and colleagues con-
the impact of colonialism on the psychological ducted one of the first analyses of mental health
well-being of the colonized, assisted the National in Algeria during and after the conflict in the
Liberation Front (FLN) in the struggle for inde- 1990s. They found that post-traumatic stress dis-
pendence after implementing changes at the men- order (PTSD) was dependent on gender (women
tal hospital in Blida-Joinville as clinical director. had higher rates than men) and torture (in spite of
Hussein Bulhan discusses how Fanon released rates lower than the other countries in the survey,
shackles on patients who had been chained to including Cambodia, Ethiopia, and Gaza). Algeri-
their beds, inaugurated a journal to which both ans also had the highest rate of PTSD.
patients and staff could contribute, eliminated Three kinds of indigenous healers are used to
special privileges for European patients, imple- treat challenges to mental health, particularly as
mented innovative therapeutic means, and wel- a shortage of college-trained professionals exists.
comed traditional healers in his psychiatric work. A taleb (religious healer) uses the Qur’an to treat
The hospital was renamed Frantz Fanon Hospital mental disorder. The other two are rooted in
in his honor. healing systems that existed before the influence
Ihsan Al-Issa has offered one of the more com- of exogenous elements. A marabout is seen as a
prehensive pictures of psychological behavior saint, and the descendent can exorcise demons;
 Alzheimer’s Disease 23

the clairvoyant tackles issues related to sexual/ Alzheimer’s Disease

emotional problems.
Religiosity is a community resource that offers Alzheimer’s disease is the most common type of
protective properties against mental disorders. dementia and represents a progressive, degenera-
For instance, Ahmed Abdel-Khalek and Farida tive disorder that results in loss of memory, exec-
Naceur surveyed Algerian college students and utive thought, and language skills, accompanied
found that religiosity was related to mental by behavioral changes. For a clinical diagnosis,
health. For women, the higher their religiosity, losses are not congenital, are present for at least
the lower their scores on pessimism and anxiety. six months, and most importantly, they interfere
Religious altruism was related to subjective well- with the normal activities of daily living. To fully
being among a general population of Algerians. appreciate the impact of cultural sociology on
The status of one’s physical health did not impact Alzheimer’s disease, it is important to understand
the relationship between the two in this study by the history of disease discovery. Inconsistent
Habib Tiliouine and his colleagues. definitions for the terms racial, ethnic, and cul-
Although the Algerian Psychiatric Association tural between research studies around the world
exists, it had fewer than 300 members before the challenge the true cross-cultural examination of
1990s. There are 11 mental hospitals, but only Alzheimer’s disease. Adding to the dilemma is
four before the 1990s offered medical training in the issue of varied cultural interpretations of key
psychiatry. concepts in Alzheimer’s disease such as “cognitive
impairment” or “daily function,” and the sensi-
Marilyn D. Lovett tivity of these features to cultural and educational
Livingstone College backgrounds.
In 1801, French physician Philippe Pinel
See Also: Diagnosis; Diagnosis in Cross-National described demence in a young female to describe
Context; France; International Comparisons; Spiritual incoherence of mental faculties. A century later,
Healing. in 1906, psychiatrist and neuropathologist Alois
Alzheimer performed a postmortem brain biopsy
Further Readings on a 51-year-old female who had suffered for
Abdel-Khalek, A. and F. Naceur. “Religiosity and Its five years from cognitive and language deficits,
Association With Positive and Negative Emotions auditory hallucinations, delusions, paranoia, and
Among College Students From Algeria.” Mental aggressive behavior. His biopsy description of
Health, Religion, and Culture, v.10/2 (2007). dense deposits surrounding the nerve cells (neuritic
Afifi, M. “Mental Health Publications From the Arab plaques), and twisted bands of fibers within the
World Cited in PubMed, 1987–2002.” Eastern nerve cells (neurofibrillary tangles), along with the
Mediterranean Health Journal, v.11/3 (2005). clinical symptoms of pre-senile dementia, would
Al-Issa, I. “Culture and Mental Illness in Algeria.” later be coined Alzheimer’s disease by psychiatrist
International Journal of Social Psychiatry, v.36/3 colleague and codiscoverer Emil Kraepelin.
(1990). Dementia associated with aging was rare
Bulhan, H. “Frantz Fanon: The Revolutionary before the 20th century because of the shorter life
Psychiatrist.” Race and Class, v.21/3 (1980). span. The early 1900s recognized the diagnosis of
deJong, J., I. Komproe, M. Van Ommeren, M. El dementia praecox, suggesting that dementia was
Masri, M. Araya, N. Khaled, W. van de Put, and precocious in the young but otherwise a normal
D. Somasundaram. “Lifetime Events and Post- part of aging. It was not until the early 1970s that
Traumatic Stress Disorder in Four Postconflict this view was dispelled, when neurologist Robert
Settings.” Journal of the American Medical Katzmann suggested a pathological link between
Association, v.286/5 (2001). senile dementia (occurring after age 65) and
Tiliouine, H., R. Cummins, and M. Davern. “Islamic Alzheimer’s disease (prevalent in the young). He
Religiosity, Subjective Well-Being, and Health.” inferred that Alzheimer’s disease, rarely reported
Mental Health, Religion, and Culture, v.12/1 on death certificates in 1976, was actually the
(2009). fourth- or fifth-leading cause of death. This and
24 Alzheimer’s Disease

the removal of diseases like schizophrenia from although dementia and cognitive impairment
the category of organic brain syndromes helped rates are about the same.
clarify Alzheimer’s disease and a multitude of Cultural perceptions create significant barri-
other dementias as a unique disease process. ers to the diagnosis of Alzheimer’s disease and
Although no cure currently exists for the most other dementias. Despite advancement of the
common causes of dementia (including Alzheim- science, a persistent global misconception exists
er’s), research efforts over several decades have that Alzheimer’s disease is a normal part of aging.
improved diagnostic capabilities. The 1970s Several regions, including southeast Asia and
through the 1980s gave rise to new nuclear imag- the Indian subcontinent, identify memory loss,
ing tests, including SPECT and PET scans of the but exclude other symptoms key to the clinical
brain, enabling the differentiation of the more diagnosis of Alzheimer’s disease like wandering,
common Alzheimer’s and vascular dementia hallucinations, or delusions. In many parts of
and classifications of new dementias. The 1990s the world, individuals with Alzheimer’s disease
marked discovery of genetic markers unique to are stigmatized, partly because of lost capabil-
familial variants of Alzheimer’s disease, including ity for independent living. Latin cultures associ-
presenilins (I and II) and beta amyloid precursor ate patients with el mal ojo, or the evil eye. In
protein. Several studies over the last five decades Chinese culture, afflicted individuals are thought
have identified comorbidities linked to increased of as “losing sense of sanity.” Disease associa-
risk of Alzheimer’s disease and other dementias tions, however inaccurate, with stress, lifestyle
including hypertension, hyperlipidemia, stroke, choices like alcohol consumption or tobacco use,
diabetes, and coronary artery disease. Some stud- and mental illness have led to negative labels and
ies have identified more unique associations, such social isolation.
as anemia in southeast Asia, which may be linked Several studies have identified the concept of
to incidence of Alzheimer’s disease variants. “cognitive reserve,” impacted by level of educa-
tion or prior occupation, as protective and a mask
Epidemiology and Diagnosis for early diagnosis of dementia and Alzheimer’s
A 2009 study by Alzheimer’s Disease Interna- disease. At the patient level, a high cognitive
tional found that global prevalence of dementia reserve may lead to a later diagnosis, but possi-
will double every 20 years from 35.6 million in bly contribute to better overall outcomes. At the
2010 to 65.7 million by 2030. Sharpest increases population level, higher education of a society
are predicted in low- and middle-income coun- contributes to a better understanding of demen-
tries. Rates of increase are not uniform, with tia and related syndromes, allowing for early and
numbers in developed countries projected to effective intervention. In the advanced stages of
increase by 100 percent, while numbers in China, dementia and Alzheimer’s, comorbidities like
India, and surrounding southeast Asian/west- post-traumatic stress disorder, depression, and
ern Pacific regions expected to increase by 300 schizophrenia play an important role in symptom
percent. Several studies from the United States control and disease management.
have found higher rates of cognitive impairment, In English-speaking nations, ethnic differences
dementia, and Alzheimer’s disease among ethnic in cognitive testing prove an important barrier to
minorities (predominantly African Americans diagnosis. Current accepted research criteria for
and Hispanics) than among whites. Studies have a possible Alzheimer’s disease diagnosis require
also reported a higher mortality rate associated neuropsychological tests demonstrating impair-
with dementia among blacks, although there is a ments of performance in memory and two other
lack of consistent data. With a large immigrant cognitive domains. However, few cognitive ability
population, some studies in the United States measures have been validated for use among eth-
suggest that environmental or cultural exposures nic minorities. Poor literacy and education among
are associated with increased risk of developing elders is also an important detractor from accu-
Alzheimer’s disease, as seen in Japanese Ameri- rate cognitive testing because several tests utilize
cans in Hawai‘i. Native Americans seem to have basic arithmetic, reading, and writing compre-
a lower rate of Alzheimer’s disease than whites, hension to quantify impairment.
 Alzheimer’s Disease 25

Care a supportive network around the adult afflicted

A large number of studies relate racial and eth- with Alzheimer’s disease. In Latino and Chinese
nic disparities in health care to socioeconomic communities in the United States, home care
factors including education, income, and wealth. services pose a dilemma with language barriers.
These factors impact use of the health care system Arabic and Asian communities express resistance
and health expenditures. While several countries to gender issues, whereby an older female may
around the world have a national health care sys- not accept home care from a male health service
tem, many are reliant on individual medical insur- worker, or vice versa. Throughout the world,
ance or private pay. In the United States, available religious and community organizations fill in the
data conservatively estimate that one in four His- gaps left by health care systems and provide a
panics and one in eight African Americans lack complex network of support for caregivers and
health insurance, pending the implementation of the Alzheimer’s disease patient.
the Affordable Care Act.
In India and Latin America, there is a heavy Caregivers
use of private medical services because of the gen- One of the key criteria for diagnosis of Alzheim-
eral perception that cheaper government medical er’s disease is loss of ability to live independently.
services are ineffective in the care of Alzheimer’s The role of caregivers becomes imperative in this
disease. In developing countries, long travel times setting. An important contributor to caregiver
and scarcity of health care access in rural areas strain is the behavioral and psychological symp-
prohibits regular use of clinic-based primary care toms of dementia associated with Alzheimer’s
services, which are often oriented toward treat- disease. Socially and culturally based understand-
able acute care services. ings of dementia impact all aspects of caregiving,
Here, chronic diseases like Alzheimer’s are including recognition of symptoms, utilization of
relatively undertreated and underdiagnosed. supportive programs, and compliance with treat-
Existing drug therapies for Alzheimer’s disease ment regimens. Worldwide, caregivers most com-
are not curative and come at a cost prohibitive monly comprise family members of older adults
to widespread use in poorer demographics. Also, who have lost the capacity for independent living.
medications used to treat the behavioral and psy- However, caregiving in the developing world is
chological symptoms of dementia associated with associated with substantial economic disadvan-
Alzheimer’s disease are expensive, a significant tage, with few older persons covered by govern-
source of caregiver strain. ment/occupational pensions or retirement plans.
Severe cognitive impairment with Alzheimer’s Cultural observations tend to overestimate the
disease is a leading cause of institutionalization caring role of family, and potentially fail to rec-
among older people. In Asian, Arabic, and Greek ognize the vulnerable position in society of older
cultures, there is a lower likelihood of institu- adults with mental illness.
tional care as elders are traditionally cared for In developing countries, globalization and eco-
at home. However, there is a growing realization nomic development have given rise to social and
that families and children already have responsi- economic change, leading to changing attitudes
bilities and are limited in their ability to care for toward older adults. Increases in the number of
the elderly. Several studies from the United States educated and working women have given rise to
have found that African Americans and Latinos less caregiver availability at home. China’s one-
are less likely to be placed in nursing homes, child family law and declining fertility have left
although it is unclear whether this is because of increasing numbers of older adults lacking ade-
lower socioeconomic strata or issues related to quate family support.
cultural preferences and bias. Even bereavement related to the Alzheimer’s
Despite trends toward nuclear family structure patient varies by ethnicity. A study from the Uni-
in developed nations like the United States and versity of Pittsburgh found whites and Hispanics
the United Kingdom, oftentimes local children more likely than African American caregivers to
provide support to their infirm parents. Here, report emotional relief when a patient they cared
home care services play a large role in providing for died.
26 American Psychiatric Association

Alzheimer’s disease is among the most costly American Psychiatric

diseases for society in Europe and the United
States because of direct medical costs like nursing Association
home care, nonmedical costs like in-home day-
care, and indirect costs like loss of productivity The American Psychiatric Association (APA),
of patient and caregiver. United States estimates founded in 1844, is today the world’s largest psy-
are close to $100 billion per year. Caring for the chiatric organization. It is a medically focused
adult with Alzheimer’s disease or dementia at organization representing more than 36,000 psy-
home represents a considerable financial burden, chiatric physicians from the United States and
with estimates around $18,000 annually. Care- around the world. Its members include medical
giving in the developing world is associated with doctors and physicians who work together with
significant economic burden that is more difficult the goal to ensure the best care and the most effec-
to quantify because of underreporting of actual tive treatment for patients with mental disorders,
informal care costs and loss of productivity. including intellectual disabilities and substance
Buddhist and Hindu cultures tend to consider use disorders.
illness a consequence of some negative actions A psychiatrist is a medical doctor who special-
done by a person or family. Conceptually, both izes in the diagnosis, treatment, and prevention
faiths believe that good deeds bring positive of mental illnesses and is qualified to diagnose
rewards and that bad deeds bring negative con- and assess both the mental and physical aspects
sequences. Catholics, Jehovah’s Witnesses, and of psychological disturbances. A psychiatrist has
Pentecostals find comfort in religion, which does completed medical school and has earned a doc-
not impact decisions related to illness. Priests tor of medicine (M.D.) or a doctor of osteopathic
in these faiths provide a supportive network. medicine (D.O.) degree, as well as completed
Islamic culture believes that dementia, like all ill- an additional four years of residency training in
nesses, is God’s will and must be accepted. The psychiatry. Many psychiatrists are in training far
association of Alzheimer’s disease with mental beyond four years, especially in such specialty
illness in many religions is a source of stigma and areas as addiction, geriatrics, child and adolescent
concern in the appropriate care of these vulner- psychiatry and/or forensic psychiatry. Because
able elderly. they are physicians, psychiatrists can order or
carry out a full range of medical assessments in
Bavna Bagyalakshmi Vyas addition to psychological tests. Using these assess-
Independent Scholar ments used in combination with clinical interviews
and discussions with patients can help provide a
See Also: Age; Dementia; Dementia Praecox; clear analysis of a patient’s physical and mental
Kraepelin, Emil; Neo-Kraepelinian Psychiatry; functioning. Psychiatrists engage in a variety of
Stigma; Stigma: Patient’s View. actions to assist patients in treatment, including
psychotherapy and psychopharmacological meth-
Further Readings ods. Psychiatrists work in multiple settings in both
Adler, R. N. and H. K. Kamel. Doorway Thoughts: private and public facilities such as hospitals, com-
Cross Cultural Health Care for Older Adults. munity mental health centers, college campuses,
Boston: Jones and Bartlett, 2004. schools, universities, correctional facilities, and
Alzheimer’s Australia Vic. Perceptions of Dementia even in corporate and business settings.
in Ethnic Communities. Hawthorne, Australia: The APA provides a recognized platform for
Alzheimer’s Australia Vic/Cald Resources, 2008. the promotion of topics of interest to its profes-
Prince, Martin and Jim Jackson, eds. “World sionals. It also discharges ongoing peer-review
Alzheimer Report 2009 Executive Summary.” responsibilities associated with member activities,
London: Alzheimer’s Disease International, 2009. including research and publications. It has 74 dis-
World Health Organization (WHO). Neurological trict branches and/or state associations, publishes
Disorders: Public Health Challenges. Geneva: five professional journals, and supports the APA.
WHO, 2006. The main goals of the APA are to make available
 American Psychological Association 27

the highest quality of care and treatment for those than two dozen labs. The association, which was
with mental disorders, including but not limited established for interested men to come together
to intellectual disabilities and substance-abuse and discuss matters of psychology, included indi-
disorders affecting the patient and his/her family. viduals of various academic backgrounds and
The APA also promotes psychiatric education and orientations, such as psychiatry and philosophy.
research and advances and represents the profes- Originally, the association consisted of 31 male
sion of psychiatry as a whole. The association also members, with a group of officers and a presi-
serves the professional needs of all of its member- dent. Under the leadership of its first president,
ship of medical doctors. G. Stanley Hall, the membership was diverse reli-
The APA publishes various journals and pam- giously and in terms of age.
phlets as well as the Diagnostic and Statistical A constitution for the association was estab-
Manual of Mental Disorders (DSM). The DSM, lished in 1893, which included policies for mem-
which released its fifth edition in spring 2013, bership, association goals, and guidelines for
identifies psychiatric conditions and is used electing officials. In 1893, two women (both
worldwide as a key guide for diagnosing disor- published authors in psychological journals)
ders. The APA has its headquarters in Arlington were nominated for and granted membership, a
County, Virginia. It holds an annual meeting as notable decision for the time period. According to
well as numerous conferences throughout the the APA’s 1893 constitution, members had to be
year in various U.S. states. nominated and elected; however, no specific qual-
ifications were needed. Men only needed to have
Alyssa Gilston an interest in the field and pay dues. Eventually,
University of the Rockies a degree and published research in the field were
required for membership.
See Also: American Psychological Association; The APA required status as a psychologist
DSM-5; Psychiatry and Neuroscience. beginning in 1906. Psychiatrists and philoso-
phers, no longer eligible for membership in the
Further Readings APA, had established their own organizations by
American Psychiatric Association (APA). Practice this time. In the early 1900s, philosophers split
Guidelines for the Treatment of Psychiatric from the APA to form their own associations (the
Disorders Compendium 2002. Washington, DC: Western Philosophical Association and American
APA, 2002. Philosophical Association) as did psychiatrists
Hutchinson, G. “American Psychiatric Association who in 1844 formed the precursor (Association
Practice Guidelines.” International Review of of Medical Superintendents of American Institu-
Psychiatry, v.11/1 (1999). tions for the Insane) to the American Psychiatric
Munoz, R. A. “American Psychiatric Association Association.
Practice Guidelines for the Treatment of Psychiatric The primary goal of the association was to
Disorders: Compendium 2000.” American Journal develop the field of psychology and advance its
of Psychiatry, v.159/6 (2002). status as an accepted field of science. Member-
ship in the association grew each year from the
original 31 members to a membership of over 500
in 1930. The period after World War II marked a
dramatic increase in membership, as key psycho-
American Psychological logical studies on conformity (such as Solomon
Asch’s research in the 1950s and Stanley Mil-
Association gram’s studies in the 1960s) brought psychologi-
cal research to international attention.
The American Psychological Association (APA) As membership in the APA grew, the association
was founded in July 1892. At that time, the field reorganized and formed divisions to acknowledge
of psychology was nascent in the United States; the specific interests of its members. Advance-
there were only two published textbooks and less ments in research and the desire for a forum in
28 American Psychological Association

Organizations with similar names include the

American Psychological Foundation, which is
affiliated with the APA but also independently
funds psychological research. The Association
for Psychological Science is unaffiliated with the
APA. That organization was formerly called the
American Psychological Society but changed its
name in 2006 to reflect the association’s mission
of psychological research on a global scale.

Contributions to the Field of Mental Health

Member benefits include access to members-only
resources and the opportunity to participate in the
annual convention. APA members have the abil-
ity to work with the organization and contribute
to raising awareness of important psychological
issues, with specific attention to mental health.
As the association developed, its members
brought attention to the need for improved men-
tal health care in the United States. Although the
APA did not create the Diagnostic and Statistical
Manual of Mental Disorders (DSM) that is used
to diagnose patients with mental illness, the orga-
nization has brought attention to mental disorders
as an experience deserving medical attention and
not just a form of deviant behavior. The APA is
concerned with the mental health of children and
Granville Stanley Hall (1844–1924), the first president of the adults as well as the larger family structure. Aware-
American Psychological Association, which was founded in July ness and education efforts within the APA have
1892 with 31 male members. The membership was diverse in shaped public policy related to mental health.
terms of religious affiliation and age. The APA benefits both members and the
broader mental health community through its
commitment to research on topics of psychologi-
cal importance. The journals sponsored by the
which to share its results led the association to association have made research and information
develop a number of psychological journals, each easily accessible to psychologists everywhere,
representing a different subject within the field. increasing efficiency of information exchange
The APA currently sponsors 75 journals, includ- within the field. The APA also plays a role in regu-
ing its core journals and various topics of psy- lating doctoral programs and internships in psy-
chology, including basic/experimental, clinical, chology; programs can apply for status as APA
developmental, educational, health, industrial/ accredited. Although not all licensed psycholo-
organizational, and social psychology. gists are required to be members of the American
Currently, the APA is the largest organization Psychological Association, all must know and fol-
of psychologists, with 150,000 members as of low the ethical code—the Ethical Principles and
2012; its purpose is to provide resources to its Code of Conduct of the APA—that is included in
members, to support psychology as a science, and the psychology licensing exam, the Examination
to contribute to the application of psychology for Professional Practice of Psychology (EPPP).
within the broader community. This regulatory role of the APA serves to support
The organization has its headquarters in Wash- the position of psychology as a science and the
ington, D.C., and sponsors an annual convention. practice of psychologists.
 Amphetamines 29

Implications for the Cultural Sociology American Psychological Association (APA). “APA
of Mental Illness History.” http://www.apa.org/about/archives/
As the field of psychology advanced, the valid- apa-history.aspx (Accessed December 2012).
ity of the concept of mental illness was explored Fernberger, S. W. The American Psychological
through labeling theory, which suggests that Association: A Historical Summary, 1892–1930.
certain behaviors are labeled as deviant or ill- Philadelphia: University of Pennsylvania Press,
ness only because society has deemed them as 1932.
such. Within this view, mental illness may be Sokal, M. M. “Origins and Early Years of the
viewed as socially constructed. In 1961, Thomas American Psychological Association, 1890–1906.”
Szasz presented this view in The Myth of Men- American Psychologist, v.47 (1992).
tal Illness, and sociologists have followed in a Szasz, T. S. The Myth of Mental Illness: Foundations
modified way by exploring the extent to which of a Theory of Personal Conduct. New York:
mental illness and the industry around it may Harper & Row, 1961.
be constructed. Other scholars working in this
tradition include Allan Horwitz and Peter Con-
rad. Labeling theory has sparked debates within
psychological and sociological communities on
the issue of mental illness as actually existing Amphetamines
or something that is socially constructed. When
this theory first arose, the APA published articles Amphetamines are psychostimulant drugs that
in its journals on the subject, fueling the debate have been used historically to treat attention defi-
further. The reification of symptoms into disease cit hyperactivity disorder (ADHD), narcolepsy,
and disorder is considered by some scholars as obesity, and depression. These drugs have become
carrying important social, cultural, and health iconic not only as drugs of abuse but also as mark-
implications. ers for a redefined meaning of childhood. None of
The field of psychology has also had a recent this was anticipated when researchers synthesized
shift in its attention to promoting mental health. the first amphetamine.
Originally the field of psychology focused only on In 1929, in his search for an asthma and allergy
the negative aspects of mental health, but there drug better than ephedrine, chemist Gordon Alles
has been a shift to also look into the positive injected himself with 50 milligrams of beta-phe-
aspects, such as resiliency. Through this form of nyl-isopropylamine, which is better known today
study, psychologists can focus on how to improve as amphetamine. Having done previous tests in
happiness in people’s lives instead of focusing guinea pigs, he expected it to increase his blood
on what is wrong with people. The APA has pressure. In addition to experiencing a rapid rise
expanded its scope to include this new focus on in blood pressure, Alles discovered that it cleared
positive psychology and plays a large role both his nose and left him with a feeling of well-being
in shaping and reflecting changes in the field of and difficulty in falling asleep. In 1930, Alles dis-
psychology broadly. covered ecstasy (MDA) in the process of trying to
find an allergy drug with fewer of the stimulating
Alexis T. Franzese side effects present in amphetamine. He experi-
Kendall Dodge enced hallucinations and feelings of well-being
Elon University on ecstasy. He did not see as much of a future
for ecstasy, and he did not develop it further at
See Also: American Psychiatric Association; Clinical that time.
Psychology; DSM-III; DSM-IV; DSM-5. While Alles was still investigating the clini-
cal effects of amphetamine, Smith, Kline, and
Further Readings French (SKF) released Benzedrine, which was
American Psychiatric Association (APA). Diagnostic the same compound as Alles’s amphetamine.
and Statistical Manual of Mental Disorders. 4th There is some controversy over whether Smith,
ed. Washington, DC: APA, 2000. Kline, and French’s chemist Fred Nabenhauer
30 Amphetamines

discovered amphetamine independently of Alles monoamine oxidase inhibitors and the tricyclic
or whether he had been informed by Alles’s pre- antidepressants. However, overall amphetamine
sentation of amphetamine at a 1929 American usage did not decline until the 1970s, when the
Medical Association (AMA) meeting. At any government became involved in limiting the sup-
rate, the Benzedrine Inhaler was advertised as ply of pharmaceutical amphetamines in order to
decongestant in 1933. curb drug abuse. Amphetamines were replaced by
Abraham Myerson, a psychiatrist interested cocaine in the 1970s as the preferred stimulant.
in depression, tried giving Benzedrine to his Illegal use of amphetamine is sometimes seen as
depressed patients in 1935 because it was said self-medication by people who lack access to psy-
to increase one’s pep. At a 1936 American Psy- chiatry and need help adjusting.
chological Association meeting, Myerson recom- Despite the notoriety that has accompanied
mended prescribing Benzedrine to patients suffer- amphetamines over the last several decades, they
ing from depression or even the average person have continued to play a major role in defin-
suffering from a low mood. In 1937, the AMA ing and treating a number of psychiatric dis-
approved the use of Benzedrine in institutional- eases. Though usage had been gradually increas-
ized depressives but not in normal people needing ing, since the early 1990s, psychostimulant use
a pick-me-up. However, in the same year, Time (including methylphenidate) has increased dra-
magazine reported that college students were matically. Between 1990 and 1996, for example,
abusing the drug to study and take exams. psychostimulant usage increased by 370 percent.
Charles Bradley, in 1937 at the Emma Pendle- This increased use of stimulants has been driven
ton Bradley Home in Rhode Island, demonstrated as much by market and cultural forces as by med-
that amphetamines were effective for treating ical ones.
hyperactive and impulsive behavior in children.
Because it was believed that children’s misbehav- Christine Tarleton
ior was caused by abnormalities in the structure of University of California, Los Angeles
the central nervous system, a pneumoencephalo-
gram was performed on groups of children admit- See Also: Antidepressants; Biological Psychiatry;
ted to the Bradley Home. One side effect of this Children; Dopamine; Drug Abuse; Mood Disorders;
neurosurgical remedy was that the children com- Patient Activism; Ritalin.
plained of headaches, which Bradley treated with
Benzedrine, a new amphetamine. However, while Further Readings
the children did not experience relief from their Mayes, Rick and Adam Rafalovich. “Suffer the
headaches, their behavior at school, including Restless Children: The Evolution of ADHD and
their overall academic performance, improved. Paediatric Stimulant Use, 1900–80.”History of
Bradley tried the drug in a group of children who Psychiatry, v.18 (2007).
had not had the neurosurgical procedure, and he Rasmussen, Nicolas. “America’s First Amphetamine
found the same results, that upon withdrawal of Epidemic 1929–1971: A Quantitative and
the drug, the children’s behavior problems reap- Qualitative Retrospective With Implications for
peared. Bradley’s studies were not replicated until the Present.” American Journal of Public Health,
the 1950s. v.98/6 (2008).
During World War II, amphetamines were used Rasmussen, Nicolas. “Making the First Anti-
in the military as performance-enhancing drugs to Depressant: Amphetamine in American Medicine,
counter fatigue. By the 1950s, family doctors pre- 1929–1950.” Journal of the History of Medicine
scribed amphetamines for their depressed patients and Allied Sciences, v.61/3 (2006).
and used them as diet pills for the obese. How- Rasmussen, Nicolas. On Speed: The Many Lives of
ever, in the late 1950s, researchers discovered that Amphetamine. New York: New York University
amphetamines are addictive and that heavy usage Press, 2008.
can cause psychosis. Consequently, by the 1960s, Smith, Matthew. Hyperactive: The Controversial
psychiatrists abandoned the use of amphet- History of ADHD. London: Reaktion Books,
amines for the newer antidepressants along with 2012.
 Anthropology 31

Anthropology However, this cultural analysis also takes the

specific problems, methods, and results of social
Mental illness is a major disorder of social ties and cultural anthropology and feeds them back
and a universal problem for all societies. The for- into more specialized and applied debates that are
mation and transformation of local treatments of part of the medical field of mental health. The key
mental illness are therefore a major area of study difficulty is to avoid reduction to the role of a spe-
within social and cultural anthropology. In this cialist of culture, understood in a somewhat flat
perspective, treatment should be understood on sense as interference to filter out or an obstacle to
three different levels: first, as treatment of the overcome, whether as an expert in public health or
problem that mental illness poses to social order; as a critic of the medicalization of the experience
second, as treatment of an ailment on the basis of of human suffering. Similarly, it is important to
a therapeutic system that can call upon specialist avoid becoming caught up in certain disputes, for
knowledge or not (e.g., a classification, etiology, example, regarding the nature of mental illness,
or pharmacopoeia) in order to identify the disor- because they give rise to contradictory anthro-
der or to determine its nature, and to then provide pological theories, either seeking to explain one
appropriate intervention; third, as moral treat- form or other of mental illness (as evidenced by
ment of people experiencing mental illness, and Grégory Bateson or Jules Henry’s work), or look-
trying to find a solution to their state of disorder. ing to show the metaphorical or mythological sta-
This definition of the anthropology of men- tus of mental illness, as sometimes propagated by
tal illness does not confer special status upon a naïve constructionism still in vogue today.
psychiatry, psychology, or psychoanalysis in the Thus, in this interdisciplinary area that can
approach to these elementary forms of otherness sometimes seem confusing because of the pro-
and irrationality. Rather, these are all possible liferation of different labels in circulation (e.g.,
areas of anthropological inquiry as illustrated by cultural psychiatry, ethnopsychiatry, ethnopsy-
a number of studies that have become classics in choanalysis, primitive or folk psychiatry, and
the field, such as Tanya Luhrmann’s work on two transcultural or comparative psychiatry or psy-
opposing conceptions of personhood in American chology), the issues that arise are mainly profes-
psychiatry, Robert Barrett’s study on the hospi- sional problems approached from a clinical and/
tal management of schizophrenia, and Lorna or epidemiological perspective. It is the act of
Rhodes’s research on psychiatric treatment in a applying psychiatric knowledge to populations,
maximum security prison. such as migrants or members of a different soci-
ety who exhibit expressions and conceptions of
Cultural Analysis of Personhood mental illness, which is far from self-evident to
Far from a narrow and specialized field of research the ordinary clinical gaze. In these studies, it is
in medical anthropology, the theoretical goal of important to bear in mind the theoretical and
the anthropology of mental illness is instead to methodological problem inherent in applying
contribute to the wider cultural analysis of moral psychological concepts of a theory of personality
conceptions of personhood and of the contempo- (i.e., psychiatric, psychoanalytic, and psychologi-
rary making of ethical subjectivities. The moral cal) to cultural analysis, rather than to the cul-
language used to speak of oneself and of relation- tural analysis of personhood.
ships to others establishes a specific form of life in
which boundaries have been negotiated between Methods of Cultural Analysis
the normal and the pathological, the tolerable Social anthropology inherits issues and repre-
and the intolerable, monstrosity and humanity, sentations deriving from a long social history of
responsibility and irresponsibility, and what is mental illness that also permeates current com-
moral and immoral. All of these boundaries come mon understanding. The accounts of travelers,
together to define the framework of what is think- evangelists, or military doctors from antiquity
able and feasible in a particular time and place. to the present day have continued to perpetuate
They define the facts that are embodied in com- conflicting representations about mental illness
mon understanding. or the irrationality of members of exotic cultures
32 Antidepressants

to better emphasize their otherness. These can individual narratives can give rise to different types
serve either to enhance the conservative idea of of insight for cultural analysis, according to the the-
a harmonious community living without stress in oretical problem under consideration: the strategic
opposition to the pathogenic modern society of uses of theories of mental health (Didier Fassin
individuals, or to promote the racist and reduc- and Richard Rechtman); the cultural production
tive identification of entire societies with forms of of a type of subjectivity (Emily Martin); the impact
mental illness. This can be seen in many literary and footprint of mechanisms of domination in the
accounts concerning the emotions conducive to expression of social suffering (Arthur Kleinman,
mental illness in Africans in general, or more spe- Veena Das, and Margaret Lock); and the phenom-
cifically in colonial psychiatry concerning types of enological structure of the experience of a mental
pathology that are supposedly characteristic of a disorder (Janis Jenkins and Els Van Dongen).
given group and the presumed existence of nega-
tive personality traits. Samuel Leze
In order to take the facts of common understand- Ecole Normale Superieure de Lyon
ing beyond their fixed and limited dimension and
allow a complete picture to form, anthropologists See Also: Diagnosis in Cross-National Context;
retrace the path that leads from the formation of a Epidemiology; Ethnopsychiatry; Mental Illness
concept to the moment when it is taken up in clin- Defined: Historical Perspectives; Mental Illness
ical practice, in patient experiences, and in popu- Defined: Sociological Perspectives.
lar culture. Three methodological approaches can
be identified, while keeping in mind that in the Further Readings
absence of an overriding and defining key anthro- Brodwin, Paul. Everyday Ethics: Voices From the
pological research issue, there is a risk of studies Front Line of Community Psychiatry. Berkeley:
becoming fragmented into areas focusing on spe- University of California Press, 2013.
cific societies or psychopathologies. Davis, Elizabeth Anne. Bad Souls: Madness and
When a concept has a long history and dis- Responsibility in Modern Greece. Durham, NC:
plays changes in value over time, the genealogical Duke University Press, 2012.
method is often used, in the manner of Fredrich Fassin, Didier and Richard Rechtman. The Empire
Nietzsche and Michel Foucault, as illustrated by of Trauma: An Inquiry Into the Condition of
the work carried out by Allan Young or Didier Victimhood. Princeton, NJ: Princeton University
Fassin and Richard Rechtman on the cultural suc- Press, 2009.
cess of the category of trauma. Hinton, Devon E. and Byron J. Good, eds. Culture
When there is wide circulation of a given cul- and Panic Disorder. Palo Alto, CA: Stanford
tural object (like the popular image of Freud University Press, 2009.
and the proliferation of images of depressive or Kitanaka, Junko. Depression in Japan: Psychiatric
schizophrenic brains in the mass media), then Cures for a Society in Distress. Princeton, NJ:
the method employed is that of the “social life of Princeton University Press, 2011.
things,” in the manner of anthropologist Arjun
Appadurai. This is illustrated by the work of
Joseph Dumitt on the neurobiology of depression,
Andrew Lakoff on the impact of American psy-
chiatry in Argentina and, in part, Junko Kitanaka Antidepressants
on the social and political success of the category
of depression in Japan. The history of antidepressants begins in the 1950s
Anthropologists usually complete this approach following the discovery of the antipsychotic
by conducting local or multisite fieldwork in psy- chlorpromazine. While it can be argued that the
chiatric institutions in close proximity to profes- amphetamines prescribed in the 1940s and 1950s
sionals and patients. They can also choose to focus were both used and marketed in very similar
solely on the moral and emotional experience of ways to the selective serotonin reuptake inhibi-
persons affected by a disorder of social ties. Then, tors (SSRIs) in the 1990s, it was in 1952, with the
 Antidepressants 33

discovery of the effects of the monamine oxidase promising results, Hoffman–LaRoche (HLR) was
inhibitor iproniazid (MAOI), that the term anti- skeptical about the market for an antidepressant.
depressant was coined. Over the next half cen- Kline managed to meet the president of HLR in
tury, antidepressants would go on to become one secret and convince him of the benefit in continu-
of the most widely prescribed classes of drugs in ing the studies for this indication. The market was
the world. confirmed when 400,000 patients were prescribed
The first recognized antidepressants, MAOIs, iproniazid even though it was still only licensed
were discovered by chance as a side effect to new for tuberculosis.
antitubercular medications. Iproniazid was an
effective antitubercular medication but was almost Reports of Side Effects
abandoned after researchers found that it had a Quite soon after the MAOIs started to be widely
worse safety profile than the similar isoniazid. prescribed for depression, reports began to sur-
However, some of the physicians who had been face of serious side effects. There were reports of
testing it noticed that previously lethargic patients jaundice, nephrotoxicity, and hepatotoxic effects
displayed increased energy and sociability. At the across all the MAOIs, and iproniazid was with-
1957 annual meeting of the American Psychiat- drawn from the U.S. market in 1961. Tranylcy-
ric Association, a few research teams reported on promine, an MAOI developed by Smith, Kline,
the positive mood effects they had noticed with and French was withdrawn from the U.S. market
iproniazid; however, only Nathan Kline and his in 1964. It had been hoped that it would have
team had conducted a trial to purposively test fewer side effects, as it was an amphetamine ana-
its antidepressant properties. They reported that logue as opposed to a hydrazide derivative like the
they saw improvement in 70 percent of their other MAOIs. Unfortunately, it was discovered
nontubercular, depressed patients. Despite these that an interaction between the medication and
foods rich in tyramine, such as certain cheeses,
could cause hypertensive events accompanied by
severe headaches and sometimes subarachnoid
intracranial hemorrhages. It also became clear
that MAOIs could have fatal interactions with
tricyclic antidepressants (TCAs) and over-the-
counter pain medication. After the early 1960s,
MAOIs were considered the second- (or third)
line antidepressants.

G22355: The First Tricyclic Antidepressants

The TCAs were the next class of antidepressants
to gain primacy. They were discovered by chance
in the search for new antihistamines. Scientists
at the pharmaceutical company Geigy produced
the first TCA, G22355, which was a derivative of
a compound that had been developed as a dye a
half century before. Geigy worked with psychia-
trist Ronald Kuhn in testing G22355. He tested it
in patients with a variety of diagnoses, expecting
it to have an antipsychotic effect because of its
structural similarity to the antipsychotic chlor-
promazine. It did not display the expected effects,
but Kuhn noticed that his patients developed
Fluoxetine HCl (Prozac) is in a class of drugs called selective elevated moods or even “manic” behaviors. He
serotonin reuptake inhibitors (SSRIs). SSRIs are one of the most suggested that Geigy conduct a trial on G22355’s
frequently prescribed medications in the world. effectiveness in depression. They tested it in 40
34 Antipsychiatry

patients, but dramatic results in the first three led unpublished, clinical trials. They conducted more
Kuhn to write to Geigy in strong support of the trials during the 1980s, which found the drug
medication as an antidepressant after only one to be as effective as TCAs and with fewer side
month. Geigy named it imipramine. Despite con- effects. In 1987, they licensed fluoxetine with
tinued skepticism about the ability to treat depres- the Food and Drug Administration (FDA) under
sion with a medication, the support of eminent the trade name Prozac. By 1990, it was the most
psychiatrists such as Paul Kielholz and Raymond widely prescribed psychotropic medication in
Battegay convinced Geigy to put imipramine on North America, and by 1994, it was the second
the European market in 1957 and 1958 under the most widely prescribed drug overall worldwide.
trade name Tofranil. The astronomical success of Prozac and the
Merck, Roche, and Lundbeck simultaneously other SSRIs was mirrored in popular culture
developed the next TCA to come to market, ami- with a plethora of news stories, cartoons, books,
triptyline, facilitating its distribution worldwide. and even movies that featured the medications
Merck and Roche had stronger marketing strate- appearing over the course of the decade. As the
gies than Geigy and were able to sell more of their 1990s came to a close, reports of serious side
product. When it became clear that there was a effects again began to appear, including akathisia
market for antidepressants, a battle began for the (intense and unpleasant inner restlessness) that
rights to amitriptyline in which Merck emerged was linked with increased suicidality and aggres-
victorious. Merck developed the strategy of mar- sion, especially among adolescents and young
keting not only the drug but also the concept of adults. Despite continued concerns about safety
depression as a disease treatable by antidepressant and new trials, which put into question the effi-
medications. Though the pharmaceutical indus- cacy claims made about SSRIs, they continue to be
try did not create the disease of depression out of the first choice of treatment for major depression.
whole cloth (as individuals have always suffered
from various ills that constitute the disease), they Rebecca Wilkinson
did successfully help forge these symptoms into a University of California, Los Angeles
market for these new drugs that defined the dis-
ease they treated. TCAs went on to rule the anti- See Also: Amphetamines; Mood Disorders; Suicide.
depressant market for the next 30 years.
However, as early as the first trials, it had been Further Readings
noted that patients with brain disorders experi- Healy, D. The Antidepressant Era. Cambridge, MA:
enced side effects such as dry mouth, excessive Harvard University Press, 1997.
sweating, constipation, and confusion. Patients Lopez-Munoz, F. and C. Alamo. “Monoaminergic
and clinicians had disregarded these side effects Neurotransmission: The History of the Discovery
as being minimal in the face of the relief that of Antidepressants From 1950s Until Today.”
patients experienced, but in the late 1980s, SSRIs Current Pharmaceutical Design, v.15 (2009).
came on the market with the promise of greater Rasmussen, Nicolas. “Making the First Anti-
efficacy and fewer side effects. Though carefully Depressant: Amphetamine in American Medicine,
controlled trials failed to find that SSRIs had 1929–1950.” Journal of the History of Medicine
greater efficacy, the TCAs were soon eclipsed and and Allied Sciences, v.61/3 (2006).
relegated to, at best, a second-line treatment.
Scientists at Eli Lilly first synthesized SSRIs
in the early 1970s. A team led by pharmacolo-
gists Ray Fuller and David Wong tested deriva-
tives of phenoxyphenypropylamines to try to find Antipsychiatry
a compound that selectively inhibited the reup-
take of serotonin. Jong Horng, a member of their Antipsychiatry is a term coined by David Cooper
team, discovered that fluoxetine chlorhydrate in 1967. Antipsychiatry is a set of ideas and peo-
was the most effective. Lilly decided to fully sup- ple who challenge mainstream psychiatry con-
port the drug after a series of promising, though cerning the validity of diagnoses, the efficacy of
 Antipsychiatry 35

psychiatric treatment, and the power differential to be conscious and observed by the practitio-
between mental health practitioners and mental ner. Because psychiatric disorders require a great
health patients. By the late 1960s, deinstitution- deal of subjectivity, they are open to interpreta-
alization was completely under way. The popu- tion or error. For instance, the diagnosis or label
lation of psychiatric hospitals peaked in 1955 of mental illness can be placed by psychiatrists
and decreased steadily through the 1980s. Three onto patients who hold political ideology that
reasons are often given for deinstitutionalization: is not favored by the current government. There
(1) the high cost of operating psychiatric hospi- are examples of political dissidents in the Soviet
tals, (2) new drugs that became available in the Union being “diagnosed” and placed in psychiat-
1950s to treat mental illness, and (3) the belief ric facilities for simply holding beliefs contrary to
that people should be free from governmental those of the government.
and institutional control as much as possible. Dr. Thomas Szasz, a trained psychiatrist and
The late 1960s were a time of protest against noted antipsychiatrist, describes the socially con-
the Vietnam War. Arrestee rights were affirmed structed mental illness of “drapetomania.” Ref-
by the U.S. Supreme Cout and embodied in the erencing Dr. Samuel Cartwright in pre–Civil War
Miranda warning. There were civil rights pro- America, Szasz describes the disease of drapeto-
tests for ethnic minorities. In this social situation, mania as something that caused slaves to want
antipsychiatry found a foothold. to run away from their plantation. The treatment
Those involved in antipsychiatry have ques- suggested was the whipping of the slave. In some
tioned the scientific validity of psychiatric diag- cases, the big toes of slaves were removed to pre-
noses. Psychiatric diagnoses are made based on vent the slave from running away. While today’s
symptoms that are subjective, as opposed to audience sees drapetomania as a medically insti-
objective criteria. The Diagnostic and Statisti- tutionalized form of racism, the audience of the
cal Manual of Mental Disorders (DSM) has been 1800s took this seriously and applied the “treat-
used for 60 years. The DSM lists mental disor- ment” for the “illness.” In this respect, psychiat-
ders, describing them by a list of symptoms expe- ric diagnoses have been used to legitimize racism.
rienced for a duration of time (e.g., two weeks), Antipsychiatrists have also challenged the
not because of a general medical condition (e.g., validity of psychiatric diagnoses in modern times.
cancer). For instance, the DSM-IV defines the In the earlier versions of the DSM, homosexu-
criteria for a major depressive episode as five or ality was listed as a psychiatric disorder. In the
more symptoms, including depressed mood daily, later versions (e.g., DSM-III), homosexuality
diminished interest of pleasure in activities most was not listed as a psychiatric disorder. What is
of the day, significant weight changes, insomnia at issue for those who subscribe to antipsychia-
or hypersomnia nearly every day, psychomo- try is how the status of homosexuality changed
tor agitation or retardation nearly every day, in the DSM. In 1973, gay activists took on the
fatigue, feelings of worthlessness or inappropri- American Psychiatric Association at one of their
ate guild, diminished ability to think or indeci- meetings. Eventually, after a vote by the nomen-
siveness nearly every day, or recurrent thoughts of clature committee, homosexuality was removed
death. Symptoms are not from a mixed episode, as a psychiatric disorder. Szasz and other anti-
cause clinically significant distress in functioning, psychiatrists view this as odd for a “disease”
are not directly attributable to the effects of sub- diagnosed by doctors. In the antipsychiatrists’
stances, and are not due to bereavement. view, would doctors simply vote diabetes or can-
If a person has cancer and is in a coma, doctors cer in or out as a disease? In those cases, doctors
can detect the cancer through objective measures would have to yield to objective evidence. But in
such as blood work or a biopsy. How the patient the case of homosexuality, the decision to keep
feels or the observations of the physician are not or get rid of a diagnosis is based on special inter-
necessary. There are many examples where the est groups pressuring the American Psychiatric
diagnostician has little or no contact with the Association. The issue of homosexuality and the
patient when they receive the diagnosis. Psychiat- method of deleting it as a diagnosis simply pres-
ric illnesses, on the other hand, require the patient ents more evidence that psychiatric diagnoses are
36 Antisocial Behavior

too subjective and therefore run the risk of being characterized by difficulties at home and school,
social judgments, not scientific facts. which may include truancy, running away, cru-
Antipsychiatrists also include mental health elty to animals and people, destruction of prop-
consumers/survivors/ex-patients. Many of these erty, theft, and other rule violations. Estimates
people discuss mental health treatment and how of CD in children have ranged from 7 to 25 per-
detrimental it was to their health. Since the early cent. Prevalence among gender tends to be equal.
days of deinstitutionalization, many former Children with early-onset conduct problems are
patients have discussed the deplorable conditions more likely to drop out from school and engage in
of state psychiatric hospitals, the harsh side effects interpersonal violence as adolescents. Individuals
of pharmaceuticals, the therapists who did not with conduct problems through adolescence are
really understand them, and the therapists who more likely have substance abuse problems and
were more harmful than helpful. While those who have interactions with both the juvenile and adult
favor antipsychiatry have provided great critiques criminal justice system.
of psychiatric treatment, they have not always Researcher Terrie Moffitt has described two
depicted the good that psychiatric treatment has developmental paths for juvenile delinquency and
done, the consumers who favor psychiatric treat- antisocial behavior. First, life course persistent
ment, and they have not provided an adequate (LCP) offenders tend to develop a long trajectory
alternative model. of antisocial behavior at a very early age—even
exhibiting misbehavior as early as 3 years old.
Daniel W. Phillips These individuals tend to exhibit difficult tem-
Lindsey Wilson College perament as infants, have childhood disorders
such as CD or attention deficit hyperactivity dis-
See Also: American Psychological Association; order (ADHD), and have neurological problems
Mental Illness Defined: Historical Perspectives; or learning deficits. LCP offenders tend to have
“Normal”: Definitions and Controversy. a lifelong history of aggression and violence. The
second group of individuals are adolescent lim-
Further Readings ited (AL). There developmental histories differ
American Psychiatric Association (APA). Diagnostic from LCP offenders. These individuals tend to
and Statistical Manual of Mental Disorders. 4th engage in crimes that are profitable and reward-
ed. Washington, DC: APA, 1994. ing, as well as offenses that symbolize privileges
Palermo, G. B., M. Smith, and F. J. Liska. “Jails of adults such as vandalism, running away, tru-
Versus Mental Hospitals: A Social Dilemma.” ancy, and drug and alcohol offenses. AL offend-
International Journal of Offender Therapy and ers’ antisocial behaviors tend to peak around age
Comparative Criminology, v.35/2 (1991). 16 and then decline in their late teens to early
Szasz, T. Insanity: The Idea and Its Consequences. adulthood. Given the course of LCP offenders,
New York: John Wiley & Sons, 1987. early interventions are recommended. Early treat-
ment interventions greatly reduce the likelihood
of future criminal behavior.

Antisocial Personality Disorder (ASPD)

Antisocial Behavior and Psychopathy
Recurring patterns of antisocial behavior may be
Antisocial behavior intentionally or unknowingly considered disordered. Antisocial Personality Dis-
disregards the well-being and safety of others. order (ASPD) is characterized by a pervasive pat-
Behaviors of this sort are considered maladaptive, tern of disregard for and violation of the rights of
depending on societal norms. Antisocial behav- others. The Diagnostic and Statistical Manual of
iors can range in severity from aggressiveness Mental Disorders, 4th edition (DSM-IV) estimates
and impulsivity to criminal and illegal behavior. that the overall prevalence of ASPD is three per-
Antisocial behavior can be found in early child- cent in males and one percent in females. Higher
hood and adolescence. Conduct disorder (CD) is prevalence rates have been observed in substance
 Antisocial Behavior 37

abuse treatment settings and the criminal popu- Treatment of Antisocial Behavior
lation. In individuals with ASPD, the patterns There is much controversy surrounding the treat-
of maladaptive behaviors are noticed by age 15 ment of antisocial behavior, ASPD, and psychop-
and are chronic in nature, meaning that they are athy. Because ASPD is considered a personality
maintained throughout the life span. Diagnostic disorder, which is described as an “enduring
criteria for ASPD include impulsivity; failure to pattern [that] is inflexible and pervasive across
follow rules, laws, and societal norms; repeated a broad range of personal and social situations,”
lying, aggressiveness, and irresponsibility; and many people question whether the behaviors
lack of remorse. exhibited can be changed or if the disorder can
Psychopathy is commonly associated with be treated. Most individuals who seek treatment
antisocial behavior and ASPD. Researcher Rob- for mental illness are experiencing some level of
ert Hare is world renowned for his research on distress or impairment. Those with ASPD often
the concept of psychopathy. He created the Psy- do not experience distress or view their atti-
chopathy Checklist-Revised (PCL-R) to assess tudes or behaviors as wrong or dysfunctional.
for characteristics that are associated with psy- Studies have shown that psychopathic individ-
chopathy. Characteristics of psychopathy include uals who receive treatment are actually more
heightened sense of self-worth, need for stimu- likely than those who are untreated to commit
lation, pathological lying, manipulative, lack of crime. Theories suggest that treatment can cre-
remorse, history of early behavioral problems, ate unintentional consequences, such as enhance
and impulsivity or irresponsibility. His research their ability to deceive and manipulate others.
estimates that 1 percent of individuals in the However, there has been some evidence that suc-
general population could be considered psycho- cessful completion of treatment, such as cogni-
paths. Of individuals with ASPD, it has been esti- tive behavioral therapies, may reduce recidivism
mated that 10 to 20 percent of those individuals rates in both juvenile and adult offenders with
would meet the criteria for psychopathy. There- antisocial behaviors. Therefore, early treatment
fore, most psychopaths meet criteria for ASPD, intervention is recommended to minimize future
but a majority of individuals with ASPD are not risk and harm.
psychopaths. There have been gender differ-
ences found with regard to the presentation of Apryl Alexander
psychopathy. Female psychopaths tend to be less Florida Institute of Technology
aggressive, less violent, and recidivate less often
than males. Research and assessment of ASPD See Also: Dangerousness; Forensic Psychiatry; Jails
and psychopathy has been conducted across and Prisons; Prison Psychiatry; Violence.
cultures, and similar prevalence rates have been
observed, with congruent ranges of PCL-R scores Further Readings
found in various cultures. Babiak, Paul and Robert Hare. Snakes in Suits:
There is no known cause for ASPD or psy- When Psychopaths Go to Work. New York:
chopathy. Neuroimaging studies have attempted HarperCollins, 2007.
to find functional and structural differences in the Bartol, Curt and Anne Bartol. Introduction to
brain between individuals labeled as psychopaths Forensic Psychology. London: Sage, 2004.
and nonpsychopaths. These studies have found Hare, Robert. Without Conscience: The Disturbing
that psychopaths have difficulty with executive World of the Psychopaths Among Us. New York:
functions (i.e., reasoning, planning, and deci- Guilford Press, 1999.
sion making), impulse control, and affective/ Harenski, K., R. E. Hare, and K. A. Kiehl.
emotional processes. No significant structural “Neurodevelopmental Bases of Psychopathy:
differences have been found; however, significant A Review of Brain Imaging Studies.” In
reductions in executive functioning have been Responsibility and Psychopathy: Interfacting Law,
found to be correlated with higher scores on the Psychiatry and Philosophy, M. Malatesti and J.
PCL-R, which may indicate differences in frontal MacMillian, eds. New York: Oxford University
lobe functioning. Press, 2010.
38 Anxiety, Chronic

Meyer, Robert and Christopher Weaver. The Genes are thought to play a role in the develop-
Clinician’s Handbook: Integrated Diagnostics, ment of a wide variety of chronic anxiety disor-
Assessment, and Intervention in Adult and ders, as researched in familial aggregation stud-
Adolescent Psychopathology. 5th ed. Long Grove, ies of first-degree relatives and twins. The rate of
IL: Waveland Press, 2007. genetic involvement appears to vary somewhat by
specific disorder, with other factors contributing,
including shared family environment, individual
environment, and stress or trauma exposure.

Anxiety, Chronic Diagnostic Terms Across Cultures

Different diagnostic labels for anxiety disorders
The term anxiety covers a broad array of emo- exist across cultures. Research shows that though
tional, cognitive, behavioral, and physical symp- anxiety is universal, the cultural understanding
toms. Emotional indicators include feelings of ner- of anxiety (both the experience and the believed
vousness, fear, restlessness, irritability, or panic. etiology) varies widely. Because of the important
Cognitive indicators include obsessions, difficulty effect of shared cultural understanding, the Amer-
concentrating, and worry. Behavioral indicators ican Psychiatric Association’s Diagnostic and Sta-
include phobic avoidance, sleep disturbances, and tistical Manual of Mental Disorders includes an
compulsions. Physical indicators include fatigue, appendix of anxiety syndromes that it calls “cul-
musculoskeletal pain, numbness, heart palpita- ture-bound.” There are opponents of this term
tion, dizziness, tingling, feeling hot or sweating, because culture is a dynamic force, though the
and muscle tension. Suicidality may be pres- chronic anxiety syndromes detailed are instruc-
ent. Some of the above indicators may be found tive to the clinician who in one treatment locale
more or less commonly in a culture, depending may see patients originating from many cultures.
upon accepted norms. For instance, in equatorial Somatization of anxiety (physical symptoms)
regions of Africa, a common physical indicator is was formerly thought to be characteristic of non-
a “peppery feeling” in the head. Western cultures, though it is now believed that
Conceptually, anxiety can be broken into the physical expression of anxiety occurs world-
“state anxiety” and “trait anxiety.” State anxi- wide. A particular physical expression may be
ety refers to acute anxiety at a given time. Trait culturally mediated, just as emotional expression
anxiety refers to a stable tendency in a person to is culturally mediated by emotion display rules
be anxious over their lifetime. Neither necessarily for a given culture. Each culture has a different
refers to disordered anxiety, which causes func- understanding of what emotions are acceptable at
tional impairment. Disordered anxiety has gone all, and what emotional expression is acceptable
by many names over the years and across cultures, for a given person within that culture based on
including neurasthenia, anxiety neurosis, shell their gender, socioeconomic status, or other fac-
shock, malignant anxiety, and névrose d’angoisse. tors. Symptoms are not only based in illness, but
Chronic disordered anxiety can be intense and also in interpersonal communication, which is
debilitating and may require periodic stabilization highly culture dependent.
in times of crisis or hospitalization. Disordered Social phobia has been shown to exist across
anxiety is highly prevalent, and though rates of cultures, though it may take unique form within
specific disorders vary by culture, as a group, life- a given culture. Social phobia can generally be
time prevalence can reach 25 percent. defined as extreme anxiety in social situations, or
When referring to mental health disorders, chro- other situations where performance may be judged.
nicity is defined by a diagnosed illness, long-term As in all disordered anxiety, the intensity, persis-
duration, and psychosocial disability as a result of tence, and related disability are beyond the normal
the illness. Some theorize that cultures in the West range in a given culture. In Western cultures, this
that highly value individualism are more prone to is often experienced as intense embarrassment. In
chronic conditions because of fusion of the sense Japan, there is a form of social phobia called taijin
of self with the illness. Research remains mixed. kyofusho (TKS), where the concerns are not with
 Anxiety, Chronic 39

one’s embarrassment but with upsetting or offend- Susto (fright illness) is experienced in Cen-
ing others. The feared offense is often localized in tral America, and is caused by the soul leaving
one’s body odor, blushing, or eye contact. the body after a traumatic or stressful incident.
Generalized anxiety disorder (GAD) is the most A curandero is required to perform rituals that
common chronic anxiety disorder diagnosed in return the soul to the body. Symptoms include
primary care settings and has been diagnosed in sleep problems, somatic symptoms, anxiety, and
cultures worldwide, including Chile, China, Nige- anorexia. Espanto is a more severe form and is
ria, and Turkey. It is defined, in part, by its chro- associated with increased mortality. As with other
nicity (six months or more). It causes a level of anxiety disorders, women experience it more
psychosocial disability similar to chronic medical commonly than men.
diseases. This also has economic effects for the Nervios is a syndrome experienced in Latin
community. For example, in the United States, America and by Latinos in the United States. As
GAD is the top cause of workplace disability, and with other anxiety disorders, symptoms are emo-
is correlated with increased medical health care tional, cognitive, and physical, with associated
utilization. Only about a quarter of cases occur functional impairments.
with no comorbidities, so when a physician diag-
noses GAD, assessment should also be made for Common Characteristics and Treatment
common comorbidities. For most chronic anxiety disorders, particularly
Panic disorders have also been found world- GAD and social phobia, comorbidity should be
wide, though the explanation of the panic may considered the rule, rather than the exception.
vary by culture. In some cultures, panic arises Anxiety disorders are often comorbid with each
from excessive fear of witchcraft or magic. In other, with affective disorders such as depressive
panic disorder, as well as specific phobias, it is disorders, and with substance abuse. High rates
important to consider the normative amount of of comorbidity may exist because of the factor of
fear for the object within a certain culture when chronicity. Some individuals may carry a chronic
assessing whether an individual’s fear is excessive. anxiety disorder across their lifetime, which
Brain fag/fatigue is a syndrome experienced in means that any other disorder occurring within
west Africa. It has also been called brain tiredness that lifetime is by definition comorbid. Because of
and refers to somatic and cognitive symptoms in the frequent comorbidity of depression and anxi-
response to schooling. ety, some theorize that these two factors exist on
Dhat is a syndrome experienced in India. The a continuum, rather than as discrete categories.
symptoms are anxiety, weakness, and hypochon- Chronic anxiety can start as young as child-
driasis. The believed etiology is a loss of semen, hood, and frequently begins in the mid-20s.
either through ejaculation or through the urine. When diagnosing children, practitioners need to
Similar syndromes also occur in Sri Lanka (sukra consider not a decline in functioning but a failure
prameha) and China (shen-k’uei). to reach expected levels of functioning in social
Ghost sickness is a syndrome experienced in or academic milieus. Some specific phobias are
some Native American tribes. The etiology is common in childhood and are unlikely to persist
believed to be the ghost of a deceased person or into adulthood. Women have higher prevalence
witchcraft, and the sufferer may become preoccu- rates of chronic, disordered anxiety than men, as
pied with the deceased beyond traditional mourn- well as higher rates of the most common comor-
ing. Symptoms include nightmares, fear, confu- bid disorder, depression. Religion does not appear
sion, sense of suffocation, and weakness. to be correlated with chronic anxiety, though a
Hwa-byung or wool-hwa-byung (anger syn- given individual’s religion may provide for unique
drome or fire illness) is experienced in Korea. The expressions of anxiety. For instance, the rituals
believed etiology is the suppression of anger, par- of one’s religion may be taken to the extreme in
ticularly anger at collective injustice or interper- an obsessive-compulsive disorder, where rituals
sonal conflict. Sufferers may experience gastroin- exceed the cultural norms of that religion.
testinal discomfort, anxiety, depressive symptoms, Medication treatments for chronic anxiety
and pain. include antidepressants (e.g., selective serotonin
40 Architecture

reuptake inhibitors, tricyclic antidepressants, and Kirkbride Plan

serotonin-norepinephrine reuptake inhibitors). It The institution of state-funded mental hospitals in
may also be treated with benzodiazepines, though the United States dates to the mid-19th century,
this is on the decline, partly because of problems when reformers like Dorothea Dix petitioned leg-
with long-term use, such as addiction. Cognitive islatures and Congress to adopt a system to care
behavioral psychotherapies have shown effective- for mentally ill indigents. When such patients
ness with multiple types of chronic anxiety. A were housed at all, they were placed in jails or
good relationship with a prescribing physician or other government buildings intended for other
a psychotherapist is also an important component uses. Activists like Dix brought about a wave of
of treatment. In some cultures, where anxiety is mental hospital construction. Many of those early
believed to be derived from witchcraft or other hospitals were built according to the standardized
spiritual causes, a faith healer, curandero, or sha- plan developed by Dr. Thomas Kirkbride, a sur-
man is the preferred provider of treatment. geon who became the superintendent of the Penn-
sylvania Hospital for the Insane in 1840 (having
Laura Johnson trained at an asylum before his surgery career).
Chicago School of Professional Psychology Kirkbride developed what became known as the
Kirkbride Plan over the next few years, and in
See Also: Obsessive-Compulsive Disorder; Panic 1854, he published On the Construction, Orga-
Disorder; Phobias; Post-Traumatic Stress Disorder. nization, and General Arrangements of Hospitals
for the Insane With Some Remarks on Insanity
Further Readings and Its Treatment, one of the foundational texts
American Psychiatric Association (APA). Diagnostic of the century. Kirkbride’s notion that the design
and Statistical Manual of Mental Disorders. 4th of a building would impact the mood and treat-
ed. Washington, DC: APA, 2000. ment of the patients within was an early form of
Hettema, John M., Michael C. Neale, and Kenneth what is now grouped under the rubric of archi-
S. Kendler. “A Review of Meta-Analysis of the tectural determinism, which privileges the built
Genetic Epidemiology of Anxiety Disorders.” environment (surroundings constructed for and
American Journal of Psychiatry, v.158/10 (2001). by humans) as a primary factor determining social
Kirmayer, Laurence J. “Cultural Variations in the behavior. Outside the mental health field, architec-
Clinical Presentation of Depression and Anxiety: tural determinism is popularly adhered to by uto-
Implications for Diagnosis and Treatment.” pianists and invoked by urban renewal activists.
Journal of Clinical Psychiatry, v.62/13 (2001). Over the course of the 19th century, the view
developed that mental illness was the result of an
interaction between biological and environmen-
tal factors. During this time, the idea of mental
illness—as opposed to madness or insanity—was
Architecture invented. Kirkbride was a doctor whose treat-
ment of the mentally ill was founded on the belief
Architecture has historically played a role in the that many of his patients (as many as 90 percent)
stigmatization and more broadly the characteriza- could be cured, an attitude that many of his pre-
tion of mental illness. While there are today many decessors and contemporaries did not share. He
means of treating mental illness that do not involve belonged to the Moral Treatment school, which
nor even entertain the possibility of sequestering had developed during the Enlightenment as both
the patient (as in an institution), the history of humanist and religious figures argued for more
mental health care is virtually synonymous with humane, empathic treatment of the mentally ill.
the history of asylums and other institutions. The The idea had best taken hold in Pennsylva-
role of the design of those institutions in the treat- nia, where at the turn of the 19th century, Dr.
ment of their patients has always been under dis- Benjamin Rush adopted a series of practices
cussion, though the philosophies and goals under- that required attendants to deal with patients
lying the discussion have considerably changed. sensitively, engaging them in conversation and
 Architecture 41

Two large mental hospitals demonstrate differing architectural approaches for housing patients. The Hudson River State Hospital for
the Insane, Poughkeepsie, New York (top), here in 1874, is an example of the Kirkbride Plan for architectural design, which stressed
that the building was an innate part of the cure. Later, Cottage Plan facilities, as demonstrated by Pilgrim State Hospital, Brentwood,
Long Island, New York (bottom), here in the 1930s, were far more grim and utilitarian. Pilgrim warehoused patients in the thousands.

physical activity; however, he also used mercury donated by wealthy patrons; and society may
vapors and bloodletting. The empathy Rush have preferred maintaining a physical distance
called for in dealing with patients was justified from its mental hospitals.
not simply on moral grounds, as one would jus- These large Victorian hospitals remained in use
tify kindness to animals, but on the grounds that until the 20th century, and often well into the 20th
empathy was therapeutic, or that at a minimum, century, though Kirkbride’s idea that the build-
cruelty and neglect were counterproductive. In ing was an innate part of the cure was abandoned
Kirkbride’s time, the opposition to Moral Treat- as part of official practice after the 1890s. The
ment by mental health professionals (physicians, first Kirkbride Plan hospital, the New Jersey State
bureaucrats, and asylum administrators) was Hospital, built in 1848, was founded by Dix and
just beginning to subside. The adoption of Kirk- remains in use today. Other hospitals include the
bride’s ideas coincided with the professionaliza- Jacksonville (Illinois) State Hospital, the Pennsyl-
tion of the psychiatrist. vania State Lunatic Hospital, the Western State
The Kirkbride Plan called for hospitals with Hospital (Kentucky), the Dayton State Hospital
multiple, long wings, staggered to provide equal (since converted into an assisted living facility),
access to sunlight and fresh air, which Kirkbride the Northampton (Massachusetts) State Lunatic
considered essential. They were usually located Hospital, and the Hudson River State Hospital
on large estates, for a variety of reasons: Kirk- for the Insane.
bride emphasized the importance of physical
activity, which in the mid-19th century meant Cottage Plan
having the patients work farmland; in some The Kirkbride Plan was succeeded in popularity
cases, the hospitals were built on or in estates by the Cottage Plan, which began not as a reaction
42 Architecture

against the Kirkbride Plan, but as an adaptation physical phenomenon, whether treated pharma-
of the idea based on developments discovered ceutically or by other means, has reduced the
once it was put into practice. The first Cottage prevalence of the large-scale mental hospital.
Plan hospitals addressed Kirkbride’s silence on the Objecting to what he perceived as a long-
matter of violent or otherwise disruptive patients standing tradition of mental health care facilities
by consisting of multiple buildings, rather than designed to be as unobtrusive as possible or located
one multiwinged building. in remote areas, and a desire underlying that tra-
The earliest were built in the 1890s, and the dition to make the mentally ill invisible, Spanish
plan grew in popularity with the waxing of the architect Jose Javier Gallardo Ortega came at the
20th century. Cottage Plan buildings were typi- design of the children’s psychiatric center in Zara-
cally connected by tunnels for the sake of the goza with a very different approach. The roof is
staff, and were rarely higher than two stories. The gabled, and the exterior is a loud, bright red, like
use of multiple buildings was to segregate admin- an expressionist interpretation of a firehouse. It is
istrative facilities from care facilities, as well as to intended to draw attention to itself, which Ortega
segregate patients by both sex and type. To avoid said is the best way to integrate the children into
unnecessary redundancy, some hospitals included the community.
common buildings housing facilities like an audi- Inside, the angle of the ceiling in each room
torium, gymnasium, or chapel. represents the degree of activity taking place on
Cottage Plan facilities lacked the grandeur of that room, with a 60 percent slope in the bed-
the Victorian-era Kirkbride buildings. This was rooms and a 240 percent slope in the common
even more evident as utilitarian institutional areas. The project was criticized, though, for
architecture became dominant, with buildings not paying enough attention to the needs of and
lacking individual character, often resembling effects on the patients. Work on the impact of
warehouses more than medical facilities. Mul- facility design on the mentally ill, from the design
tifloor plans became more common, as did the of public spaces or educational facilities to the
use of dormitory buildings in lieu of individual construction of therapeutic spaces as part of a
rooms for patients. Nowhere was the idea of larger approach to treatment, continues to be a
warehousing enacted more vigorously than in vibrant theoretical field.
New York, where in the 1930s hospitals like Pil-
grim State Hospital were built with capacities in Bill Kte’pi
the thousands. Independent Scholar
After World War II, the effect of building design
on patient care was reconsidered, and new men- See Also: Anthropology; Art and Artists; Board and
tal hospital architecture tended to more closely Care Homes; Hospitals for the Criminally Insane.
resemble the early Cottage Plan buildings. Insti-
tutional warehouses were depreciated as the dein- Further Readings
stitutionalization movement sought to move the Hejduk, Renata and Jim Williamson, eds.
mentally ill out of care facilities and back home The Religious Imagination in Modern and
by finding pharmaceutical treatments for their Contemporary Architecture: A Reader. New York:
problems. The term socioarchitecture was coined Routledge, 2011.
in 1951 by psychologist Humphry Osmond in Moran, James, Leslie Topp, and Jonathan Andrews,
building the Weyburn Mental Hospital, both eds. Madness, Architecture, and the Built
a working hospital and a research facility. The Environment: Psychiatric Spaces in Historical
design was inspired both by zoologist Heini Context. New York: Routledge, 2007.
Hediger, who had established guidelines for the Payne, Christopher. Asylum: Inside the Closed World
building of zoo environments based on social and of State Mental Hospitals. Cambridge, MA: MIT
cognitive factors, and on Osmond’s inspirational Press, 2009.
explorations with LSD. Yanni, Carla. The Architecture of Madness: Insane
Outpatient care was also encouraged. In recent Asylums in the United States. Minneapolis:
generations, the treatment of mental illness as a University of Minnesota Press, 2007.
 Argentina 43

Ziff, Katherine. Asylum on the Hill: History of a 2003, just 47 percent of men and 43 percent of
Healing Landscape. Miami: Ohio University Press, women were in paid employment positions, and
2012. the national rate of suicide rose nearly threefold in
just five years to make it the second most common
cause of death among all individuals in Argentina.
Argentina’s health care system includes a tax-
backed public sector, a voluntary-insurance-
Argentina backed private sector, and a mandatory-insurance-
backed social security sector. Buenos Aires and
Cultural values, customs, and expectations pro- all of the republic’s provinces support a network
vide a collective framework within which mental of both public and private health care facilities.
illness is viewed and addressed by different societ- Argentina’s Ministry of Health is responsible for
ies. In Argentina, those factors have created an setting health care policies, implementing health
environment in which mental illness is generally care programs, and managing the overall opera-
stigmatized and frequently dealt with by fami- tion of the country’s health services and facilities.
lies rather than by mental health professionals. According to estimates by the World Health
Those individuals who do seek assistance through Organization, mental illness will be the top cause
the country’s health care system are likely to find of disability across the globe by the year 2020.
themselves sequestered away for extended peri- As a region, Latin America accounts for 10.5 per-
ods of time in neglectful or abusive institutions cent of the world’s total burden of disease due to
designed less for treatment and more to keep psychiatric disorders, including depression, bipo-
patients separated from the rest of society. lar disorder, schizophrenia, and substance abuse.
A new national mental health law was enacted Only one in five mentally ill patients in the region
in 2010 in response to a comprehensive public receives needed treatment from a mental health
activism campaign that aimed to raise social and care professional. This is partly because geograph-
political awareness about the state of Argentina’s ical distribution of services favor more urbanized
mental health care perceptions and practices. The areas and partly because most Latin American
law incorporates a plan to integrate mental health patients first try nonprofessional support, fol-
care more seamlessly into the primary health care lowed by nonspecialized medical help, before
infrastructure. The assimilation effort includes finally considering consulting a psychiatrist.
activities to reduce institutionalization, increase Argentina’s Ministry of Health estimates that
community care services, and facilitate training mental illness accounts for approximately 36 per-
for mental health care professionals. cent of all disabilities within the country. Like
most Latin American countries, Argentina allo-
Demographics and Health Care System cates only a small percentage of its total health
Argentina is one of the most populated coun- budget to the mental health segment. Tradition-
tries in South America. A majority of its inhab- ally, the majority of monies that are allotted to
itants have ethnic or cultural ties to Spain or cover treatment for mental illness go to support
Italy. Catholicism is most prevalent, but many long-term institutional care. The focus on asy-
individuals in rural areas of the country continue lum-provided segregation rather than outpatient
to practice folk religions and follow alternative and community-based treatment services reflects
sects. Significant differences in wealth, education, Argentina’s deep-rooted cultural belief that men-
infrastructure, and services exist between urban tal illness is something that should be kept out of
and rural areas of the country. the public purview.
Throughout its history, the republic has expe-
rienced a long record of political, economic, and Mental Illness Perceptions and Practices
social upheaval. Argentina’s infamous financial Mental illness is little understood by most Argen-
crisis in the late 1990s and early 2000s debilitated tineans and is considered disgraceful to the
the nation, creating widespread unemployment patient as well as to his or her family. Many see
and insecurity throughout the population. By mental illness as a sign of religious reckoning or
44 Argentina

imposed penance for an individual’s or family regarding the treatment of mentally ill individu-
member’s misdeeds or bad character. The prevail- als. Among other things, the law bans the devel-
ing stigma means that many individuals suffering opment of new psychiatric hospitals and outlines
from mental health issues refuse to seek help. The stringent parameters for involuntary institution-
reluctance may be further fueled by the fact that it alization, including identifying acceptable cir-
has been common practice in Argentina over the cumstances for consideration and ensuring the
years to commit persons with suspected mental ill- involvement of a human rights representative in
ness to long-term institutionalization against their the patient internment process.
will. The country’s asylums have a reputation for In addition, the new mental health law stipu-
abhorrent conditions, both in terms of living envi- lates that 10 percent of Argentina’s total health
ronment and patient treatment. Neglect, abuse, care budget be assigned to the mental health seg-
and even death have not been uncommon occur- ment. Specific allocations in mental health include
rences in the past. economic subsidies for community services and
Other Argentines with mental illness try to find education, treatment resources and facilities such
support through unofficial channels such as fam- as halfway houses and day hospitals, and profes-
ily members or church associates in an attempt to sional training for care providers. Grants are also
stay off the popular radar and avoid public ridi- funded to help patients reintegrate into society.
cule. Large and extended families are common A major component of Argentina’s men-
in Argentina and as a cultural norm they tend to tal health care reform plan is the integration of
attempt to support each other throughout diffi- mental health care into the nation’s primary care
culties and illnesses. Even with personal support, health system. Critics claim that the deinstitution-
prospective patients face Argentina’s lack of read- alization is not about improving patient care at
ily available clinical mental health services, and all. Rather, they contend it is the government’s
some may find themselves interned at one of the way of reducing new economic burdens associ-
country’s many asylums. ated with the provision of mental health services
It is estimated that approximately 0.05 percent under the health care reform law. Regardless of
of the Argentinean population, or about 20,000 motive, the primary and mental health amalga-
people, are committed in Argentina’s mental mation involves slowly reducing bed capacity
health institutions at any given time. Of those at long-term psychiatric institutions, expecting
individuals, an average of 80 percent will remain general medical care hospitals to address mental
institutionalized for more than one year. Some health issues and absorb serious mental health
patients will live out the rest of their lives in the cases using dedicated wings and short-stay admis-
country’s asylums because of family or societal sions, and enhancing community mental health
abandonment, financial paucity, and/or inadequa- services to provide accessible support for new and
cies of the external mental health infrastructure to newly released mental health patients.
support their reintegration into society. The changes are gradually trickling down
through Argentina’s health care system. A shift
Mental Health Care Reform toward community-based care in Neuquén Prov-
A public awareness campaign driven by human ince has helped maintain an 80 percent stabiliza-
rights organizations, legal groups, affected indi- tion rate among mental health care patients in the
viduals, and others designed to shed light on region. The ability to remain within their com-
Argentina’s mental health situation succeeded in munity and continue income-producing activities
attracting sufficient support to move the Argen- helps relieve some of the traditional stigma asso-
tine Ministry of Health into action in 2010. At ciated with mental illness and enables patients to
that time, a new mental health law was enacted maintain social ties and economic status while
that shifted the definition and treatment of men- receiving needed treatment support.
tal health patients from that of objects of wel- By 2011, the number of practicing psycholo-
fare to that of individual citizens with imbued gists in Argentina surged to 196 per 100,000
human rights. The legislation more closely aligns Argentineans, compared to just 27 psychologists
Argentina’s philosophy with worldwide standards per 100,000 people in the United States. The
 Art and Artists 45

increase in practicing psychologists in Argen- Di Filippo, Patricia. “It’s a Mad, Mad, Mad World.”
tina reflects the efforts of the nation’s health Argentina Independent (October 10, 2012).
care reform as well as the changing perspectives Romero, Simon. “Do Argentines Need Therapy?
among the populace regarding mental illness and Pull Up a Couch.” New York Times (August 18,
mental health support services. While some pri- 2012). http://www.nytimes.com/2012/08/19/world/
vate health plans refuse to cover psychotherapy americas/do-argentines-need-therapy-pull-up-a
as a treatment option, many plans provide cov- -couch.html?pagewanted=all&_r=0 (Accessed
erage for dozens of therapy sessions per patient March 2013).
annually. In an effort to provide more people World Health Organization (WHO). Integrating
with needed services—and to remain competitive Mental Health Into Primary Care: A Global
in the expanding market—many psychotherapists Perspective. Geneva, Switzerland: WHO, 2008.
offer services at discounted rates based on patient http://www.who.int/mental_health/policy/services/
income or even provide free services in exchange Argentina.pdf (Accessed March 2013).
for temporary labor. The abundance of affordable
psychotherapy offerings has increased popular
access to therapy services, and by 2012 psycho-
therapy was being viewed less broadly as shame-
ful among Argentineans and more widely as chic. Art and Artists
While increased psychotherapy services and
other improvements are being seen across the As far back as the time of Aristotle, people spec-
country, many prejudices and discrepancies in ulated about the connection between creativity
care remain in regard to Argentina’s mentally ill and mental illness. Ideas that come to mind when
population. For example, some primary care phy- discussing artists and writers are often media-
sicians are reluctant to give the same level of care driven stereotypes based on extreme examples of
and attention to a patient presenting with mental well-known painters and writers who both have
illness as they do to patients with physical ail- done notable work and have behaved in unusual
ments. Many medical physicians also have a pro- ways. Vincent Van Gogh’s self-amputation of an
pensity to prescribe drugs rather than psychother- ear, Leonardo da Vinci’s mirror writing, Ernest
apy as treatment, creating potential widespread Hemingway’s suicide, Jean-Michel Basquiat’s
drug dependency issues and financial burdens drug overdose, Emily Dickenson’s reclusiveness,
on patients. Another unexpected offshoot of the and Jackson Pollock’s alcoholism are extreme
health care reform has been within Argentina’s behaviors that have embellished their reputations
penal system. An abundance of mental patients as unique characters. The quality of their artistic
who may have been institutionalized in the past accomplishments stands alone but is underlined
are still being stigmatized as shameful outcasts by the stories of their lives, which highlight their
and are ending up in the nation’s jails. psychological struggles. The stories of artists’
struggles combined with their fresh visions of the
Shari Parsons Miller world as expressed through their artwork has
Independent Scholar given the aura of deviance to artists as a group.
Whether their unique vision is a result of emo-
See Also: Asylums; Community Mental tional struggles, biological predispositions, tech-
Health Centers; Compulsory Treatment; nical-professional skills, addictions, or a combi-
Deinstitutionalization; Family Support; Global nation of these factors has been examined from
Mental Health Movement; Informed Consent; Jails several points of view.
and Prisons; Stigma. There is romance in the idea of artists creat-
ing because they are mentally ill. For many artists,
Further Readings the creating of the work is a release of emotional
Alarcon, Renato D. “Mental Health and Mental tension, a way of working through pain and
Health Care in Latin America.” World Psychiatry, loss. Artists are masters at interpreting the cur-
v.2/1 (2003). rent social climate into visually and intellectually
46 Art and Artists

provocative works. Yet, artists are not so different Yet, in some ways, artists may have chosen a
from other people who struggle daily with mental career path that gives emotional outlet to an
challenges. Some of the best-known artists, such inner life containing a unique perspective on the
as Hemingway and Pollock, are identified with world around them and makes use of their tal-
their excessive drinking. Retrospective analyses ents. Whether one is a fine artist or a commercial
of their lifetime behaviors suggest that they may artist, successful production of art requires both
both have suffered from bipolar disorder in an motivation to produce and significant talent to
age before psychotropic mood stabilizers. Alco- execute the creative idea.
hol may have been a variety of self-medication,
a way to calm their manic symptoms. For other What Makes Something a Work of Art?
artists, alcoholism and addiction may have been What may make artists unique is that all art is a
both biologically and socially driven. form of cultural symbolism, a commentary on the
In addition to the celebrated fine artists are contemporary world. Other craftspeople may not
the many more commercial artists who use their have a trade that so readily interprets the social
techniques to interpret the currents of society into climate into a product. For creative work to be
cereal boxes, stage sets, and advertisements. They viewed as artistic, the result must resonate with
also struggle with issues of mental illness, neuro- the viewer as expressing an idea that is simulta-
sis, and addiction like the rest of the population. neously familiar and novel in approach. When

Ernest Hemingway writes at his campsite in Kenya, circa 1953. Some well-known artists such as Hemingway and Jackson Pollock are
identified with their excessive drinking, which may have been a self-medicating way to calm their manic symptoms. Hemingway’s
lifetime behaviors now suggest bipolar disorder, although he lived in an age before psychotropic mood stabilizers. He committed
suicide with a shotgun on July 2, 1961; several months earlier, he had been treated with electroshock therapy and medications.
 Art and Artists 47

the great masters of the Renaissance learned to and exciting. The labeling of artists as social devi-
use light and perspective to create new forms of ants helped create the romantic idea about artists
painting during the 1500s, it was a new approach as people living a rebellious or alternate lifestyle.
worthy of admiration, while depicting recogniz- In some cases, financial and social circumstances
able social and religious subjects. Mastering the were more responsible for the deviant lifestyle than
ability to create three-dimensional images on a desire on the part of the artist.
two-dimensional surface was a skill that Raphael
perfected and made him a celebrated painter of Psychopathology in Artists
his day. Today, learning to paint or draw with Artists may use their art as a way to express and
perspective is a basic aspect of art education. rework their psychological issues, allowing a
In the art world, timing is everything. The venue for expression of psychological tensions
introduction of an art form at a time when it can that is visible to a public audience and resonates
be received by a public audience as new and fresh as a work of art. For other people, the expression
makes a difference. There is plenty of evidence of psychological tensions is expressed through less
that Picasso could paint with exacting realism if public acts, such as the obsessive-compulsive who
he chose, yet he chose to distort his subjects into compulsively cleans or the spider-phobic person
exaggerated forms. His unique interpretations of who can’t leave the house while Halloween deco-
individuals or common objects caused Picasso to rations are in place. The development of mental
receive recognition, both positive and negative. illness may stem from life experiences that created
It was the novel form combined with purpose- inhibitions and focus on issues relevant to that
ful technique that made his artwork fresh to the individual’s life, or it may have biological roots,
viewer. Because it contains a visual flow of com- and often the intensity of psychological struggles
position and color that triggers emotional cues in comes from both sources. There is no one path of
the viewer, powerful art often looks as if it was experience that leads to becoming an artist.
effortless to produce. The work of Jackson Pol- There are medical conditions that have been
lock, known for his paint-splattered canvases, associated with creativity. Hypomania and cyclo-
often makes museum goers comment that “any thymia are the less destructive relatives of bipo-
3-year-old” could create art like Pollock. On lar disorder that can enhance artistic produc-
closer analysis, the balance of color, density, and tion and motivation to express ideas that come
style chosen by Pollock are what makes the differ- from hyperassociations. Hypomania is the inner
ence between a Pollock work of art and the scrib- drive to produce numerous ideas, art, or activi-
bles of a 3 year old. When he received recognition ties, combined with the need for less sleep. With
within the art world, Pollock became labeled as hypomania, unlike with true mania, the artist or
an abstract expressionist. person remains in control of his or her behaviors
About 30 years later, Jean-Michel Basquiat’s and can direct them in a useful way. Organic dis-
original art form was graffiti. He expanded his orders such as temporal lobe epilepsy and some
exposure by selling T-shirts featuring his designs forms of frontotemporal dementia have been
on the street and finally received recognition within linked to hypomanic traits that cause a pressure
the New York art scene as a fresh visionary. Before to produce creative output. Van Gogh is thought
Basquiat was accepted on the New York art scene, to have had temporal lobe epilepsy, which was the
graffiti was considered the work of deviants and underlying cause of his unpredictable moods, an
vandals, not artists. Only later did it become ele- extraordinary amount of work produced within a
vated to an art form in Basquiat’s time. In the music short time, and numerous hospitalizations. Sub-
world, jazz was considered a disreputable musical stance abuse and alcoholism may have the abil-
form because of its African American beginnings; ity to reduce inhibitions and self-doubts, allowing
rock and roll was considered “noise” made by the artist to work. However, there is no evidence
“misfits” such as Elvis Presley. Creative expression that alcohol improves the quality of ideas.
that fell into an artistic subgroup from the major- Carson’s model of shared vulnerabilities has
ity culture caused the artists to be labeled social been proposed to explain that the same biological
deviants. It also made the art newsworthy, fresh, basis that enhances creativity may also predispose
48 Art and Artists

an individual to mental illness, particularly mood that unconventional thoughts are useful and non-
disorders with an emphasis on bipolar spectrum threatening.
disorders, schizophrenia spectrum disorders, and Being able to identify qualities that are often
alcoholism or drug addictions. Characteristics present in artists is only part of the picture. The
shared by creativity and these psychopathologies characteristics of cognitive disinhibition, neural
increase the ability for material normally pro- hyperconnectivity, and an attentional style quick
cessed at a level below consciousness to be both to recognize novelty enhance both creativity and
monitored and manipulated at a level of aware- psychopathology. Concommitant with these char-
ness that is neither overwhelming nor totally frac- acteristics in artists are also high IQ, an increased
tured. The ability to use stimuli at this level may working memory capacity, and enhanced cogni-
require a reduced latent inhibition, an increased tive flexibility to enlarge the range and depth of
ability to recognize and appreciate novelty, and stimuli available to conscious awareness to be
biologically enhanced neural hyperconnectivity. manipulated and then recombined to form novel
How an individual controls, or is unable to con- and original ideas. These are the qualities that
trol, internal and external stimuli makes the dif- underlie creativity.
ference between creativity and mental illness. It Creative drive is fueled by more than neurotic
is often a fine line, with individuals moving from tensions and psychopathology. It can be fueled
brilliant creativity during one part of their lives to by the desire to playfully produce—for personal
debilitating illness at another. satisfaction, because of financial need, or other
Protective factors that allow artists to tolerate reasons known only to the artist. When creativity
and synthesize novel ideas have been suggested has been measured with psychometric scales, the
to be high IQ for a particular field of endeavor, results have demonstrated that creativity corre-
enhanced working memory skills, and a creative lates with higher scores of scales of psychoticism,
flexibility that, when combined, allow for facile impulsivity, and venturesomeness, while corre-
idea manipulation. The ability to hold a number lating with lower scores on the neuroticism and
of concepts within the mind simultaneously and conformity scales of a personality test. How well
use them effectively is what contributes to cre- these characteristics promote or inhibit output is
ativity, rather than psychosis. Some mental input related to mood. Managing mood through the use
might initially be considered bizarre, but when of medications, alcohol, or other substances can
joined with concepts that anchor them in a social be helpful and harmful.
reality, artists can produce novel and exciting Mental illness can increase the production of art
work. Artists’ ability to entertain bizarre thought by an artist through the need to release emotional
requires a cognitive flexibility that allows numer- tension. In the case of mania, artistic output can be
ous perspectives on the same subject. The shared rapid and numerous. However, production under
vulnerability model suggests that cognitive flex- manic circumstances does not guarantee quality
ibility is also a protective skill that keeps the artist work if the artist does not possess an underlying
from labeling his thoughts as crazy. technical skill and vision. In far more cases, men-
tal illness such as depression will prevent an artist
Productivity of Art and Mental Illness from creating through a lack of energy, negative
What might be called “brainstorming” in other thoughts, and difficulty with motivation. For art-
arenas may be a common way of viewing the ists with garden-variety neuroses, work can come
world for an artist. Artists are known for com- to a halt in the form of writer’s block and anxiety.
bining ideas in novel ways, often through the use When artists suffer from the debilitating mania or
of free association, which creates new ways of depression of bipolar disorder, the romantic ideal
looking at aspects of life that others have not put of being an artist is no longer quite so romantic.
into play. Free association is not randomness but At a certain point, mental illness becomes so
rather a process of being highly attuned to stim- debilitating to daily functioning that the artist
uli in the world and manipulating them in novel cannot create meaningful work. The stereotypi-
ways. This requires a latent inhibition that does cally “crazy” artist may be recklessly labeled as
not censure the bizarre thought and confidence schizophrenic by the public because of ideas that
 Assessment Issues in Mental Health 49

are unusual or that do not immediately resonate literature, in some cases contributed to periods of
with the viewer. Schizophrenia, however, is a mental anguish and early demise for artists. Per-
chronically debilitating disease with accompany- haps for even more artists who were inhibited or
ing vacancy of affect, and thoughts that are dis- may have lacked technical skills, personal emo-
torted or disordered. Harnessing the creativity tional struggles prevented them from expressing
within the individual and transforming it into a themselves in a manner that might reveal those
product while in that state becomes impossible. inner struggles to the world. These are the artists
Through a series of family history interviews who may have gone unrecognized for visionary
of well-known contemporary writers by N. C. thinking about the social milieu. Successful artists
Andreasen, the link between the affective disor- often possess the ability to balance the motivation
ders, especially bipolar disorder, was established. to create, an appreciation of novel stimuli, and
Creative writers and their first-degree relatives were the skills to express their interpretations.
more likely to have illness that appeared episodi-
cally and hampered creativity in discreet episodes, Robin Green
rather than continually. Unlike affective disorders, Kris Bevilacqua
schizophrenia was not linked to writers and their Albert Einstein College of Medicine
families. Because it is chronic, rather than episodic,
schizophrenia was more likely to inhibit creativity See Also: Creativity; Intelligence; Mania; Suicide;
rather than enhance it. The bizarre thoughts that Visual Arts.
accompany schizophrenia are not able to be used
in a productive way to create unique art because Further Readings
periods of normalcy are so limited. Andreasen, N. C. “Creativity and Mental Illness:
Like most individuals, artists create their best Prevalence Rates in Writers and Their First-Degree
work when they are emotionally stable enough to Relatives.” American Journal of Psychiatry, v.144
create the artistic concept, produce the work, and (1987).
analyze their results to some degree before shar- Carson, S. H. “Creativity and Psychopathology:
ing it with a public audience. An artist’s original A Shared Vulnerability Model.” Canadian Journal
viewpoint may have been through a neurotic fil- of Psychiatry, v.56/3 (2011).
ter, but it does not mean that if the neurosis is Flaherty, A. W. “Brain Illness and Creativity:
treated through psychotherapy or medication, Mechanisms and Treatment Risks.” Canadian
the talent will disappear or an artistic vision will Journal of Psychiatry, v.56/3 (2011).
be lost. Often, it is a relief to be finished with an Janka, Z. “The Impact of Mood Alterations on
issue that has been so burdensome. Creativity.” Ideggyogy, v.59 (2006).
What is unique to artists is their skill at commu- Kubie, L. S. Neurotic Distortion of the Creative
nicating with an appreciative audience in a mas- Process. New York: Noonday Press, 1967.
terful and fresh manner, regardless of the medium
they choose, not mental illness. Artists are not
more or less psychologically conflicted than other
people, but artists may find a way to express or
work through their conflicts in a manner that Assessment Issues
resonates with the viewer and readers. For some
artists, personal emotional struggles provoked the in Mental Health
tension in their work and narrowed their subject
matter to issues that they were trying to psycho- Assessment in mental health has always gener-
logically master. For others, a combination of bio- ated a vast array of issues of concern. These issues
logical predisposition and technical skills allowed include those related to the purpose of assessment
them to view the world in a unique way and show and the way in which it is conducted. Psychomet-
this in a manner that resonated with a wider ric issues include those of reliability and validity,
audience. The underlying biological differences, particularly with respect to the selection of men-
while often supporting great works of art and tal health assessment instruments.
50 Assessment Issues in Mental Health

What is Assessment? mental health assessment continues to evolve as

Assessment involves the collection of data that new challenges arise.
reflects the mental health status of the individual. There are clearly racial and ethnic disparities
It is the initial phase in helping an individual with in the United States and elsewhere with respect to
mental health problems to understand treatment mental health assessment, diagnosis, and clinical
options and eventually realize their full potential. disposition. For instance, schizophrenia is more
The client is understood to be the primary source frequently diagnosed among African Americans,
of data and should be informed of their mutual while mood disorders such as bipolar disorder are
roles and responsibilities in the assessment process. more often identified among white Americans.
By definition, mental health assessment is a African Americans are also overrepresented in
comprehensive and interdisciplinary review of rates of involuntary commitment. Asian Ameri-
a person’s behavioral, cognitive, emotional, and cans have been found to score higher on measures
other abilities in relationship to the functional of social anxiety. A closely related issue is that
demands of the environments in which they are many African Americans and those of other ethnic
expected to participate. These collaborative minority groups may have difficulties in establish-
assessments include social, educational, and voca- ing rapport in interethnic situations, such as those
tional evaluations to develop a holistic and indi- involving mental health assessments. At any rate,
vidualized plan of treatment and rehabilitation. ethnocultural and linguistic bias remains difficult
Understood as a comprehensive process within to overcome in mental health assessment. Stan-
an ecological paradigm, mental health assessment dardized approaches, with respect to instruments
focuses on the individual’s ability to function as and methods at least, are clearly needed to reduce
an independent actor in their community, family, the apparent discrepancies in mental health prev-
school, vocation, and other situations. A mental alence rates among various subpopulations and
health assessment, in this strictest sense, should to be better able to clinically differentiate between
endeavor to gain an overall picture of the indi- conditions that require treatment and those that
vidual, consisting of both his or her abilities and may be less severe syndromes.
deficits. Unfortunately, in practice, the dysfunc- An important aspect of assessment rests in
tions and limitations of a client are focused on all the way that the mental health professional
too often. approaches a participant and is able to form a
therapeutic relationship of trust and rapport. This
The Assessment Framework should minimally include being nonjudgmental,
Mental health professionals regularly assess indi- willing to listen, and maintaining an openness
viduals, either explicitly or implicitly, to determine toward other opinions. It may also be helpful
whether the person has a mental illness. If they do, to be flexible and, if needed, be willing to meet
then the assessment moves toward establishing a at different places and at irregular times. Active
diagnosis and planning for appropriate interven- listening and creating an atmosphere of profes-
tions. The assessment framework is generally sional confidence can be very useful in conducting
shaped by one of the major mental health diag- a mental health assessment. Getting the individ-
nostic classification systems, such as the American ual to actively engage in the assessment process is
Psychiatric Association’s Diagnostic and Statisti- crucial to being able to obtain meaningful results.
cal Manual of Mental Disorders (DSM-IV-TR) or Any method of mental health assessment
the World Health Organization’s International involves selecting some method of observation
Statistical Classification of Diseases and Related that enables the collection of information on
Health Problems (ICD-10). These systems, how- the subject. This data is then analyzed and inter-
ever, assume that their categories are universally preted to produce some understanding of the
applicable and ignore the fundamental truth that individual and his or her condition, providing the
all such categories are to some extent at least cul- opportunity to then make predictions about how
turally constructed. Further, the DSM has been that individual might function under particular
criticized for being overly descriptive and not use- circumstances, including participation in a spe-
ful for making clinical interventions. The role of cific treatment regimen. Mental health assessment
 Assessment Issues in Mental Health 51

instruments are one of the most typical tools a given person to that of a sufficiently relevant,
used to quantitatively measure an individual and large group of comparable individuals. The ethnic
attempt to estimate the scale or size of an existing background and other demographic characteris-
problem. tics of an individual must also be considered in
evaluating whether appropriate normative infor-
Assessment Instruments mation is available, which could seriously affect
There are numerous instruments available to the interpretation of a score on a particular men-
assess one or more facets of mental health. Some tal health assessment instrument as well as influ-
popular examples include the Beck Depression ence the choice of treatment.
Inventory, the Center for Epidemiological Studies Administrative options available with the use
Depression Scale, the Eysenck Neuroticism Scale, of a respective mental health assessment instru-
the Rosenberg Self-Esteem Scale, the Spielberger ment must also be examined. Alternative admin-
State-Trait Anxiety Inventory, and the Taylor istration procedures include written self reports,
Manifest Anxiety Scale. Instruments have been interviews, computer administration, and col-
developed for use with distinct populations such lateral inquiry formats, such as via a spouse or
as the Geriatric Depression Scale and the Geri- significant other. Some of these approaches have
atric Hopelessness Scale for older adults and the demonstrated greater engagement of clients in the
Kaufman Assessment Battery for Children and assessment process and even heightened the accu-
the Kiddie Schedule for Affective Disorders and racy of responses. Some assessment instruments
Schizophrenia for use with children. More cultur- require substantial training for proper admin-
ally relevant assessment instruments, such as the istration as well as for results interpretation.
Hispanic Stress Inventory and the Asian Ameri- Related issues of concern with the use of these
can Family Conflicts Scale, are sorely needed. The types of mental health assessment instruments are
purpose, intended target population, adminis- the availability of computerized scoring and the
trative options, and psychometric properties are charging of any fees for use.
some of the issues to consider in the selection of
specific instruments. Reliability and Validity
The use of a mental health assessment instru- Psychometric properties of respective instruments
ment should be consistent with its intended raise a significant set of issues with respect to
purpose. Unfortunately, this is often ignored by mental health assessment. Principal areas of con-
mental health practitioners in its application. A cern are those of reliability and validity, of which
common misuse is to employ a screening instru- there are several different types. The importance
ment for the purposes of diagnosis. For instance, placed upon these particular psychometric issues
the Michigan Alcoholism Screening Test (MAST) varies in accordance with the nature of the instru-
was intended to detect the proportion of individ- ment and its intended application.
uals in a study sample who may be at risk for
alcohol-related problems; it was not designed to Reliability. Reliability refers to the likelihood
explicate the nature or extent of such a problem that one would get the same or at least similar
in any one individual. However, for many years results with repeated assessment administrations.
it was widely used for screening individuals into Thus, reliability is concerned with the generaliz-
alcoholism treatment programs. In a similar man- ability of the assessment instrument across dif-
ner, diagnostic instruments have sometimes been ferent evaluators, settings, times, and so forth.
used for clinical research studies. Any assessment technique that has low reliability
In selecting a mental health instrument, it is would necessarily have low validity. On the other
essential to consider its suitability for a given hand, an assessment technique may have high
individual with respect to the intended target reliability, being very consistent across adminis-
population. Many instruments developed for and trations and administrators, but may or may not
on adult populations have been administered to be valid.
adolescents. A related issue is whether there are Some of the most common types of reliability
norms available to compare the performance of issues are test-retest, split-half, internal consistency,
52 Assessment Issues in Mental Health

and parallel forms. The similarity of results for of other variables that would typically be expected
administration of the same assessment measure to be associated in predictable ways with what
at two points in time is known as test-retest reli- the instrument purports to measure.
ability. For instance, an assessment instrument Criterion validity is concerned with how well
may be administered to a sample population and the assessment instrument scores relate to rel-
then again in four weeks. There should be suffi- evant and significant behaviors.
cient time between assessment administrations Concurrent validity generally refers to the
so that test subjects cannot simply be remember- degree of agreement between the assessment
ing their earlier responses. The correlation coef- instrument results and those of some other mea-
ficient between the first and second administration sure of the same variable that is obtained at
would indicate the degree of test-retest reliability. approximately the same time, or concurrently.
Higher test-retest reliability scores are generally Discriminant validity refers to the ability of the
expected on measures of relatively stable mental instrument to discriminate between the respective
health characteristics such as those considered as subscales used in many assessment instruments.
traits as opposed to those considered as more tran- Interscale correlations can be used to indicate the
sient states. degree of discriminant validity.
Split-half reliability is measured by correlation Other approaches have been used in conducting
coefficients calculated between half the items of a mental health assessment, including a screening
an assessment instrument with those of the other interview. Various diagrams have also been devel-
half such as odd-numbered to even-numbered oped to aid mental health practitioners. Family
items. Internal consistency measures evaluate mapping and the genogram, for instance, have
how well responses on individual items of an been used for family work. Drawings by patients
instrument correlate with those of the other items. have also been used in mental health assessment.
For assessment instruments intended to assess a These other types of assessment approaches can
single phenomenon, high correlation coefficients generally be regarded as qualitative in nature,
for internal consistency are expected. Split-half while those such as the administration of assess-
and internal consistency measures assess the ment instruments are more quantitative.
agreement of content covered within the instru-
ment itself. Conclusion
Parallel forms reliability refers to the degree of By its very nature, assessment is fundamentally an
obtaining comparable results from two different exploratory exercise. Although the specific con-
sets of items designed to address the same men- tent and respective methodologies for conducting
tal health issue; this necessitates creating equiva- an assessment are extremely variable, the process
lent forms of the same assessment instrument, an is always intended to gain a better understanding
endeavor that is rarely utilized. of the individual client before taking any action.
From a clinical perspective, the primary ben-
Validity. Validity refers to the extent to which the efit of assessment is to efficiently and accurately
assessment instrument actually measures what it determine any treatment needs of a particular
purports to assess. Some of the most commonly individual. Mental health assessment should
considered types of validity considered are con- be broad enough in scope to consider multiple
tent, construct, criterion, concurrent, and dis- variables that might potentially play a signifi-
criminant. cant role in the functioning of an individual such
Content validity is concerned with the extent to that they could warrant targeted intervention in
which assessment items appropriately and com- an individualized treatment plan. Assessment is
prehensively sample the domain of interest; con- essentially concerned with individualizing each
tent validity is generally built into an instrument mental health case, providing individualized
by means of careful construction and selection of feedback that can enhance an individual’s moti-
assessment items. vation for change.
Construct validity is supported when an assess- Mental health treatment programs that incor-
ment instrument correlates highly with measures porate formal assessment procedures have been
 Asylums 53

found have higher client retention. It is also a Asylums

dynamic process that should be ongoing through-
out the course of treatment delivery. Mental Preceding the emergence and acceptance of asy-
health professionals should continuously col- lum care in the late 18th century, family members,
lect data that are accurate, comprehensive, and almshouses, and jails assumed primary respon-
systematic. Mental health assessment should be sibility for those grappling with mental illness.
regarded and utilized as an integral part of the Americans and Europeans still inhabited a social
treatment process, not separate and apart from it. world deeply entrenched in religious traditions.
For many, mental illness was conceptualized as
Victor B. Stolberg a moral failing, and most people were unsympa-
Essex County College thetic to the problems of the insane. The massive
industrialization and urbanization that altered the
See Also: Cultural Prevalence; Diagnosis; Diagnosis social landscape in the 19th century also called for
in Cross-National Context; DSM-IV; Ethical Issues; a refashioning of mental health care. Cordoned
International Classification of Diseases; Measuring off from society, asylums were presided over by
Mental Health; Mental Illness Defined: Psychiatric medical superintendents and their attending staff.
Perspectives; “Normal”: Definitions and Controversy; The enthusiastic creation, tumultuous course, and
Psychiatric Training. eventual dissolution of the asylum are connected
to the complex understanding of the precise origin
Further Readings and appropriate treatment of mental illness held
Andary, Lena, Yvonne Stolk, and Steven Klimidis. by the medical community. Not merely reserved
Assessing Mental Health Across Cultures. Bowen for professionals, asylums also captured the lay
Hills: Australian Academic Press, 2003. public’s attention. The trajectory of the asylum
Cuellar, Israel and Freddy A. Paniagua, eds. reveals the emergence of not only an organized
Handbook of Multicultural Mental Health: psychiatric medical profession but also plots the
Assessment and Treatment of Diverse Populations. changing expectations and rights of those battling
San Diego, CA: Academic Press, 2000. serious mental illness.
Gibbons, Robert D., David J. Weiss, David J. In Europe, the oldest asylums were founded in
Kupfer, Ellen Frank, Andrea Fagiolini, Victoria J. Spain under Islamic rule. In the English-speaking
Grochocinski, Dulal K. Bhaumik, Angela Stover, world, Bethlem Royal Hospital (known as “Bed-
R. Darrell Bock, and Jason C. Immekus. “Using lam”) on the outskirts of London began to spe-
Computerized Adaptive Testing to Reduce the cialize in providing for the insane early in the 14th
Burden of Mental Health Assessment.” Psychiatric century, albeit on a very small scale. By the 18th
Services, v.59/4 (2008). century, a private “trade in lunacy” centered on
Hudson, Walter W., Paula S. Nurius, and Sorel profit-making madhouses developed in England,
Reisman. “Computerized Assessment Instruments: maisons de santés accommodated small numbers
Their Promise and Problems.” Computers in of the insane in France, and colonial America
Human Services, v.3/1–2 (1988). made its first provision for lunatics in the base-
Snowden, Lonnie R. “Bias in Mental Health ment of the Quaker-run Pennsylvania Hospital in
Assessment and Intervention: Theory and 1753. It was not until the 19th century that the
Evidence.” American Journal of Public Health, expansion of the asylum as the first-line response
v.93/2 (2003). to mental illness on both sides of the Atlantic
Switzer, Gary E., Mary Amanda Dew, and Evelyn J. occurred, with the creation of tax-supported asy-
Bromet. “Issues in Mental Health Assessment.” lums alongside a number of private institutions
In Handbook of the Sociology of Mental Health, for wealthier families.
Carol S. Aneshensel and Jo C. Phelan, eds. New The historiography of asylum creation has
York: Springer, 1999. been told from multiple viewpoints, with each
Tracy, Elizabeth M. and James K. Whittaker. “The camp claiming to isolate the precise cause for the
Social Network Map: Assessing Social Support in asylum movement that swept the West. Advo-
Clinical Practice.” Families in Society, v.71 (1990). cates of the meliorist perspective see the birth of
54 Asylums

the asylum as a positive, humanitarian gesture; Deploring the atrocious conditions that the
while others, particularly French philosopher- mentally ill faced, one of the most vocal and suc-
historian Michel Foucault, have argued that cessful advocates of asylum creation in America
it constituted a form of moral imprisonment. within this moral tradition was Dorothea Dix.
Others have attempted to tie the rise of asylums Given women’s exclusion from the vote and the
to the birth of a market economy, to efforts at public sphere, this female moral entrepreneur’s
social control, and to a growing belief in human widespread influence was highly unusual. She
perfectibility, or at least malleability. The 19th- frequently exchanged letters with President Mil-
century asylum was born amid utopian notions lard Fillmore. In addition, the rapid acceptance
about the possibility of cure because the degree of the asylum idea in southern and border states
of control it appeared to offer over patients’ lives, in antebellum America is even more striking
a phenomenon particularly noticeable in Amer- because Dix hailed from Boston, Massachusetts,
ica, where a “cult of curability” emerged in the and ran in liberal circles. Despite her close affili-
1830s and 1840s, helping persuade politicians to ations with abolitionists Ralph Waldo Emerson
allocate funds to build new institutions. Medical and Horace Mann, Dix ignored the slavery issue,
men soon monopolized the business of running focusing her moral energies only on the white
asylums, and the rise of the asylum also marked insane; this strange moral blindness may have
the emergence of an organized group of special- benefited her southern asylum creation endeav-
ists in the diagnosis and treatment of mental ill- ors. The effectiveness of her efforts may also be
ness. For almost a century, the fate of the asylum a testament to her strong conviction that even
and the profession that became psychiatry were the worst asylum would be better than the best
intertwined. home treatment because of the opportunities
that moral treatment would open up, and there-
Moral Architecture and Treatment fore the crucial step that states needed to make
The use of physical space to enforce moral was to build asylums because they could always
boundaries (known as “moral architecture,” as be improved afterward—a woefully mistaken
advocated by American asylum superintendent assumption.
Thomas Kirkbride), and the consistent encourage-
ment of patients to reassert self-control (known Growth and Criticism
as “moral treatment,” as championed by French The extreme optimism that had greeted the con-
physician Philippe Pinel and British Quaker struction of these institutions soon turned out to
reformer William Tuke) were central features of be misplaced, and was replaced in the last third
the asylum reform program. Consequently, the of the 19th century by an equally profound pes-
design of space within which the mentally ill were simism. While asylum superintendents used to
confined and treated was an important element boast of extraordinary, albeit inflated, cure rates,
in the expansion of the asylum system in the first the tune had slowly changed. Asylums grew
six decades of the 19th century. Orchestrated lin- larger and more overcrowded as public authori-
early, the typical asylum built during this time had ties grew ever more skeptical of the possibility of
a central administrative building, flanked by an cure, and the cruelties that had helped legitimize
all-male and all-female ward on each side. In a the building of asylums re-emerged in intensified
hierarchical fashion, the better-behaved patients form in the huge “museums of madness” that
were lodged close to the administration, whereas became a familiar part of the landscape. From
the poorer-behaved were farthest away. New the lay public to respected social critics, the plight
York City’s Central Park architect Frederick Law of those confined to asylums became a popular
Olmstead designed many asylum landscapes. topic. Charles Dickens, the prolific fiction writer
Patients were encouraged to participate in main- who constantly attended to issues of social con-
taining the often elaborate grounds and assist in cern, toured asylums in the northeastern and mid-
asylum upkeep because this was thought to foster western states during his two extended visits to
the sense of responsibility and purpose pivotal to America. He penned in his publication, American
the moral treatment program. Notes for General Circulation, that “everything
 Asylums 55

many as 14,000 patients and staff occupied an

establishment larger than a small town. A patient
protest literature emerged, with some of the most
vociferous critiques authored by women like Eliz-
abeth Packard in the United States and Louisa
Lowe in Britain, who complained of the ease with
which women in particular were confined in these
establishments. Mary Todd Lincoln, widow of
the recently assassinated President Abraham Lin-
coln, wrote extensively to her lawyer and his wife
during her involuntary inpatient stay at Bellevue
Place in Batavia, Illinois, pleading for assistance
in securing her release. She eventually succeeded.
Women were not the only patients protesting the
asylum system; Clifford Beers’s autobiography,
A Mind That Found Itself, painted a bleak pic-
ture of asylum life and helped launch the mental
hygiene movement in America.
The Great Depression and the impact of war-
time restrictions brought about a further dete-
rioration in asylum conditions. Exposés of the
failings of asylums in the postwar era were made
especially vivid by the publication of photo-
graphic evidence of the conditions under which
patients languished. Life magazine published a
In 1814, asylum reformers discovered James Norris, who had particularly powerful photo essay called “Bedlam
been cruelly restrained for about 10 years at Bethlem Royal 1946,” displaying horrifying images from inside
Hospital (“Bedlam”) in London. The ensuing public interest asylum walls. Patients looked malnourished and
was a catalyst for the Mad House Act of 1828, which sought to mistreated; asylum wards swarmed with inmates
license, regulate, and improve treatment in asylums. kept in dilapidated squalor. After previously glo-
rifying the asylum establishment, Albert Deutsch,
a self-educated journalist, lambasted the asylums
for their derelict conditions, likening asylums to
had a lounging, listless, madhouse air, which was concentration camps. Given the outrage regarding
very painful.” Despite asylum reformers’ intent the atrocities committed against European Jews
to improve the mental patients’ living conditions and Gypsies within Nazi concentration camps and
and life chances, the asylums were increasingly the availability of images of Nazi death camps to
painted in a negative light. The haunting portrait the public, such a comparison only furthered asy-
by Francisco de Goya, titled The Madhouse, cap- lums’ disrepute.
tures this impression. Deutsch and other journalist critics of the asy-
Asylums came to be culturally seen as ware- lum had sought to reform the system and shame
houses for the unwanted, holding pens where the states into funding asylums more generously.
legions of the mad were sequestered out of harm’s During the 1950s, however, a series of sociologi-
way. Psychiatrists adopted pessimistic explana- cal studies of the mental hospital by such figures
tions of mental illness that emphasized its roots as Morris Schwartz, Ivan Belknap, and Erving
in biology and hereditary defect, and the asylum Goffman—most of them funded by the National
acquired a dismal reputation among the public at Institute of Mental Health—painted an increas-
large. By the early 20th century, a single asylum ingly grim portrait of its failings, no longer believ-
on the outskirts of London contained as many as ing that the mental hospital could be salvaged.
12,000 patients; and in Milledgeville, Georgia, as Goffman’s Asylums, in particular, damned such
56 Asylums

places as “total institutions” that, far from pro- A final contribution to the abandonment of the
viding therapy, systematically damaged and dehu- asylum idea was signaled by a shift in the psy-
manized the patients they contained. He also crit- chiatric profession. As asylum-based psychiatrists
icized the hierarchical moral architecture design, became increasingly pessimistic about their mis-
condemning the system as entirely misguided sion, psychoanalysis rose to dominance in the
in assisting patients to prepare for life outside 1950s and 1960s in elite psychiatric circles. To
the asylum. Further buttressed by the extreme some extent, this reflected the psychoanalytically
antipsychiatry critiques of Thomas Scheff and inclined Brigadier General William Menninger’s
Thomas Szasz, the claim that asylums could ever leadership of army psychiatry during World War
be therapeutic establishments was dismissed as a II. This shift helped move the psychiatric profes-
carefully crafted fiction. Szasz’s best-selling radi- sion’s center of gravity from the asylum to outpa-
cal book, The Myth of Mental Illness, asserted tient practice. The elevated status and increased
that institutional psychiatry provided a medical pay that accompanied highly individualized talk
fig-leaf for the incarceration of people who soci- therapy weakened the profession’s commitment
ety wanted to put away. to the asylum. Psychoanalytical techniques pos-
sessed a lack of applicability to inpatient treat-
Deinstitutionalization ment—a few well-endowed and unusual private
Asylum populations in the United States and Brit- establishments such as the McLean Hospital in
ain peaked in the mid-1950s. Thereafter, what Boston, Massachusetts; the Chestnut Lodge in
had been Western societies’ first-line response to Rockville, Maryland; and the Menninger Clinic
the problems of serious mental illness entered a in Topeka, Kansas, being the exceptions that
period of increasingly rapid decline. What was prove the rule. This professional shift did not
soon dubbed the “deinstitutionalization move- cause the abandonment of the asylum and the
ment” or “decarceration” saw public policy mak- massive trans-institutionalization that followed,
ers increasingly turn away from involuntarily but it made it easier to accomplish.
committing mental patients to custodial institu- Psychiatry, a profession originally born in the
tions for lengthy periods. The delegitimization of asylum, increasingly transferred its preferred
the asylum by social scientists, which began to be locus of practice from the institution to outpa-
echoed in fiction and movie depictions of asylum tient, office-based practice, largely abandon-
life, most notably in Ken Kesey’s One Flew Over ing the most gravely disturbed to their fate, and
the Cuckoo’s Nest and Samuel Beckett’s Malone embracing psychopharmacology as its treatment
Dies and Murphy, spurred such changes and of choice.
helped obscure the absence of alternatives to tra-
ditional asylum provision. Alongside the growth Lauren D. Olsen
of the sidewalk psychotic as a familiar feature of University of California, San Diego
modern urban existence, many mental patients
were not deinstitutionalized at all but merely See Also: Architecture; Deinstitutionalization;
trans-institutionalized into board and care homes Mental Institutions, History of; Movies and Madness;
and prisons. Similar to the 17th-century private Social Control.
madhouses in England, the board and care homes
constituted a new trade in lunacy, funded in part Further Readings
by such federal programs as Medicare and Sup- Goffman, Erving. Asylums: Essays on the Social
plemental Security Income. Many of the former Situation of Mental Patients and Other Inmates.
asylum attendants purchased property near the New York: First Anchor Books, 1961.
old asylums and continued to take care of the Grob, Gerald N. Mental Institutions in America:
mentally ill, this time for profit; however, these Social Policy to 1875. New York: Free Press, 1973.
homes were rife with corruption, to the detriment Rothman, David. The Discovery of the Asylum.
of the patient—many board and care home oper- Boston: Little, Brown, 1971.
ators soon realized that the less they spent on the Scull, Andrew T. Social Order/Mental Disorder:
patients, the more profit they could amass. Anglo-American Psychiatry in Historical
 Attention Deficit Hyperactivity Disorder (ADHD) 57

Perspective. Berkeley: University of California sociological problem, given that ADHD is such a
Press, 1990. common childhood abnormality.
Tomes, Nancy. A Generous Confidence: Thomas These sociological variables structure the prob-
Story Kirkbride and the Art of Asylum-Keeping lem of ADHD as an ambiguity. The ways in which
1840–1883. Cambridge: Cambridge University the disorder is defined and diagnosed are not
Press, 1984. consistently applied across cultures, leading to
disproportionality among some cultural groups.
This inequity is difficult for medical and psycho-
logical communities because the treatment proto-
cols for this disorder must be culturally defined.
Attention Deficit The implications for educational systems are criti-
cal because the intervention cycle takes a different
Hyperactivity Disorder form across cultural groups when the disabling
(ADHD) condition of this disorder affects teaching and
learning. Overall, these cultural variations in the
Attention deficit hyperactivity disorder (ADHD) conceptualization of ADHD lead to substantial
is among the most frequently identified child- ambiguity in understanding how the impairment
hood problems in both medical and educational takes shape in childhood.
settings. In American schools, over 4 million
children and adolescents are diagnosed with this Definitions and Diagnostic Criteria
disorder, and over half of those are treated with The Diagnostic and Statistical Manual of Men-
medications. Outside the U.S. setting, however, tal Disorders (DSM) remains the major basis
there is wide discrepancy in the reported global for identifying and classifying ADHD and other
prevalence rates of ADHD, ranging from 0.5 to impairments; however, the ways in which differ-
20 percent of school-aged children around the ent cultures view the DSM definition of this disor-
world. This could be caused by the lack of cross- der are as varied as its symptoms. For more than
cultural agreement about the epidemiology and a decade, the DSM has been criticized as primar-
etiology of this disorder. ily Western-delineated, with very limited cross-
Because there are no clear evidence-based indi- cultural applicability. Despite its claims that most
cators (i.e., medical tests, neurological profiles, or mental disorders are universal, its classification
metabolic markers) for the disorder, and because system has been determined to be subject to cul-
there are wide variations in how its characteristics tural differences and expectations. The propensity
present in different children, no tidy agreements for varying cultures adopting precisely the same
have been reached as to the actual cross-cultural definition and delineation of ADHD, therefore, is
definitions of the disorder. There is a substan- weak. Culturally vague applications of this disor-
tial dependence upon observational identifica- der are a current element of study in the medical
tion; therefore, problems exist with regard to its and psychological exploration of the problem.
tracking and, because of the ways in which dif- The theory that ADHD is a disorder of adap-
ferent cultures perceive the identification crite- tation suggests that children’s neuronal plastic-
ria, diagnosis is varied across social and cultural ity and responsiveness to environmental cues is
landscapes. heavily dependent upon the cultural landscape
Social and cultural factors provide interesting of interaction and learning opportunities. The
lenses through which to view ADHD. Across cul- theory that ADHD is a social construct suggests
tural groups, treatment protocols take different that children’s behaviors related to inattention,
forms and functions, theories of causation and impulsivity, and hyperactivity are reliant upon
etiology are varied, and epidemiological statistics the way in which society defines and interprets
appear to wax and wane. Many scientists believe limits of abnormality among children’s behaviors.
that these group differences yield evidence for By contrast, the theory that ADHD is a neurologi-
ADHD as a culturally determined phenomenon, cal manifestation suggests that the features and
rather than a medical disorder. This presents a characteristics of the disorder are derived from
58 Attention Deficit Hyperactivity Disorder (ADHD)

neuropsychological processes that are related neuropsychological functioning, there is no physi-

directly to the organic capacity of the brain. All ological indicator in brain function or mechanics.
of those theories, among others, rest upon the Taking the disorder out of the context of univer-
assumption that various cultures and community sal neurological fact, the essence of cultural impli-
settings offer different stimulus and enrichment cation is clear.
opportunities for children. Therefore, the likeli- Without having a determinant of consistent
hood that culturally specific bias would weight a demonstration of neurological symptom, the
definition of the disorder is high. This is a key focus upon social variables may be the more per-
point of interest when examining the DSM-5 cri- tinent viewpoint for considering the manifesta-
teria for the diagnosis of ADHD, and some prob- tion of ADHD symptoms. The general schema for
lems arise when considering the ways in which considering this disorder can be examined across
the criteria are applied. those three important perspectives to clarify the
First, the symptoms/characteristics of the dis- need to describe it in culturally relevant terms.
order are developmentally bound. For instance,
DSM criteria are written to highlight difficulties Implications
that may be expected to occur prior to a specific Critical implications of this cultural issue in the
age. Individual criterion statements perpetuate identification and treatment of ADHD are evident
the notion of developmental inappropriateness in both the medical and educational settings. At
(i.e., children of a particular age or stage should the basic level of difference, cultural groups vary
be expected to engage in a particular behavior with regard to the prevalence rate of the disor-
while avoiding another). Definitions of inatten- der. Despite the application of global diagnostic
tion, hyperactivity, and impulsivity are presented criteria that are designed to describe all children
as developmentally undesirable features. All of uniformly, Caucasian children are more likely to
these issues illustrate Westernized appropriations be identified as having ADHD than their African
of childhood. Adult expectations of children’s American or Hispanic peers. Within the Hispanic
behaviors and cognitive features in Western-dom- culture, countries of origin vary distinctly in diag-
inated homes, classrooms, and community set- nostic statistics, with Mexican children fivetimes
tings are the normality by which all patients are more likely than Puerto Rican children and 10
evaluated. This leaves the identification of ADHD times more likely than Cuban children to be iden-
up to cultural interpretation because the viable tified as having the disorder. Within all racial and
developmental trends and characteristics of child- ethnic groups, male children are more likely to be
hood are largely defined in cultural terms. diagnosed than females. Children with externaliz-
Second, the symptoms/characteristics of the ing behavior problems (i.e., aggression) are more
disorder are without behaviorally specific appli- likely to be diagnosed than those with internal-
cations to cultural norms and/or expectations. izing issues (i.e., cognitive problems).
When considering the diagnostic criteria, quali- Medically, there are cultural differences in the
fiers and quantifiers are rare. Intended frequency, preferences for treatment of ADHD. There are
duration, and intensity of behaviors and cogni- connections between cultural perceptions of the
tive elements are not specified. Specific qualities identification of the disorder and the likelihood
of actions and thought processes are not delin- for accepting medical intervention. As a result,
eated. These would be up to cultural interpreta- an estimated 76 percent of Caucasian children
tion when applied in real-world situations. The with ADHD take prescription medications to
degree to which a particular behavior is consid- control symptoms, whereas 56 percent of African
ered abnormal is highly bound by societal and American children with ADHD and 53 percent of
cultural tolerance and reinforcement. Hispanic children with ADHD take such medica-
Third, the symptoms/characteristics of the dis- tions. Similar disparities are revealed across vari-
order lack clear connections to universal physi- ables such as help-seeking behavior, willingness
ological manifestations. Although there is a gen- to accept counseling and behavior training, and
eral relationship between the ADHD diagnostic adherence to self-management skill protocols for
criteria and the superficial characteristics of successful home and community living. The more
 Atypical Antipsychotics 59

culturally relevant the diagnosis is to a family, the A Systematic Review and Metaregression Analysis.”
more likely the family is to seek and sustain help American Journal of Psychiatry, v.164 (2007).
for the child’s ADHD condition. Thakker, J. and T. Ward. “Culture and Classification:
Educationally, students with ADHD improve The Cross-Cultural Application of the DSM-IV.”
academically and behaviorally when directed inter- Clinical Psychology Review, v.18/5 (1998).
vention is provided. However, there are some dis- Timimi, S. and J. Leo. Rethinking ADHD: From
parities that describe multicultural participation in Brain to Culture. Basingstoke, UK: Palgrave
educational interventions for the disorder. Interna- MacMillan, 2009.
tional students, English language learners, minor- Wegner, L. “The Last Normal Child: Essay on the
ity status children, and persons from low socio- Intersection of Kids, Culture, and Psychiatric
economic status groups are less likely to receive Drugs.” Journal of Developmental and Behavioral
specialized educational services that are designed Pediatrics, v.30/1 (2009).
to target symptoms of ADHD in the school setting.
Instead, these children are more likely to either not
receive services at all or to receive specialized ser-
vices but not for the eligibility category of health
impairment related to ADHD. Parents, teachers, Atypical Antipsychotics
and school service providers are also more likely
to include Caucasian children in the identification The term atypical, when applied to antipsychotic
and treatment protocols because of the increased drugs, has had multiple meanings and uses. First,
application of ADHD diagnostic criteria and eligi- atypical refers to a specific group of antipsychotic
bility determination with children from culturally drugs that includes clozapine, synthesized in 1958,
dominant backgrounds. as well as a raft of new antipsychotic drugs intro-
Although it is recognized as a significant risk duced since the 1990s. Second, atypical refers to
to childhood success around the world, ADHD their collective side-effect profile, which differs
is viewed substantially differently across cul- somewhat from the so-called first generation of
tural groups. Applying the diagnostic criteria and antipsychotic drugs. Third, aided and abetted by
symptoms, seeking and optimizing treatment pro- the pharmaceutical industry’s marketing efforts,
tocols, and perceiving effectiveness of interven- the designation “atypical” meant better and more
tion on symptomology are common variables in effective, despite the lack of supporting evidence
which cultural differences are viewed. Despite the for all atypicals except clozapine.
fact that most cultures recognize its critical link to
childhood experiences, ADHD is still a condition Development Over the Decades
that receives varied support from families, medi- From the 1970s onward, clozapine’s actions pro-
cal professionals, and educational personnel the vided a model for antipsychotic drug develop-
world over. Culturally compatible viewpoints for ment. Though first recognized in the late 1950s,
coping with ADHD must be advocated in order tardive dyskinesia had become a major problem
to fully benefit patient health and satisfaction. by the 1970s, prompting pharmaceutical com-
panies to search for drugs that acted similarly to
Russell Vaden clozapine both clinically and pharmacologically.
University of Wisconsin, La Crosse Researchers made major progress in the 1960s
Steven Arenz and 1970s in characterizing brain neurochemis-
Winona State University try and the ways in which antipsychotics acted.
In particular, researchers discovered the nature of
See Also: Children; Diagnosis; Diagnosis in Cross- chemical neurotransmission in large part through
National Context; DSM-5; Education; Social Class. studying how antipsychotic drugs acted. These
studies showed that traditional antipsychotic
Further Readings drugs block dopamine D2 receptors and that this
Polanczyk, G., M. Silva de Lima, B. L. Horta, and J. effect correlates with both antipsychotic effects
Biederman. “The Worldwide Prevalence of ADHD: and extrapyramidal symptoms (EPS).
60 Atypical Antipsychotics

In contrast, clozapine has a higher affinity for course) introduced between the 1950s and 1970s.
serotonergic than dopaminergic receptors, a fact Furthermore, pharmaceutical companies heavily
that has guided pharmaceutical development of promoted atypicals as capable not only of treat-
newer agents that act at similar sites and, incon- ing psychotic symptoms (such as hallucinations
sistently, is also how atypicality has been defined. and delusions) more effectively than the first gen-
In 1984, Janssen chemists synthesized risperi- eration of antipsychotic drugs but also as capable
done, which blocks serotergic as well as D2 recep- of treating social withdrawal and cognitive defi-
tors, and received Food and Drug Administration cits, core symptoms of schizophrenia untouched
(FDA) approval in 1993 to market it as Risperdol, by first-generation antipsychotic drugs.
the first new atypical antipsychotic drug marketed With even less evidence and, as it would later
in the United States. In 1996, Eli Lilly brought become apparent in court cases against the man-
to market the atypical antipsychotic drug olan- ufacturers, in spite of possessing proprietary,
zapine (brand name Zyprexa). A year later, the unpublished company data to the contrary, phar-
FDA approved AstraZeneca’s quetiapine (brand maceutical companies extolled the safety of atypi-
name Seroquel). Six additional atypical antipsy- cals. Manufacturers had indeed succeeded in pro-
chotic drugs have entered the U.S. market since ducing compounds that, unlike clozapine, did not
2000: ziprasidone in 2001 (brand name Geodon), substantially increase the risk of fatal agranulocy-
aripipiprazole in 2002 (brand name Abilify), pali- tosis. Also, taken together, it is likely (though not
peridone in 2006 (brand name Invega), iloperi- certain) that atypicals cause fewer movement dis-
done in 2009 (brand name Fanapt), asenapine orders than do the first-generation drugs. Clozap-
in 2009 (brand name Saphris), and lurasidone in ine, however, remains the only antipsychotic vir-
2010 (brand name Latuda). tually free from producing this set of side effects.
The launch of Risperdol in 1993 inaugurated a What remained hidden from view until the
transformation of the antipsychotic drug market early to mid-2000s, however, was a whole set
that produced previously unimaginable profits. of metabolic side effects that would undo these
On the eve of Risperdol’s introduction, world- unsubstantiated declarations of safety. Through-
wide sales of antipsychotic drugs amounted to out the 1990s and early 2000s, few questioned
less than a billion dollars, with clozapine, the pharmaceutical company claims of improved
only marketed atypical, accounting for only a efficacy and safety, a fact that allowed atypicals
small fraction of this sum. Over the next decade, to rapidly conquer the market of patients with
atypical antipsychotic drugs captured more than schizophrenia and to expand far beyond that
90 percent of the market, and worldwide sales of initial usage. Though initially approved only
these compounds mushroomed to more than $10 for the treatment of schizophrenia, off-label use
billion. By 2011, antipsychotic drug sales topped grew rapidly as the illusion of safety and efficacy
$28 billion, becoming the fifth-largest selling drug encouraged physicians to prescribe atypicals for a
class, just behind oncologics, respiratory agents, variety of psychological ills ranging from insom-
antidiabetics, and lipid regulators. The U.S. phar- nia, anxiety, depression, and dementia to a host of
maceutical market accounted for the majority of childhood disorders.
these expenditures (as it does for the majority of Few of the claims that justified the extensive use
pharmaceutical classes). Of the $28 billion spent and cost of atypicals have held up to close scrutiny.
on antipsychotic drugs in 2011, expenditures in Clozapine remains the only atypical antipsychotic
the United States accounted for 64 percent of the drug with proven superior efficacy over the older
total, or $18.2 billion. drugs. Published in 2005 and 2006, two studies
have proven especially influential demonstrations
Mushrooming Success, Hidden Dangers that atypicals, as a class, offer few advantages
The spectacular success of atypical antipsychotic over the older drugs. One study was funded by the
drugs was fueled by a belief that these drugs con- National Institutes of Health (NIH), and the other
stituted a unique class that were more efficacious was funded the by the United Kingdom National
and had fewer and less-severe side effects than Health Service Health Technology Assessment
all the antipsychotic drugs (except clozapine, of Program. Both found no substantial differences
 Australia 61

in effectiveness between the first- and second- claims), the term atypical increasingly has lost its
generation antipsychotic drugs. Further, claims meaning. After all, other than clozapine, all anti-
that atypicals improve cognition and the negative psychotic drugs have nearly equivalent efficacy,
symptoms of schizophrenia (such as the social all produce nasty side effects, some potentially
withdrawal and apathy) have remained unproven. fatal, and none work nearly as well as clinicians
None of the new drugs have been able to mimic and patients wish they did.
clozapine’s virtual absence of EPS side effects and
tardive dyskinesia. They all produce some degree Joel Tupper Braslow
of motor side effects, though perhaps less often University of California, Los Angeles
than first-generation drugs. At the same time,
these newer drugs produce a variety of meta- See Also: Clozapine; Deinstitutionalization;
bolic side effects that are as serious, if not more Reserpine; Tardive Dyskinesia; Thorazine and First-
so, than those that plagued the first generation of Generation Antipsychotics.
antipsychotics. Significant weight gain, diabetes,
and hyperlipidemia (elevated levels of lipids in the Further Readings
bloodstream associated with heightened risk of Carpenter, W. T. and J. M. Davis. “Another View of
cardiovascular disease) are common side effects, the History of Antipsychotic Drug Discovery and
though these drugs vary in the extent to which Development.” Molecular Psychiatry, v.17 (2012).
they produce these side effects. Healy, D. The Antidepressant Era. Cambridge, MA:
Harvard University Press, 1997.
The Fate of the Atypical Category Healy, D. The Creation of Psychopharmacology.
The drug companies have not escaped unscathed Cambridge, MA: Harvard University Press, 2002.
from the growing disenchantment with atypi- Kendall, T. “The Rise and Fall of the Atypical
cals. Eli Lilly, Pfizer, AstraZeneca, Bristol–Myers Antipsychotics.” British Journal of Psychiatry,
Squibb, and Johnson & Johnson have been v.199 (2011).
charged with or investigated for health care
fraud. In 2007, Bristol–Myers Squibb paid $515
million to settle allegations that the company had
promoted Abilify (aripiprozol) for use in children
and to treat dementia. In 2009, Eli Lilly paid Australia
$1.4 billion to settle allegations that it marketed
Zyprexa (olanzapine) for a variety of unapproved Mental health has been designated as a national
uses. In the same year, Pfizer settled a major suit health priority area in Australia since 1996. Aus-
for the illegal marketing of Geodon (ziprasidone), tralian mental health policy is centered on provid-
and in 2010, AstraZeneca paid $520 million for ing early intervention and recovery-focused, com-
the illegal marketing of Seroquel (quietiapine). munity-based services. Australia has a National
The atypical category may not survive much Mental Health Policy, released in 1992 and revised
longer. With an absence of convincing evidence in 2008, setting out the broad objectives of reform,
that these drugs are a more efficacious class than and five-yearly National Mental Health Plans to
the older antipsychotic drugs and, with side-effect implement these objectives. This was the first
profiles that have proven at least as problematic attempt to establish a uniform policy agenda across
as the first generation of drugs if not more so, a the nation to reform public mental health services,
growing number of researchers have suggested which had been the exclusive responsibility of the
abandoning the adjective altogether. In retrospect, eight states and territories. Each state and territory
atypicality has served as much as a marketing tool has a plan for program development and service
as it has as a legitimate description of a differently delivery that draws on key elements of the national
acting class of antipsychotic drugs. Unmoored plan. Mental health legislation has remained the
from a belief in the superior efficacy and lessened responsibility of the state and territories, and all
side effects of these drugs (as studies over the last legislation has an explicit focus on protecting the
decade have undermined previous drug company human rights of people and providing care and
62 Australia

treatment in the least restrictive manner. Although private sector are involved in mental health ser-
major improvements have been made in service vice delivery in Australia. General practitioners
reform and policy initiatives since the early 1990s, are the first port of call for most people seeking
the scale and pace of change has been uneven assistance (71 percent), especially for more com-
across the different jurisdictions, and surveys indi- mon problems. The proportion of encounters
cate significant levels of unmet need. with general practitioners for mental health prob-
lems increased from 10.4 percent in 2006–07 to
National Mental Health Policy 11.7 percent in 2010–11. Depression, followed
The First National Mental Health Plan (1993– by anxiety and sleep disturbance, were the three
98) gave strong commitment to deinstitutional- mental health problems managed most frequently
ization through the principles of mainstreaming by general practitioners.
(establishing acute psychiatric inpatient units in The primary care sector has expanded in recent
general hospitals) and integration of hospital and years, largely in response to the Better Access to
community services. The Second National Men- Mental Health Care initiative (2006) by the fed-
tal Health Plan (1998–2003) continued these eral government, which allowed allied health
structural reforms in developing community practitioners (e.g., psychologists, social workers,
mental health services but expanded its focus to and occupational therapists) in private practice
include depression, in part a response to World to register as medical providers of psychological
Bank and World Health Organization statistics interventions. Under this scheme, service users
on depression as a significant contributor to are eligible for national health insurance scheme
the global burden of disease. It also emphasized rebates to cover counseling sessions when referred
mental health promotion, prevention, and early by their general practitioner or psychiatrist as part
intervention, cross-sectoral partnerships between of a formalized mental health care plan. Mental
health services and other human services, and health nurses in private practice can register as
the participation of patients and careers in ser- medical providers under a similar scheme, and
vice provision. The Third National Mental under the Mental Health Nurse Incentive Pro-
Health Plan (2003–08) continued these priori- gram, the federal government provides funding
ties, but adopted a population health approach for community-based general practices and pri-
and added that service delivery should be “driven vate psychiatry practices to employ mental health
by a recovery orientation.” The Fourth National
Mental Health Plan (2009–14) focuses on these
key areas: social inclusion and recovery, service
access, coordination and continuity of care, pre-
vention and early intervention, quality improve-
ment and innovation, and accountability.
In line with policy objectives, community-
based treatment and support services have been
expanded. In 1993, 29 percent of government
spending on mental health was dedicated to
community services, increasing to 53 percent by
2008. The mainstreaming of acute inpatient care
has continued over this period, with 55 percent
of acute inpatient beds based in general hospitals
in 1993 and increasing to 86 percent in 2008.
These figures mask regional differences; Victo-
ria closed the last of its stand-alone hospitals in
2000, whereas several stand-alone hospitals in
other jurisdictions are yet to close. A mentally ill man wanders the streets in Sydney, Australia,
Primary care providers, public agencies, non- December 18, 2009. According to population surveys, less than
governmental organizations (NGOs), and the half of those with a mental disorder are accessing services.
 Australia 63

nurses to coordinate clinical care for people with and federal governments funded beyondblue,
severe and persistent mental illnesses. a national depression initiative. Its antistigma
Each state and territory government provides campaign has been highly visible, and increased
specialist inpatient and community-based mental mental health literacy has been reported in areas
health services, which include outpatient clinics, where advertising was taken up from the early
assertive outreach, crisis intervention and home years of the initiative.
treatment, and early intervention. Around 30 per-
cent of admissions to inpatient units are involun- Prevalence of Mental Illness
tary. Schizophrenia, followed by depression, is the The second National Survey of Mental Health
most common diagnosis for adult patients using and Wellbeing (2007) indicated that one in five
public community mental health services. Australians had experienced one of the common
Funding to NGOs to provide mental health ser- mental disorders in the preceding 12 months. It
vices in Australia has increased significantly since was estimated that 14 percent of the population
the beginning of the National Mental Health had experienced an anxiety disorder; 6 percent
Policy, with most growth occurring since 2003. an affective disorder (mainly depression); and 5
Less than 2 percent of mental health funding was percent a substance use disorder. The highest rate
dedicated to the nongovernmental sector in 1993; of these mental disorders as a group occurred in
by 2008, this had increased to 8 percent. In some people aged 16 to 24 years (26.4 percent), with the
jurisdictions, NGOs have been used to replace overall prevalence decreasing with increased age
clinical services provided by public agencies; in to around one in 20 (5.9 percent) in the oldest age
others, they have been deployed in their more group (75–85 years). Women had a higher preva-
traditional roles of providing psychosocial sup- lence of both anxiety disorders (17.9 percent of
port and rehabilitation, including assistance with women versus 10.8 percent of men) and affective
accommodation, employment, and living skills. disorders (7.1 percent of women versus 5.3 per-
The private sector has expanded since deinsti- cent of men), but men had a higher prevalence of
tutionalization. In 1993, 14 percent of all psy- substance use disorders (7 percent of men versus
chiatric beds were in private hospitals; by 2007 3.3 percent of women).
to 2008, this figure had climbed to 22 percent. In addition to schizophrenia, the low-preva-
Mood disorders, followed by alcohol and sub- lence disorders include bipolar disorder, other
stance disorders, are the most common diagno- forms of psychosis, eating disorders, and severe
ses of patients using private psychiatric hospitals. personality disorder. The second National Survey
Private psychiatric inpatient and outpatient care of Psychotic Illness (2010) reported that the prev-
is subsidized by Australia’s national health insur- alence of psychotic disorders was higher in males
ance scheme. Australians have differential access (3.7 per 1,000) than females (2.4 per 1,000).
to private psychiatrists; most are concentrated in Schizophrenia was the most common psychotic
the wealthier areas of state capital cities. From disorder, and most people had experienced their
2007 to 2008, 1.3 percent of the population con- first psychotic episode before the age of 25.
sulted a psychiatrist in private practice. Accord- Indigenous Australians suffer a higher burden
ing to population surveys, less than half of those of emotional distress compared with nonindig-
with a mental disorder are accessing services. enous Australians; substance use disorders and
Women, people aged over 35, and those living suicides are particularly high in remote Aborigi-
in cities are more likely to use mental health ser- nal communities. Suicides made up 4.2 percent
vices; and people with mood disorders are more of all registered deaths of people identified as
likely to access services than those with anxiety or indigenous in 2010, compared with 1.6 percent
substance use disorders. of all Australians. In Australia, the suicide rate for
From the early 2000s, public attention has males is 16.7 per 100,000, and for females, 4.4
focused on the high-prevalence disorders of per 100,000 people.
depression, anxiety, and substance misuse; and In Australia, expenditure on mental health
the mental health of young people, indigenous accounted for 7.6 percent of government health
Australians, and refugees. In 2000, the Victoria expenditure in 2008. Although overall spending
64 Autism

on mental health has markedly increased in recent gestures that are used to regulate social interac-
years, this represents only a very marginal increase tions; failure in the development of appropriate
in the context of overall increases in government peer relationships; lack of sharing interests, plea-
spending on health. sure, or achievements with others, such as a lack
of pointing out objects that interest the individual;
Anne-Maree Sawyer and lack of social or emotional reciprocity, includ-
La Trobe University ing lack of emotional responses to others.
Impairments in communication must be pres-
See Also: Cultural Prevalence; Policy: Federal ent in at least one of the following four areas:
Government; Primary Care. delays in or total lack of the development of spo-
ken language; impairment in the ability to start
Further Readings and continue conversations with others; unusual
Australian Institute of Health and Welfare. “Mental or repetitive language; and lack of developmen-
Health Services—In Brief.” Cat. No. HSE 125, tally appropriate play, such as a lack of make-
Canberra: AIHW, 2012. believe play. Finally, individuals with ASD dem-
Department of Health and Ageing. “National Mental onstrate restricted, repetitive, and stereotyped
Health Report 2010: Summary of 15 Years of behaviors, interests, or activities in at least one of
Reform in Australia’s Mental Health Services Under the four following ways: preoccupation with nar-
the National Mental Health Strategy 1993–2008.” row, stereotyped, and restricted interests that are
Canberra: Commonwealth of Australia, 2010. overly intense or focused; inflexibility in follow-
Meadows, Graham, et al., eds. Mental Health in ing specific routines and insistence on sameness;
Australia: Collaborative Community Practice. repetitive motor mannerisms; and preoccupation
South Melbourne, Australia: Oxford University with parts of objects rather than the whole object.
Press, 2012.
Incidence and Prevalence Around the World
Incidence and prevalence rates of autism and
ASDs vary by region and country, most likely
due to differences in sampling methodology and
Autism whether only autism rates are recorded. Cur-
rent prevalence rates in Asia, Europe, and North
Autism and autism spectrum disorders (ASDs), America are about 1 percent for ASD. However,
usually diagnosed in childhood, affect a small but a recent study in South Korea indicates a preva-
significant proportion of the population. Often lence rate closer to 2.6 percent.
debilitating, treatment for ASDs requires long- Prevalence rates of autism have continued to
term mental health and supportive care in the rise since the 1990s to a current all-time high of
home and school environment. one in 88 children in the United States. A similar
The fourth edition, text revision of the Diag- pattern is found in other countries.
nostic and Statistical Manual of Mental Disorders There are several theories on why there has
(DSM-IV-TR) classifies autistic disorder, more been such an increase in the incidence of ASD.
commonly referred to as autism spectrum disor- One theory centers on the increase in the aware-
der, as one of five pervasive developmental disor- ness of ASD in the general public and improved
ders. The essential features of ASD are delays in identification of children with ASD by clinicians.
the development of social interactions and com- As more people become aware of ASD, they are
munication, along with restrictive behaviors and more likely to seek help from the medical com-
interests. There must be impairment or abnormal munity and more likely to be diagnosed. Several
development in at least one of these areas by age 3. studies provide support for this theory.
Impairments in social interactions must be present Another theory, which is highly publicized and
in at least two of the following four areas: impair- controversial, centers on the impact of immuni-
ment in the use of nonverbal behavior, such as zations (specifically the measles, mumps, rubella
inappropriate eye contact, facial expressions, or [MMR] vaccination) and thimerosal, the mercury
 Autism 65

binder used in some immunizations, on ASD. differences in social norms and spoken language
Andrew Wakefield, a British researcher, published may contribute to the increased diagnoses of ASD
research on a link between the MMR vaccine and among immigrant children.
the development of ASD. This created an interna- In the United States, research results differ on
tional health scare and resulted in the reduction whether there are differences in prevalence rates
of children receiving immunizations. However, based on ethnicity. For example, the U.S. Depart-
the results of this study were never replicated and ment of Education found that the rate of ASD in
conflicts of interest related to the lead researcher children identified as black or Asian was double
led to the retraction of published data and sanc- the rate of ASD in children identified as American
tions against the researcher (the loss of his medi- Indian or Hispanic. However, in a separate study,
cal license). researchers found that the prevalence rates across
Mark Geier, a researcher with the National race and ethnic groups were similar over an eight-
Institutes of Health, also published research in year period in California.
the 1990s linking thimerosal exposure to ASD. While several studies have compared the symp-
However, these studies were discredited due to tom presentation of ASD across countries and
serious methodological flaws. To date, no meth- have found areas of significant difference, over-
odologically sound research has found a direct all the presentation of ASD remains fairly con-
link between immunizations or heavy metals and sistent. One area of difference has been in the
the development of ASD. Despite this, parents behavioral expression of symptoms. Children
continue to report concerns about the number with ASD often exhibit challenging behaviors,
and frequency of vaccinations in early childhood. and the severity of ASD symptoms is correlated
Decreased rates of children receiving immuniza- with the severity of behaviors. The presence and
tions has led to an increase in childhood diseases severity of challenging behaviors is largely consis-
such as measles, long-term medical problems tent between the United States, South Korea, and
from these diseases, and in some cases death. Israel. In areas where significant differences were
Genetic factors appear to play a strong role in found, the United States had higher rates of diffi-
the development of ASD. After the birth of one cult behaviors. There were significant differences
child with ASD, the risk of having another child found in the presence of challenging behaviors in
diagnosed with ASD is between 3 and 15 percent, children from the United Kingdom compared to
which is significantly higher than the incidence children from the United States, with children in
rate in unrelated populations. The concordance the United Kingdom exhibiting more challenging
rate of ASD in monozygotic twins is approxi- behaviors. In another study, children in the United
mately 60 percent, while the concordance rate for States were rated as having more adaptive social
dizygotic twins is approximately 5 percent. skills than children from the United Kingdom.
Research is mixed on whether the behavioral Another cross-cultural study comparing chil-
components of ASD vary across culture, ethnic- dren from the United Kingdom, the United
ity, race, gender, and socioeconomic status. Some States, Israel, and South Korea found that across
researchers suggest that the presentation of ASD core ASD symptoms domains, children from the
is consistent across cultures, while others suggest United Kingdom were found to have significantly
that it is sensitive to cultural differences. There is more impairment across all domains while chil-
a gender difference, as the prevalence rate of ASD dren from Israel demonstrated less impairment
is four to five times higher in males than females. across all domains. Another study suggested that
Females with ASD have been found to have more there are significant differences across cultures in
severe cognitive delays when compared to males the structure of children’s social networks and
with similar diagnoses. Some studies have sug- parental attitudes, though mother-child attach-
gested that there is an increase in the rate of ASD ment relationship and the cognitive and emo-
among immigrant children compared to native tional functioning of children were found to be
children in the United States, though this may independent of culture.
be due to cultural differences rather than ethnic There are several reasons why there may be cul-
differences in prevalence rates. It is possible that tural differences in the rates and presentation of
66 Autism

ASD. In some cultures, there may be a reluctance The Treatment and Education of Autistic and
to have a child assessed for a disability. Therefore, related Communication of Handicapped Chil-
rates of ASD may be lower due to not seeking out dren (TEACCH) program is another prominent
services rather than actual differences in prevalence intervention utilized in the treatment of ASD and
rates. In some cultures, a diagnosis of a develop- is used internationally. It was developed at the
mental disorder such as an ASD may be preferable University of North Carolina and provides train-
to having a child diagnosed as being cognitively ing to psychologists, teachers, and other provid-
delayed. Therefore, there may be increased rates ers. It is a structured, classroom-based interven-
of ASD found in cultures where having an intellec- tion that is also used to structure children’s home
tual disability is looked down upon. Developmen- environments, using an approach called struc-
tal expectations also vary across cultures, which tured teaching that emphasizes the combination
can affect timeliness of diagnosis. of highly structured and predictable classroom
environments with the use of visual learning
Treatment Options tools. The typical TEACCH classroom has specif-
There are several treatment interventions for ASD ically defined task areas and uses visual schedules
that are used both in the United States and inter- to assist students with transitions from activity to
nationally. Two comprehensive early behavioral activity.
interventions are empirically supported, validated Data suggests that complementary and alterna-
by objective scientific studies as effective treat- tive medicine (CAM) approaches are commonly
ment interventions for ASD: Applied Behavioral used by families along with other interventions.
Analysis (ABA) and the Early Start Denver Model They encompass a wide range of interventions,
(ESDM). ABA is used internationally and is recog- including the use of melatonin to promote sleep
nized by mental health professionals and numer- as well as the use of vitamins, acupuncture, music,
ous government agencies as a safe and effective and special diets. Surveys suggest that approxi-
treatment for autism. It is based on the principle mately 74 to 95 percent of children in the United
that learning occurs when a behavior is followed States, 52 percent of children in Canada, and 40
by either a reward or a negative reinforcement. percent of children in China have utilized CAM
Behaviors that result in reward will increase in approaches alone or in combination with other
frequency and those that result in a lack of reward treatment choices. Many CAM methods have lit-
will decrease in frequency. Trained applied- tle to no research to support their use in the treat-
behavior analysts work with ASD individuals to ment of ASD. The type of CAMs utilized varies
increase positive behaviors and decrease nega- across cultures. For example, in the United States,
tive behaviors, thereby promoting the learning of biologically based CAMS are most frequently
appropriate and complex skills. ABA principles utilized, while in China, acupuncture is most fre-
and techniques begin by fostering basic skills such quently utilized.
as eye contact and imitation. ABA then builds on
those basic skills to promote the development of April Bradley
more complex skills, such as joint attention and Erin Olufs
perspective taking. University of North Dakota
The Early Start Denver Model (ESDM) is a
comprehensive behavioral early-intervention See Also: Adolescence; American Psychological
approach for children with autism. It incorpo- Association; Amphetamines; Attention Deficit
rates the behavioral teaching methods of ABA Hyperactivity Disorder (ADHD); Children; China;
that are validated by research with a relationship- Cross-National Prevalence Estimates; Cultural
focused developmental model. Therefore, ESDM Prevalence; Learning Disorders; Refrigerator Mother.
promotes the utilization of naturalistic ABA strat-
egies along with the promotion of shared enjoy- Further Readings
ment with parents, teachers, and providers. For American Psychiatric Association (APA). Diagnostic
example, language and communication are taught and Statistical Manual of Mental Disorders. 4th
through positive, affect-based relationships. ed. Washington, DC: APA, 2000.
 Autism 67

Chung, K. J., et al. “Cross Cultural Differences in Sipes, M., F. Furniss, J. L. Matson, and M. Hattier.
Challenging Behaviors of Children With Autism “A Multinational Study Examining the Cross
Spectrum Disorders: An International Examination Cultural Differences in Social Skills of Children
Between Israel, South Korea, the United Kingdom, With Autism Spectrum Disorders: A Comparison
and the United States of America.” Research in Between the United Kingdom and the United
Autism Spectrum Disorders, v.6/2 (2012). States of America.” Journal of Developmental and
Kearney, A. J. Understanding Applied Behavior Physical Disabilities, v.24/2 (2012).
Analysis: An Introduction to ABA for Parents, Sotgiu, I., et al. “Parental Attitudes, Attachment
Teachers, and Other Professionals. London: Jessica Styles, Social Networks, and Psychological
Kingsley Publishers, 2008. Processes in Autism Spectrum Disorders: A
Matson, J. L., et al. “A Multinational Study Cross-Cultural Perspective.” Journal of Genetic
Examining the Cross Cultural Differences Psychology: Research and Theory on Human
in Reported Symptoms of Autism Spectrum Development, v.172/4 (2011).
Disorders: Israel, South Korea, the United Volkmar, F. R. and L. A. Wiesner. A Practical Guide
Kingdom, and the United States of America.” to Autism: What Every Parent, Family Member,
Research in Autism Spectrum Disorders, v.5/4 and Teacher Needs to Know. Hoboken, NJ: John
(2011). Wiley & Sons, 2009.
 B
Bangladesh Myanmar. Bangladesh is one of the most densely
populated countries in the world. In 2012, the
Mental health care in Bangladesh is still in its population was estimated at more than 161 mil-
nascent stages. Mental illness continues to be a lion people, which is almost one-half of the pop-
highly stigmatized and taboo topic. The devel- ulation of the United States but packed into a
opment of mental health care services in rural country 1/67th its size. The capital city of Dhaka
regions is crucial for the health of the nation. is predicted to be the fastest-growing city in the
With only two mental health hospitals in the world (current estimates place the city’s popu-
country, expansion of mental health care and the lation at about 7 million). The United Nations
better integration of mental health services with (UN) predicts that by 2025, Dhaka will have a
primary care are direly needed. population numbering 20 million people.
A multifaceted approach that encompasses Bangladesh is largely agricultural, with the
support from the government, education system, majority of the population living in rural areas
research and development sector, health profes- (73 percent). The flat, alluvial, delta topography
sionals, and mental health care system is critical of Bangladesh makes the country especially prone
to address these concerns. Moreover, the impor- to cyclones and floods.
tance of socioeconomic stressors such as poverty Close to 90 percent of Bangladeshis are Mus-
and their impact upon the mental health of the lim and 9 percent are Hindu. Small numbers of
nation cannot be underestimated. Bangladesh Buddhists and Christians also reside in the coun-
faces economic, environmental, political, and his- try. Bangladesh is also home to a very young
torical hardships. This unique context must be population. About 40 percent of the population
considered in conjunction with plans for develop- is under the age of 15, and the median age is 23.6
ing community mental health programs, mental years. In 2010, the literacy rate was estimated at
health policy, and a viable mental health strategy 57 percent (males: 61 percent and females: 52
for Bangladesh. percent). Poverty is a major problem in the coun-
try, with the gross national income per capita
An Overview estimated at $640.
Bangladesh is a small country (56,938 square Bangladesh was ruled under the British Raj
miles, or 147,470 square kilometers) in the Indian from about 1700 to 1947 when, following the
subcontinent that shares borders with India and rise of Indian nationalism, war ensued to gain

69
70 Bangladesh

A Banshkhali Hindu family looks over the remains of their house, which was burned by Islamic terrorists on February 28, 2013, at
Chittagong. A religious minority, Hindus (about 9 percent) along with Buddhists (0.7 percent) in this Muslim-majority region suffer
brutal persecution by Muslim extremists, mostly in remote areas in the country. Persecution and violence such as temple burnings,
lootings, and destruction of villages have left some members of these religious minorities at higher risk for post-traumatic stress disorder.

Bangladesh’s independence from British rule. In and war trauma. Mental illness is more prevalent
the aftermath, the Hindu- and Muslim-majority among adult women (19 percent) compared to
territories of the Indian subcontinent were roughly men (13 percent).
divided into India and Pakistan, respectively. What
is now Bangladesh was ruled as East Pakistan until Urban Bangladesh
the War of Independence in 1971, during which Studies suggest that about 28 percent of all adults
millions of people were displaced, raped, and in low-income urban communities in Bangladesh
killed by the West Pakistani ruling elite. Bangla- suffer from a mental disorder. Somatoform dis-
desh finally achieved independent statehood in orders are most common (10 percent), followed
1973. Following independence, Bangladesh has by mood disorders (6 percent), sleep disorders (4
continued to suffer political turmoil and unrest. percent), anxiety disorders (3 percent), substance-
Overpopulation, poverty, and the lack of eco- related disorders (2 percent), and psychotic dis-
nomic growth remain issues of concern. orders (2 percent). Female gender and higher
socioeconomic class are associated with a higher
Mental Illness: Prevalence relative risk of mental disorder in low-income
Rates and Risk Factors urban Bangladesh. One explanation offered for
According to the 2003 to 2005 National Mental this counterintuitive finding is that the higher-
Health Survey, 16 percent of the adult popula- income class may experience stressors such as
tion of Bangladesh suffer from mental disorders crime and political violence to a greater degree
(around 25.8 million people). Anxiety disorders than lower socioeconomic groups.
are the most prevalent mental disorder in Ban- An analysis of self-reported 2006 Urban Health
gladesh (5 percent), followed by major depres- Survey data revealed that 55 percent of husbands
sion (4.6 percent) and schizophrenia/psychosis reported inflicting physical IPV and 20 percent
(1 percent). Post-traumatic stress disorder is also reported inflicting sexual IPV at some point
prevalent, especially among those affected by in their lifetime in urban Bangladesh. Among
natural disasters, intimate partner violence (IPV), reproductive-aged, ever-married women in urban
 Bangladesh 71

Bangladesh, the prevalence rate of suicidal ide- The prevalence of childhood depression for 7
ation was 14 percent, and 26 percent of these to 18 year olds is reported to be 0.95 percent. A
women attempted suicide. study of the mental health of 5 to 10 year olds liv-
ing in rural, urban, and slum areas of Bangladesh
Rural Bangladesh reported a 15 percent prevalence rate of mental
Community surveys undertaken in three villages disorders, with rural at 15 percent, urban at 10
in the rural Savar-Nabinagar area (central east percent, and slum at 20 percent. Anxiety disorders
Bangladesh) revealed an overall mental disorder were most common at 8 percent, with rural at 9
prevalence rate of 16.5 percent in rural Bangla- percent, urban at 4 percent, and slum at 11 per-
desh. Depressive disorders were most common (8 cent. Children living in slum areas were found to
percent) followed by anxiety disorders (5 percent) have a significantly higher risk of mental illness.
and psychotic disorders (1 percent). Males and According to a United Nations Children’s Fund
females in rural Bangladesh did not differ in prev- report, over 8 percent of all deaths by injury for 1
alence rates of mental disorders (16.2 percent and to 17 year olds were attributed to suicide in Ban-
16.4 percent, respectively). Increasing age, larger gladesh. In the 15- to 17-year-old late adolescent
family size, and being in the lowest income tercile period, suicide was the leading cause of death by
were significant risk factors for mental disorders. injury (about 23.5 deaths per 100,000 children).
A study carried out in a rural area 25 miles Furthermore, the disintegration of the tradi-
(40 kilometers) north of Dhaka reported a higher tional family support structure in Bangladesh has
prevalence rate of depression in rural Bangladesh: led to issues in older adult mental health. Older
the overall rate was 29 percent, with males at 28 adults face loneliness, isolation, anxiety, insom-
percent and females at 30 percent. Moreover, a 22 nia, and memory loss.
percent prevalence rate of postnatal depression at
six to eight weeks postpartum was found in the Mental Illness: Definitions and Stigma
rural subdistrict of Matlab (central east Bangla- Mental illness, or manoshik rog in Bengali, has
desh). Past and current mental illness, experience varying interpretations, and the stigma associated
of perinatal death, a poor relationship with a with mental illness is common in Bangladesh. A
mother-in-law, and domestic disputes leading to study carried out in the rural subdistrict of Mat-
the departure of a partner were found to be corre- lab found that when a case vignette of depression
lates of postnatal depression in rural Bangladesh. was presented to participants, most identified it as
A study of suicide rates in the rural Narayan- chinta rog (worry illness). Participants described
ganj Sadar subdistrict (central Bangladesh) found physical, psychological, and social dimensions of
prevalence rates of 282 per 100,000 of the popu- mental illness. They attributed the cause of mental
lation for suicide attempts and 128 per 100,000 illness to thoughts and emotions (psychological),
of the population for suicide mortality. Young age which had their root in social causes such as pov-
(20 to 29 years), female gender, being a house- erty and difficulties in marriage, work, and fam-
wife, having a low income, and being married ily. They also spoke of physical manifestations of
were risk factors of suicide attempts and mortal- mental illness such as weakness and lack of sleep
ity. The estimated prevalence rates of suicidal ide- and appetite. Older adults associated poor physi-
ation (11 percent) and attempted suicide among cal health with chinta rog. Very few participants
women who had contemplated suicide (9 percent) blamed jinn (spirits) for mental illness but rather
for rural reproductive-aged, ever-married women attributed it to socioeconomic problems.
were lower compared to urban prevalence rates. A diagnosis of mental illness was perceived as
being highly stigmatized, where a man’s ability
Mental Illness Across the Life Span to care for his family would be questioned and
It is estimated that 24 percent of children in Ban- a woman would likely be beaten and unable to
gladesh suffer from some form of mental health get married. Interviews carried out in the low-
problem. Conservative estimates number the pop- income Chuadanga district (west Bangladesh)
ulation of children and adolescents suffering from revealed that those suffering from mental dis-
mental disorders at 5 million. orders faced discrimination and had difficulty
72 Bangladesh

finding employment. They often had their job psychologists offer various types of psychother-
competence questioned and received lower sala- apy. There is about one psychologist for every 14
ries. Interviews carried out in the semiurban Kak- million people. With the widespread belief in the
abo village in the Savar subdistrict found greater supernatural origins of mental illness, religious
prevalence for the belief in supernatural causes and traditional healers are also commonly con-
for mental illness. Bhoot (ghosts) and jinn were sulted for mental health issues.
blamed for causing strange behavior and unin- Interviews carried out in the rural Matlab sub-
hibited displays of emotion. Men in Kakabo also district found that in terms of help seeking, most
identified substance abuse and addiction as a pos- participants first sought help from close relatives
sible cause of mental illness. or the village elder. If that did not solve the prob-
lem, they then sought care from the traditional
Mental Health Care System healer or village doctor. If there was no allevia-
The mental health care system in Bangladesh has tion of symptoms, they would save money to visit
developed in a piecemeal fashion without the a local bachelor of medicine, bachelor of surgery
establishment of a single authority. Mental health doctor. Most patients presented somatic com-
care is offered by both government and private plaints (such as loss of appetite and sleep) when
facilities. Social insurance in Bangladesh does consulting with the physician. Seeking mental
not cover mental illness. The majority of primary health care from psychiatrists was not mentioned
health care clinics do not have mental health by any of the participants. Lack of financial
professionals on site and rarely make referrals resources was cited as the major barrier to seek-
to mental health programs. Two large, tertiary- ing mental health care. When participants in the
level mental health hospitals exist in Bangladesh: semiurban Kakabo village in rural Savar were
Pabna Mental Hospital in Pabna district and the interviewed about the mental health care system,
government-run National Institute of Mental most believed that a doctor would not be able
Health (NIMH) in the capital city of Dhaka. to cure mental illness. They also had very little
Formal mental health care began in 1957 with knowledge about psychiatric facilities in Bangla-
the establishment of the mental hospital in Pabna desh and had never heard of psychiatrists. A few
district (northwest Bangladesh) in a local land- were aware of the Pabna Mental Hospital, but
lord’s house. The hospital started with 60 beds it was largely derided as the final destination for
and later increased to 200 in 1966. Currently, the pagol (crazy) people.
hospital offers 500 beds to patients and is one of
two mental health hospitals in the country. Mental Health Treatment and Expenditures
In the 1970s, general hospitals began offering Psychotropic drugs are commonly prescribed to
limited inpatient programs in psychiatric units treat mental illness. Electroconvulsive therapy is
and outpatient services. NIMH in Sher-e-Bangla also used in cases of severe depression.
Nagar, Dhaka, was established in 1981, offering People’s perceptions of the effectiveness of men-
free and low-cost psychiatric care. tal health treatment are vast and varying. When
participants in the rural subdistrict of Matlab
Mental Health Professionals were interviewed about mental health treatment,
The vast majority of mental health professionals some felt that mental illness could not be pre-
are concentrated in and around the capital city vented and that it was God’s will. Others named
of Dhaka. Only 0.49 per 100,000 of the popula- hard work, poverty alleviation, improvement in
tion are employed in the mental health care sec- relationships, and drug therapy as possible treat-
tor. Currently, only about 70 psychiatrists service ments. However, most did not have the financial
the mental health needs of Bangladesh’s sprawling resources to afford such drug treatment. When
population of 161 million (roughly one psychia- questioned about supernatural causes of mental
trist for every 1.4 million people). General prac- illness, participants in the semiurban Kakabo vil-
titioners are often consulted for mental health lage in Savar subdistrict felt that possession by
issues. About 30 percent of general practitioner spirits and ghosts could be cured if the patient was
visits are for psychological problems. Clinical taken to a fakir (traditional healer) early enough
 Bangladesh 73

to receive treatment. Treatment can involve the See Also: Burma (Myanmar); Electroconvulsive
use of amulets, enchanted oil, and recitation of Therapy; Electrotherapy; India; Pakistan; Post-
prescribed verses of the Qur’an. Traumatic Stress Disorder; Psychiatric Training;
In a developing nation suffering from problems Religion; Stigma; Stress; Urban Versus Rural;
such as hunger, poverty, and overpopulation, men- Violence; War; Women.
tal health is not high on the priority list. In terms
of health, infectious diseases such as malaria, Further Readings
tuberculosis, and human immunodeficiency virus Ahmed, Helal Uddin, et al. “Management of Psychotic
and acquired immune deficiency syndrome (HIV/ Depression in Bangladesh.” Japanese Society of
AIDS) are of grave concern. About 3.4 percent Psychiatry and Sociology, ss. 46 (2011). http://
of the gross domestic product is allocated to the www.jspn.or.jp/journal/symposium/jspn106/pdf
health sector. Mental health only received 0.44 /ss046-050_bgsdng11.pdf (Accessed August 2012).
percent of this already small health budget. Amnesty International. “Bangladesh: Wave of Violent
Attacks Against Hindu Minority” (March 6,
Mental Health Training 2013). http://www.amnesty.org/en/for-media/press
A small percentage of the resources available for -releases/bangladesh-wave-violent-attacks-against
training medical doctors are invested into mental -hindu-minority-2013-03-06 (Accessed June 2013).
health care training (4 percent for medical doc- Asghar, S., et al. “Prevalence of Depression and
tors and 2 percent for nurses). In terms of higher Diabetes: A Population-Based Study From Rural
education in the field of psychiatry, it was not Bangladesh.” Diabetic Medicine, v.24 (2007).
until 1975 that a postgraduate course in psy- Feroz, A. H. M., et al. “A Community Survey on the
chiatry was introduced at the Institute of Post- Prevalence of Suicidal Attempts and Deaths in a
graduate Medicine and Research, now named Selected Rural Area of Bangladesh.” Journal of
Bangabandhu Sheikh Mujib Medical University. Medicine, v.13 (2012).
Twenty years later in 1995, Dhaka University’s Foley, Dermot and Jahan Chowdhury. “Poverty,
department of psychology began offering a three- Social Exclusion and the Politics of Disability: Care
year postgraduate course in clinical psychology. as a Social Good and the Expenditure of Social
With financial assistance from the United King- Capital in Chuadanga, Bangladesh.” Social Policy
dom, this program linked Dhaka University to and Administration, v.41 (2007).
University College in London. This led to the Gausia, Kaniz, et al. “Magnitude and Contributory
establishment of Dhaka University’s Department Factors of Postnatal Depression: A Community-
of Clinical Psychology shortly afterward in 1997. Based Cohort Study From a Rural Subdistrict of
Bangladesh.” Psychological Medicine, v.39 (2009).
Future Directions Hosain, G. M. Monawar, et al. “Prevalence, Pattern,
The importance of considering the social deter- and Determinants of Mental Disorders in Rural
minants of health and their impact upon mental Bangladesh.” Public Health, v.121 (2007).
health in Bangladesh cannot be underestimated. Islam, Mohammad Manirul, et al. “Prevalence of
Stressors such as poverty, frequent natural disas- Psychiatric Disorders in an Urban Community in
ters, political unrest, and a legacy of civil war and Bangladesh.” General Hospital Psychiatry, v.25
coups are crucial factors to consider in assessing (2003).
the mental health of the nation. However, care Mullick, Mohammad Sayadul Islam and Robert
needs to be taken to refrain from painting an Goodman. “The Prevalence of Psychiatric
overly bleak picture of mental health in Bangla- Disorders Among 5–10 Year Olds in Rural, Urban
desh. Mental health encompasses not only mental and Slum Areas in Bangladesh: An Exploratory
illness and disorder but well-being as well. Future Study.” Social Psychiatry and Psychiatric
research is needed to explore this domain. Epidemiology, v.40 (2005).
Naved, Ruchira Tabassum and Nazneed Akhtar.
Farah Islam “Spousal Violence Against Women and Suicidal
Nazilla Khanlou Ideation in Bangladesh.” Women’s Health Issues,
York University v.18 (2008).
74 Barbiturates

Pathan, Tayeem and Patricia d’Ardenne. “An narrow therapeutic windows, and excessively
Exploratory Survey of Mental Health Services for long half-lives. While barbiturates proved both
Traumatized People in Bangladesh.” Asian Journal dangerous and addictive, they improved on these
of Psychiatry, v.3 (2010). http://www.sciencedirect features of their predecessors and yielded diverse
.com/science/article/pii/S1876201810000456 medical uses—preventing seizures and inducing
(Accessed August 2012). anesthesia among them—in addition to their psy-
People’s Republic of Bangladesh, Bangladesh Planning chiatric applications.
Commission. “The Millenium Development Goals
Bangladesh Progress Report 2011.” http://www.un The Road From Synthesis to Application
-bd.org/pub/MDG%20Progress%20Report%20 As with many psychoactive medications, barbitu-
2011.pdf (Accessed August 2012). rates’ pipeline from synthesis to clinical applica-
Rahman, A., A. K. M. F. Rahman, S. Shafinaz, and tion was long and twisted. The parent compound,
M. Linnan. “Bangladesh Health and Injury Survey: barbituric acid or malonlyurea, was created in
Report on Children.” Dhaka: Ministry of Health 1864 by Adolf von Baeyer, through a condensa-
Bangladesh, Institute of Child and Mother Health, tion reaction of malonic acid (derived from apples)
UNICEF, and the Alliance for Safe Children, 2005. and urea (derived from urine). Von Baeyer, who
Sambisa, William, et al. “Physical and Sexual is widely and erroneously credited with founding
Abuse of Wives in Urban Bangladesh: Husbands’ Bayer Pharmaceuticals (a distinction belonging to
Reports.” Studies in Family Planning, v.41 (2010). Friedrich Bayer), was a distinguished scientist at
Selim, Nasima. “Cultural Dimensions of Depression the heart of German chemistry; in 1905, he won
in Bangladesh: A Qualitative Study in Two Villages the Nobel Prize for his contributions to the field.
of Matlab.” Journal of Population, Health & Von Baeyer’s choice of the term barbituric acid is
Nutrition, v.28 (2010). variously explained with reference to an acquain-
Selim, Nasima and P. Satalkar. “Perceptions of Mental tance named Barbara (whose urine may have been
Illness in a Bangladeshi Village.” BRAC University von Baeyer’s source of urea), to the spiky shape of
Journal, v.5 (2008). the original compound’s crystals, or (most plau-
Tinker, Hugh Russell, ed. “Bangladesh.” Britannica sibly) to the synthesis of the compound on Saint
Academic Edition. http://www.britannica.com/EB Barbara’s feast day, December 4. Von Baeyer is
checked/topic/51736/Bangladesh (Accessed August said to have celebrated his new compound at the
2012). local tavern, where artillerymen were observing
World Factbook. “Bangladesh.” https://www.cia.gov/ the feast day of their patron saint. In their honor,
library/publications/the-world-factbook/geos/bg he named the new molecule after Saint Barbara.
.html (Accessed August 2012). Standardization of barbituric acid synthesis in
World Health Organization. “WHO-AIMS Report on 1879 by Edouard Grimaux, a French chemist,
Mental Health System in Bangladesh.” http://www enabled further experimentation with the com-
.searo.who.int/LinkFiles/Mental_Health_Resources pound. Diethyl-barbituric acid followed in 1881.
_WHO-AIMS_Report_MHS_Ban.pdf (Accessed Years passed before this compound saw serious
August 2012). study, by Josef von Mering and Emil Fischer, in
the early 1900s. Von Mering, a pharmacologist,
noted structural similarities between diethyl-bar-
bituric acid and sulphonal, a synthetic sedative
dating to the 1880s. He contacted Fischer, who
Barbiturates soon tested 5,5-diethyl-barbituric acid in dogs,
causing sedation. Fischer, himself a Nobel laure-
Beginning in the early 1900s, decades before ate in 1902, patented this compound in 1903, as
Miltown or benzodiazepines, barbiturates broke Veronal, a name generally agreed to be a tribute to
ground as a synthetic sedative for everyday peo- von Mering’s visit to the famously tranquil Italian
ple. Popular sedatives in the 19th century had city at the time of Fischer’s experiments. The drug
included chloral hydrate, bromides, and paralde- was promptly marketed under this name, arriving
hyde, which were variously limited by foul taste, in the United States in 1903. In an early twist of
 Barbiturates 75

pharmacologic branding, Veronal was renamed metabolite. Barbiturate use in anesthesia began in
Barbital for American consumption during World 1921, with Daniel Bardet and Somnifen; further
War I, when the Trading with the Enemy Act of innovations followed in the 1930s, most nota-
1917 enabled American subsidiaries of German bly with the synthesis of thiobarbiturates, which
parent companies to break their parents’ patents. offered rapid onset and deep sedation. As in epi-
Given von Mering and Fischer’s proof of con- leptology, these drugs have been largely displaced
cept, barbituric acid offered a molecular template by others with preferable pharmacodynamics and
ripe for further innovation. Of the thousands of gentler side-effect profiles.
barbituric acid derivatives, phenobarbital was the
next milestone in 1911. Within a year of its syn- Sleep and Awakening Therapies
thesis, this drug was favorably tested as a hyp- Barbiturates inspired another innovation in 1913,
notic in humans and then marketed by Bayer as when Giuseppe Epifanio pioneered the sleep cure
Luminal. Phenobarbital quickly became a main- for psychosis—inducing prolonged sedation of
stay in asylum practice—not least because its long psychotic patients—at his Turin clinic. This use
half-life (approximately 80 hours) made it a con- of barbiturates had a precedent in the bromide
venient sedative. Rapid onset and short duration sleep cure of Dr. Neil MacLeod, whose work in
of action, in contrast, were achieved with buto- Shanghai in the 1890s established the notion of
barbital (butethal, or Neonal) in 1922; a year therapeutic sedation for psychosis as both poten-
later, amobarbital (Amytal) arrived, followed tially helpful and dangerous. Epifanio published
by secobarbital (Seconal, 1929), pentobarbital encouraging results in 1915, publishing in Italian
(Nembutal, 1930) and thiopental (Pentothal, just as World War I was starting. Nevertheless,
1935), each involving small modifications to the Epifanio won little attention.
parent molecule. The psychiatrist who became famous for bar-
Eventually, more than 2,500 barbiturates were biturate sleep cures was Jacob Klaesi, who devel-
synthesized, with approximately 50 reaching the oped his dauernarkose (prolonged sedation) treat-
market. The benefits of sedation and anxiolysis ment at the Burghölzli in Zurich. Starting in the
were apparent not only in psychiatric wards but early 1920s, Klaesi administered a combination of
also on the battlefield, where barbiturates saw morphine, scopolamine, and Somnifen, a combi-
extensive use for both psychiatric and anesthetic nation with two barbiturates. He reported symp-
purposes, and in everyday life, where self-admin- tomatic improvement well beyond that expected
istration increased between the world wars and by chance in schizophrenic patients, leading to
remained common through the 1970s. widespread adoption of his methods. Controversy
Uses apart from sedation quickly became soon followed: Klaesi’s 1922 debut of his results
apparent, particularly for epilepsy and in anesthe- reported death in three of 26 subjects; by 1927,
sia. Shortly after phenobarbital hit the market in Max Müller reported a 5 percent mortality rate
1912, Alfred Hauptmann, a psychiatrist staffing in the treatment. Burghölzli clinicians Max Clo-
an inpatient epilepsy ward, gave hypnotic medi- etta and Hans Maier modified Klaesi’s cocktail in
cations to his patients so that they, and he, could 1934, documenting further treatment benefit but
rest between seizures. Hauptmann soon noted also further deaths. By the late 1930s, the barbi-
that the patients receiving phenobarbital had turate Dauernarkose trend was replaced by other
fewer seizures. Entering a field of relatively toxic interventions.
and ineffective anticonvulsants, phenobarbital In the same period as these “sleep therapies,”
was groundbreaking, enabling many patients barbiturates were being used for awakenings. In
with severe epilepsy to resume everyday activities, 1930, William Bleckwenn and colleagues found
particularly given its long half-life. Due partly to that patients with catatonic mutism, generally
World War I, however, use of phenobarbital as considered a severe manifestation of schizo-
an anticonvulsant took years to spread. Today, phrenia, could be temporarily restored to func-
global use remains common both through direct tion with sodium amytal or sodium pentothal,
application as an anticonvulsant and through enabling therapeutic interaction with physicians.
primidone, of which phenobarbital is an active This treatment technique, known as narcoanalysis
76 Benzodiazepines

with truth serum, saw wide use for years to fol- diazepam (Valium), the first two to hit the mar-
low; benzodiazepines, with a mechanism of action ket—have certain properties that render them
similar to barbiturates, remain the treatment of generally safer than barbiturates. Although barbi-
choice for catatonia. turates remained popular for years after the intro-
duction of benzodiazepines, the latter class has
Ubiquity, Abuse, and Regulation long since eclipsed barbiturates in clinical prac-
In these decades, barbiturates also became inte- tice. The advent of neuroleptic medications and
gral to everyday life. Marketed to treat anxiety mood stabilizers in the 1950s also rendered man-
and insomnia, barbiturates found their way into agement of acute agitation by barbiturate seda-
thousands, if not millions, of American homes. In tion less relevant to inpatient psychiatric care.
1950, a single dose of a barbiturate cost about 10 Today, however, barbiturates retain many medical
cents, and, in many states, could be obtained with- uses—in neurology, anesthesiology, and pediat-
out a prescription. In the same year, at least 1,000 rics, in particular—both in centers of cutting-edge
Americans were thought to have overdosed, both practice and in health systems in which they are
deliberately and accidentally. By 1962, the federal used as cheap alternatives to recommended first-
government estimated a quarter of a million bar- line drugs.
biturate addicts; that same year, Marilyn Mon-
roe’s death certificate deemed acute barbiturate Thomas R. Blair
poisoning as her cause of death. When Jacque- University of California, Los Angeles
line Susann’s Valley of the Dolls (1966) famously
depicted female entertainers abusing barbiturates, See Also: Benzodiazepines; Drug Abuse; Minor
the paradigm was already familiar to the Ameri- Tranquilizers.
can public—from the headlines if not from their
own medicine cabinets. Further Readings
As early as the 1920s, ubiquity and abuse led Cozanitis, D. A. “One Hundred Years of Barbiturates
to regulation. In 1922, for instance, New York and Their Saint.” Journal of the Royal Society of
City implemented a code by which barbiturates Medicine, v.97/12 (2004).
could only be obtained with a prescription; even Healy, D. The Creation of Psychopharmacology.
if this law had been rigorously enforced, however, Cambridge, MA: Harvard University Press, 2002.
consumers only had to leave the city’s five bor- López-Muñoz, F., R. Ucha-Udabe, and C. Alamo.
oughs to buy barbiturates over the counter. Laws “The History of Barbiturates a Century After Their
remained weak from local to federal levels. In Clinical Introduction.” Journal of Neuropsychiatric
1941, the Food and Drug Administration (FDA) Disease and Treatment, v.1/4 (2005).
issued guidelines on judicious sale of barbiturates, Tone, Andrea. The Age of Anxiety: A History of
among other drugs, but did not set actual restric- America’s Turbulent Affair With Tranquilizers.
tions. Finally, in 1951, with the Durham-Hum- New York: Basic Books, 2009.
phrey Amendment, Congress introduced pre-
scription-only access. Further restrictions came
with the Controlled Substances Act (1970), in
which barbiturates (and other drugs) were sched-
uled according to addiction potential. Benzodiazepines
The problems of oversedation, addiction, and
withdrawal spurred development of other seda- Benzodiazepines are a class of molecules with ben-
tives; out of these efforts came, first, meprobam- zene and diazepam rings as their chemical cores.
ate (Miltown, 1955) and then benzodiazepines, They are pharmacologically characterized by their
beginning with chlordiazepoxide (Librium) in binding and activity at the benzodiazepine site on
1960. These drugs, like barbiturates and alco- gamma-aminobutyric acidA (GABAA) receptors.
hol, are thought to act through gamma-amino- Benzodiazepine agonists act to enhance the activ-
butyric acid (GABA) receptors. Benzodiazepines, ity of GABA on chloride ion channels, causing
however—particularly chlordiazepoxide and hyperpolarization of the neuron membrane and
 Benzodiazepines 77

with resulting effects of anxiolysis, muscle relax- anxiolytic, muscle relaxant, and sedative prop-
ation, anticonvulsant activity, and sedation. First erties. The compound calmed a colony of wild
marketed in 1960, the family of useful benzodi- monkeys while sparing their alertness, and in
azepine compounds has grown to a large number, preclinical testing, it pacified leopards, lions, pan-
due to the varieties of potency and half-life, and is thers, tigers, and pumas at the San Diego and Bos-
now a multibillion dollar industry. ton zoos. Sternbach turned his attention back to
Ro 5-0690 and found that the synthesis of this
Discovery of Benzodiazepines compound had used methylamine, a primary
The discovery of benzodiazepines resulted from amine, causing a transposition reaction with ring
efforts to replace drugs previously used for anxio- enlargement, accounting for the difference in
lytic and hypnotic purposes that were determined activity from his previous series of 40 ineffective
to be either incompletely effective, caused exces- compounds. This new compound was patented in
sive sedation, or were associated with addiction. 1958, and the name changed to chlordiazepoxide.
Until the 20th century, alcohol, opium and its Chlordiazepoxide was first tested clinically in
alkaloids, and bromides were the pharmacologi- patients with schizophrenia. It was found to have
cal mainstays for treatment of anxiety. Bromide no antipsychotic effect but did reduce their anxi-
toxicity was widespread due to excessive dosing ety. In a second trial, large doses were given to
of bromides in conjunction with their long half- a small number of elderly patients but met with
life (up to 12 days). Thus, they were gradually negative results due to limitations of sedation,
replaced by barbiturates during the early 20th ataxia, and confused speech. A multisite trial
century. Led by phenobarbital (marketed by was then developed to test chlordiazepoxide in
Bayer as Luminal), barbiturates were considered a general psychiatric population, with consistent
the most effective compounds for treatment of results showing effective anxiolysis, few adverse
anxiety, but their use was hampered by issues of effects, and minimal impairment of awareness;
tolerance, reduction of anxiolytic effect with con- these results were later published in the Journal
tinued use, and risk of overdose. In 1955, mepro- of the American Medical Association (JAMA)
bamate (Miltown) was released as an anxiolytic in March 1960. Combining this data along with
with initial commercial success. However, it was those from other researchers, chlordiazepoxide
later found to have relatively weak anxiolytic was studied in 16,000 patients prior to Food and
properties and cause drowsiness and was associ- Drug Administration (FDA) approval in February
ated with tolerance, abuse, and dependence. 1960 and was marketed as Librium.
The first benzodiazepine was discovered by Stimulated by the success of chlordiazepox-
Leo Sternbach (1908–2005) while searching for ide, the search for other benzodiazepines began.
anxiolytics in an unrelated class of compounds. Sternbach and his group identified and synthe-
Given the success of chlorpromazine as a tranquil- sized diazepam, a metabolite of chlordiazepox-
izer, Sternbach, working at Hoffmann–La Roche, ide, which was marketed as Valium in December
wondered if he could modify the side chains of 1963. Oxazepam (Serax), developed at Wyeth
a tricyclic compound he had worked on previ- Laboratories, followed in 1965. Additional test-
ously to synthesize a new molecule with calming ing and usage of the benzodiazepines led to an
abilities. He created 40 compounds with several improved understanding of the dissociation of
secondary amines. Unfortunately, they were all anxiolytic and sedative effects in addition to the
negative in testing for sedative, anticonvulsant, hypnotic, muscle relaxant, and amnesic proper-
and relaxant properties, and Sternbach was asked ties. To this end, new compounds were developed
to discontinue this research. and marketed to target these properties individu-
While cleaning out the lab, Earl Reeder, a col- ally. For example, alprazolam (Xanax, released in
league of Sternbach’s, came upon several hundred 1983) was developed as an anxiolytic targeting
milligrams of a crystallized compound that had panic disorder, which had been recently character-
not yet been tested. The compound, Ro 5-0690, ized as a separate anxiety disorder, and triazolam
was submitted for testing and returned results (Halcion, released in 1979) was developed as a
that were superior to meprobamate in regard to hypnotic.
78 Benzodiazepines

In the decade between 1965 and 1975, ben- advent of selective serotonin reuptake inhibi-
zodiazepines became the most widely prescribed tors (SSRIs) in the 1990s led to benzodiazepines
drugs in the world, with Valium reigning as the becoming a second-line therapy for anxiety. Nev-
most successful drug in pharmaceutical industry ertheless, for the fifth straight year, in 2011, alpra-
history until the release of Prozac. zolam remained the most prescribed psychotropic
drug, with 49.1 million prescriptions. The con-
Risks Associated With Benzodiazepines tinued dominance of some benzodiazepines for
Until the development of an effective anxiolytic treatment of anxiety states is multifactorial, with
agent, treatment of anxiety disorders was concep- contributions from drug firm marketing, their
tualized as targeting the underlying neurosis with presence in celebrity culture, low cost, the visibil-
psychoanalytic techniques. Indeed, Librium was ity of anxiety education programs, and drug char-
first marketed to allow patients to be more accessi- acteristics (namely, immediate effect and good
ble and communicative. Initially, the safety profile clinical efficacy).
of benzodiazepines was emphasized, particularly The development of benzodiazepines parallels
in contrast to the older anxiolytics, lending to their that of the other major psychotropic drug classes
popularity. As the use of benzodiazepines grew, so in helping construct disease categories, spur new
did the recognition that they caused dependence, methods of evaluation, create a new set of prob-
and questions regarding their safety arose after lems leading to the search for new solutions, and a
cases of withdrawal and deaths after suicide or refined understanding of the neurobiology of drug
combination with alcohol were reported. effects. The Diagnostic and Statistical Manual of
The first major action taken in the case against Mental Disorders (DSM) diagnostic category of
benzodiazepine dependence occurred in 1973 anxiety disorders has been refined, and specific
when the National Health Service of the United anxiety disorders, such as panic disorder, have
Kingdom forced Hoffmann–La Roche to pay been described, underscoring the ways in which
nearly 4 million pounds in repayment; several drug response has helped define disease categories.
European countries followed with similar actions. Clinical trials for benzodiazepines and treatment of
Meanwhile, the social acceptance of benzodiaz- anxiety prompted the creation of quantitative anx-
epines waned as they were touted as tranquilliz- iety rating scales to track changes in subjects over
ing agents and addictive drugs and pejoratively time. Problems with tolerance and dependence have
called “opium of the masses” and “mother’s little led to wider use of effective nonpharmacological
helper,” and the term dependence was colloqui- therapies for anxiety, including cognitive behav-
ally replaced with the word addiction. ioral therapy. Finally, molecular characterization
Controls on benzodiazepines continued to of benzodiazepines brought greater understanding
tighten. In 1975, the FDA added benzodiazepines of GABAA receptor pharmacology, including the
to the list of Schedule IV controlled substances, function of GABA and its anatomical distribution.
and in 1984, the World Health Organization suc- This greater understanding, in turn, has led to the
cessfully asked the United Nations to list them as development of nonbenzodiazepine hypnotics (e.g.,
controlled substances. In New York State, benzo- zolpidem) as potentially safer agents, though these
diazepines required triplicate prescriptions start- too remain prone to dependence and tolerance.
ing in 1989, allowing prescriptions to be tracked
by the State Department of Health, a level of con- Garth Terry
trol used for opioids, amphetamines, and barbi- University of California, Los Angeles
turates. These measures also created a barrier to Joan Striebel
access benzodiazepines, and as a result, the pre- University of California, San Francisco
scription rates and adverse effects of nonbenzo-
diazepine anxiolytics and hypnotics (e.g., mepro- See Also: Anxiety, Chronic; Barbiturates; Prozac.
bamate and chloral hydrate) increased.
Based on concerns of dependence, Halcion Further Readings
was removed from the market in the UK in 1991. Goddard, A. W., J. D. Coplan, A. Shekhar, J. M.
Together, the concerns of dependence and the Gorman, and D. S. Charney. “Principles of
 Bereavement 79

Pharmacotherapy for the Anxiety Disorders.” In and new life. Burials, wakes, and funerals demon-
Neurobiology of Mental Illness (2nd ed.), D. S. strate community solidarity through one’s cloth-
Charney and E. J. Nestler, eds. New York: Oxford ing (e.g., wearing black), music (e.g., singing in a
University Press, 2004. Jamaican ceremony), preparation of meals for the
IMS Institute for Healthcare Informatics. The Use of bereaved, or food restrictions.
Medicines in the United States: Review of 2011.
http://www.imshealth.com/ims/Global/Content/ Meaning of Death Influenced by Culture,
Insights/IMS%20Institute%20for%20Healthcare Religion, and Sociological Factors
%20Informatics/IHII_Medicines_in_U.S_Report The meaning that individuals ascribe to death
_2011.pdf (Accessed July 2013). affects the duration of bereavement and its intensity,
Lader, M. “History of Benzodiazepine Dependence.” and varies according to culture, religion, and socio-
Journal of Substance Abuse Treatment, v.8 (1991). logical factors (such as individualism, collectivism,
López-Muñoz, F., C. Alamo, and P. Garcia-Garcia. and status). Explanations for death typically vary
“The Discovery of Chlordiazepoxide and the according to perceptions of fate, personal choice,
Clinical Introduction of Benzodiazepines: Half a the will of God, and the circumstances surround-
Century of Anxiolytic Drugs.” Journal of Anxiety ing the death. In cultures where death is believed to
Disorders, v.25 (2011). be caused by sorcery (e.g., parts of Africa), expla-
nations focus on reasons for the sorcery and how it
was performed. Most cultures classify the manner
of dying as a “good” (e.g., death in old age with-
out suffering) versus “bad” death (e.g., traumatic
Bereavement death or prolonged suffering), which influences the
practices and adjustment for the bereaved. Major
Bereavement is the period of grief and mourning world religions can provide meaning to death, and
following a loss. While bereavement may apply to religious organizations provide social support. For
significant losses, such as divorce or unemploy- example, religious beliefs where heaven is viewed
ment, it typically refers to the period after the death as a place where one reunites after death may aid
of a friend or loved one. Grief is defined as the the grieving process.
feelings and thoughts following a death, whereas Society typically determines the degree to
mourning reflects how grief is socially expressed. which it is appropriate to maintain a bond with
Bereavement is embedded in ever changing cul- the deceased. In some cultures (e.g., Japanese,
tural norms, including ritualized responses to Chinese), rituals are focused on communicating
death, meaning of death, relationships with the with the dead; therefore, individuals who feel,
deceased, provisions of social support, emotional see, hear, or dream about the deceased often find
expression, response to contemporary institutions it comforting. In North American and western
(e.g., social media), and human idiosyncrasies. European cultures, bonds with the deceased are
Death rituals provide an appropriate environ- usually managed privately, and grieving is typi-
ment and timeline for mourning. The duration cally a solitary experience. In the West, it is appro-
of bereavement varies according to the relation- priate to talk about one’s grief, whereas in other
ship with the deceased, whereas some mourn- cultures (e.g., in southeast Asia or Oceania) talk-
ing periods are prescribed by religion or culture. ing about the deceased is considered bad luck and
Death rituals are intended to display respect for offensive, or may evoke the spirit of the deceased.
the deceased, to help meet the spiritual needs of Deaths that conform to cultural and social
survivors, or to comfort the living. In Asian cul- norms solicit community-wide social support,
tures, mourning rituals demonstrate the degree to whereas massive traumatic events (e.g., the ter-
which the deceased was loved, filial duty, and the rorist attacks on 9/11) instigate worldwide indi-
invocation of blessings. By contrast, in some Afri- vidual and institutional responses, including ser-
can cultures, mourning rituals of animal sacrifice vices, media coverage, and fund-raising. Collective
intend to protect the surviving family from mis- responses to grief help individuals to comfort oth-
fortune, and shaving one’s head symbolizes death ers, share grief, cope, and recover. Contemporary
80 Bereavement

use of social media networks, such as memorial of emotions, others may have their basic needs
Facebook sites, provide a public space to grieve met by others for days, weeks, or years as they
and mourn for an indefinite period of time. grieve (e.g., in Egypt). Deaths that are socially
In addition to grieving a specific person, indi- stigmatized, such as death from suicide or human
viduals around the world experience losses asso- immunodeficiency virus and acquired immune
ciated with death that are economic, relational, deficiency syndrome (HIV/AIDS), can cause the
or deal with coming to terms with one’s mortal- bereaved to feel socially isolated, rejected, or the
ity. A child who loses a parent, for example, may need to conceal the cause of death.
grapple with conceptualizing death, grieve the Elisabeth Kübler-Ross’ seminal stages through
loss of an important attachment figure, and adjust which grieving individuals move—denial, anger,
to new roles (e.g., a son may be considered “man bargaining, depression, and acceptance—have
of the house” following the death of his father). shaped how lay persons and mental health pro-
In parent–child relationships, wherein children fessionals conceptualize grief around the world.
are highly valued, provide meaning to the par- However, contemporary researchers and practi-
ents, and are expected to outlive parents, the loss tioners propose that grief fluctuates, cycles, and
of a child is highly traumatic, resulting in long is relatively enduring; therefore, closure to grief
and intense bereavement. Parents living in regions is not necessarily stressed, and continuing bonds
with high rates of child mortality tend to accept with the deceased are recognized. Emotional
the loss of a child as a natural phenomenon. expression while grieving is nearly universal,
In some Muslim societies, friends and relatives though it differs in the ways that emotional expres-
will spend days living with the bereaved. While sion and intensity are tied to gender roles, societal
some bereaved individuals may return promptly rules, and traditions. For example, in Latino cul-
to their everyday life (e.g., in Bali) with little show tures, grief is expressed openly by women (e.g.,

Counselors and volunteers help stressed and grief-stricken evacuees deal with the trauma of Hurricane Katrina, September 2005.
Massive traumatic events such as hurricanes spark worldwide responses, including services, media coverage, and fund-raising.
Collective responses to grief help individuals comfort others, share their grief, cope, and recover.
 Biological Psychiatry 81

with crying and wailing) while men, according in which distress is located in the individual
to expectations of machismo, do not show overt and the brain and body rather than in its social
emotion. In contrast, Navajo customs dictate that context, shifting the focus from the subjec-
excessive emotion not be shown to avoid disrupt- tive experiences of people with mental illness to
ing the deceased’s journey to the next world. objectively measureable biological changes. As a
While grief is typically characterized by sor- consequence, environmental factors are currently
row, grief can be accompanied by anger or guilt. largely viewed as risk rather than etiological fac-
Grief may be expressed through physical symp- tors in the development of mental illness, and
toms including stress hormones, disrupted sleep, are expressed as epidemiological variables used
compromised immune system, changes in appe- to identify groups that are statistically at risk
tite, or hallucinations of the deceased. While all of developing mental illness. For example, child
cultures prescribe socially appropriate responses abuse has been found in 20 to 60 percent of cases
to death, some cultures delineate normal versus identified in clinical samples of those with mental
pathological grieving. Throughout North Amer- illness, which has led to more research into the
ica and Europe, prolonged or absent grief (also link between childhood trauma and the onset and
known as complicated grief) is considered to be maintenance of mental illness.
a bereavement-related psychological disorder for Sociology’s response to biological psychiatry
which psychological intervention is warranted. has been critical. The 1980s witnessed a growth
in sociological research that challenged diagnos-
Ariane Schratter tic categories and critically examined the science
Maryville College that informed biological psychiatry. Underpin-
ning these critiques was ongoing scientific faith in
See Also: Family Support; Religion; Religiously biological approaches in light of a failure to iden-
Based Therapies; Spiritual Healing. tify specific biological causes for mental illness.
Many sociologists sought other explanations
Further Readings for the dominance of biology. D. Pilgrim and A.
Bryant, Clifton, ed. Handbook of Death and Dying. Rogers argue, for example, that renewed inter-
Thousand Oaks, CA: Sage, 2003. est in biological psychiatry can be understood
Koenig, Harold, et al. Handbook of Religion and as a response to changes in service delivery that
Health. 2nd ed. New York: Oxford University have eroded psychiatric dominance of mental ill-
Press, 2012. ness. Among the changes identified are: delivery
Walter, Tony. “Why Different Countries Manage of services through multidisciplinary community
Death Differently: A Comparative Analysis of health teams, increasing management of high-
Modern Urban Societies.” British Journal of prevalence disorders such as depression and anx-
Sociology, v.63/1 (2012). iety in general practice and by psychologists, and
hospitalization on the basis of risk rather than
diagnosis.
Despite skepticism, there have been new devel-
opments in biological psychiatry. Initial interest
Biological Psychiatry focused on the role of genetics in the transmission
of disease, and the role of biochemistry, whereas
The history of psychiatric knowledge has been more recent theories focus upon changes in brain
one of competition between two dominant etio- structures and function, neuro-endocrinology
logical paradigms: one favoring the social causa- and neuro-immunology, and neurodevelopment.
tion of mental illness and the other favoring bio- Neuro-endocrinology and neuro-immunology
logical causes. Psychiatry is currently dominated explore the integration of the body’s hormone and
by biological models of etiology that re-emerged immune system and the brain, and how that influ-
in the United States during the 1970s. ences the development of mental illness.
Nikolas Rose associates a biological under- Molecular genetics gained impetus follow-
standing of etiology with somatic individualism, ing the launch of the Human Genome Project in
82 Biological Psychiatry

1989. Molecular geneticists have attempted to in the underlying mechanisms of the HPA axis,
demonstrate a causal relationship between genes such as increased secretion of any or all of the
and mental illness. They assume that this rela- hormones in the system or decreased sensitivity
tionship exists on the basis of earlier family, twin, to the feedback mechanisms at any or all levels of
and adoption studies that establish a correlation. the axis, can lead to significant disturbance that
Molecular geneticists initially believed that a spe- affects the synthesis of CRF and cortisol, which
cific gene could be found for mental disorders; have an effect on the activation of the sympa-
however, genetic studies have failed to identify the thetic nervous system. Studies have shown that
genes responsible for mental health conditions, during stress there is a failure in the normal feed-
contributing to polygenic theories in which the back mechanisms in the HPA axis that can lead
etiology of mental illness is believed to be found to damage in the neurons in the brain structure of
in the interaction of multiple genes that increase the hippocampus.
susceptibility to disorders. Advances in computer tomography (CT) and
Another theory associated mental illness with magnetic resonance imaging (MRI) have allowed
biochemical abnormalities. Biochemical expla- a greater understanding of brain structure and
nations of mental illness initially focused upon function and how these may be affected in men-
failures in the neurotransmitters, chemicals that tal illness. In some individuals with schizophre-
aid the transmission of information between neu- nia, for example, it has been shown that there are
rons. These theories have progressed to examin- structural changes such as dilated cerebral ventri-
ing the relationship between the neurotransmit- cles and reduced frontal lobe density, which with
ters and their associated receptor sites. Existing other evidence suggests that the condition may be
theories of the depletion or excess of neurotrans- related to neurodevelopment. Early exposure to
mitters such as dopamine, serotonin, and nor- adverse factors affecting neurodevelopment, such
adrenaline were not sufficient to explain the as low birth weight, influenza, or other viruses,
extended time taken to see therapeutic effects may lead to the changes observed in the frontal
from drugs used that block dopamine transmis- lobes that increase the risk of mental illness.
sion or increase the availability of monoamines. Despite ongoing interest in the biology of men-
These theories relating to the interaction between tal illness, many sociologists (e.g., D. Smith) argue
neurotransmitters and their receptor sites still do for a role for sociology in identifying cultural and
not completely explain what is occurring at a structural causes of suffering and in research-
neural level in mental illness because of the exis- ing the impact of service delivery on people with
tence of several subtypes of each receptor, which mental illness. Further, theories of biological eti-
have different effects depending on where they ology are increasingly recognizing the impact of
are located on the neuron. Neurotransmission social factors on biological development and sus-
is also affected post-synapses by various mecha- ceptibility for mental illness, enabling a role for
nisms that can either increase or decrease the sig- sociology.
nal sent between neurons. This has led to newer
research and models that encompass other neu- Julie Henderson
ral message mediators such as opioid peptides, Louise Roberts
neuro-endocrine factors (particularly cortico- Flinders University
trophin releasing factor, or CRF), and immune
products such as interleukin. See Also: Genetics; Mental Illness Defined:
According to D. J. Goldstein and colleagues, Psychiatric Perspectives; Psychiatry and Neuroscience.
the changes described and observed in the neuro-
endocrine system in depression and other mental Further Readings
illnesses are related to changes that occur as part Goldstein, D. J., et al. “Biological Theories of
of the stress response. The sections of the endo- Depression and Implications for Current and New
crine system that mediate the stress response are Treatment.” In Pharmacotherapy of Depression,
primarily the hypothalamus, pituitary, and adre- D. A. Ciraulo and R. I. Shader, eds. New York:
nal glands, known as the HPA axis. Changes Springer Science and Business Media, 2011.
 Bipolar Disorder 83

Pilgrim, D. and A. Rogers. “Survival and Its inpatient populations. The disorder was a very
Discontents: The Case of British Psychiatry.” debilitating and serious illness that rarely existed
Sociology of Heath & Illness, v.31/7 (2009). among outpatients.
Smith, D. “A Sociological Alternative to the The first diagnostic manuals intended for gen-
Psychiatric Conceptualization of Mental eral use among outpatient populations, the Diag-
Suffering.” Sociology Compass, v.5/5 (2011). nostic and Statistical Manual of Mental Disorders
DSM-I (1952) and DSM-II (1968), classified a
variety of manic-depressive illnesses (e.g., manic
type, depressed type, and circular type) within the
more general category of psychoses not attributed
Bipolar Disorder to physical conditions. Thus, the condition was
distinct from the psychoneurosis that dominated
The term bipolar disorder refers to a family of those manuals. In 1980, the DSM-III completely
disorders currently comprised of four different revised the diagnostic system, abolishing the cat-
disorders: bipolar I, bipolar II, cyclothymic disor- egory of psychosis. It changed the name of manic-
der, and bipolar disorder not otherwise specified. depression to bipolar disorder and placed it in the
The primary difference between bipolar I and category of mood disorders. Bipolar disorder was
bipolar II disorders is the presence or absence of the only condition that was considered psychotic
mania. Mania is a severe condition in which the that was placed in the mood disorders category.
person experiences elevated mood, nonstop activ- In the 1990s, perceptions of bipolar disorder
ity, thoughts of grandiosity, and lack of impulse began to change. One reason was the addition
control; frequently engages in reckless behaviors of bipolar II conditions in the DSM-IV (1994).
such as compulsive sexual activity, binge buying, Another was the immense popularity of psychol-
and compulsive gambling; and often requires hos- ogist Kay Redfield Jamison’s book, An Unquiet
pitalization. In some cases, mania is accompanied Mind. In this book, Jamison vividly evokes her
by psychosis. Mania only occurs in bipolar I. Bipo- bipolar condition. As an attractive, well-spoken
lar I patients can also experience mixed episodes, mental health professional, this revelation began
in which symptoms of mania and depression are to erode previous stereotypes about bipolar dis-
concurrently present. Suicide is a particular risk order. Her revelations showed that many people
in mixed episodes. Instead of mania, bipolar II with bipolar disorder can lead successful lives and
and I patients both experience hypomania, which do not require institutionalization.
is an attenuated version of mania. Both bipolar I
and II are marked by depressive episodes in which Role of Psychiatric Research
suicide is a risk. Cyclothymia is a less severe form The methods of psychiatric researchers are one
of bipolar II disorder, and bipolar disorder not prominent reason for the seeming rise in the
otherwise specified is a form of bipolar that does prevalence of bipolar conditions. The definition
fit any of the other categories. While estimates of of a bipolar condition depends on the number of
the amount of bipolar conditions vary, rates have symptoms required for a diagnosis and the length
increased in recent years. of time that symptoms must endure. Lowering
Bipolar disorder is rooted in conceptions of one or both of these thresholds leads to a greater
mania that date back to the ancient Greeks. Are- prevalence of the condition. For instance, Franco
taeus of Cappadocia first recognized alternating Benazzi and others have suggested that diagnos-
patterns of depression and mania in the 1st cen- tic criteria for bipolar II disorder (which currently
tury. French psychiatrists Jean-Pierre Falret and requires the presence of hypomania for at least
Jules Baillarger coined the term folie circulaire four days), be dropped to a two-day minimum
(circular insanity) in 1854. In 1899, Emil Krae- length of hypomania. This allows more people to
pelin outlined the nature of manic-depressive dis- qualify for a bipolar II diagnosis.
order and distinguished it from dementia praecox This research has led to a change in the crite-
(schizophrenia). Initial classifications of this con- ria for the newest revision of the DSM-5, which
dition, including Kraepelin’s, were used to classify was published in May 2013. The DSM-5 includes
84 Bipolar Disorder

a new entity called “major depressive episode serious side effects, such as permanent movement
with short (2- to 3-day) hypomanic episode.” disorders. Lithium, a naturally occurring salt that
This change will allow for the diagnosis of people had been used to treat a wide variety of conditions
whose hypomania only lasts for as brief a period for hundreds of years, was shown to effectively
as two days with bipolar II. Bipolar researchers treat bipolar conditions in the mid-1950s. Unlike
also called for expanding the bipolar spectrum to the other antipsychotic drugs, however, lithium
include bipolar 1.5, 2.5, 3, 3.5, 4, 5, and 6, argu- could not be patented, so had little commercial
ing that additional categories will allow for even value. Lithium’s value as a mood stabilizer, how-
more people to be diagnosed with a variant of ever, was gradually realized, and it became a pop-
bipolar disorder. The concept of bipolar disorder ular response to bipolar conditions in the 1960s.
was expanded in the new edition to include inter- Lithium was approved by the U.S. Food and Drug
mediate forms, but concerns have arisen about Administration as a treatment for bipolar condi-
the potential for overdiagnosis and the blurring tions in the 1970s.
of understanding. Although lithium seemed to effectively stabilize
Mental health professionals have also greatly the moods of bipolar patients, it was not prof-
expanded the pool of potential patients to include itable to pharmaceutical companies. Because of
children and adolescents. Bipolar disorder was this, in the 1970s, they developed a new class of
traditionally thought to arise in midlife, and until patentable drugs, called “atypical antipsychot-
recently, was virtually unknown among youth. In ics” because they have a different profile of side
2007, a national survey by Carmen Moreno and effects from the first generation of antipsychotic
colleagues discovered a 40-fold increase in the drugs. Sales of these drugs surged in the 1980s
number of children and adolescents treated for and 1990s, and there are now more than eight
bipolar disorder from 1994 to 2003. atypical antipsychotics on the market. Atypical
The criteria for pediatric bipolar disorder are antipsychotics are commonly given to bipolar
so vague and the diagnosis is subject to so many patients to combat psychosis and mania. People
uncertainties that many experts even question the with bipolar disorder also use mood-stabilizing
existence of the disorder. The common denomi- medications. These medications are intended to
nator among children treated for this condition eliminate the wide mood swings that are com-
seems to be that their conduct is extremely dis- mon in bipolar disorder. There are currently nine
turbing to adults, usually their parents and/or medications in this category. Antidepressants are
teachers. Pediatric bipolar diagnoses and result- contraindicated in bipolar disorder because it is
ing prescriptions for medication can be ways of believed that antidepressants can cause a manic
pacifying disruptive behavior. Bipolar conditions episode in a bipolar patient. All drugs can have
were traditionally thought to rarely arise before serious side effects for patients, however, includ-
people were in their 30s. Children as young as ing weight gain, thyroid dysfunction, diabetes,
3 years old are being diagnosed and treated for problems with memory, and movement disorders.
bipolar disorder. While it is questionable whether In 2008, the psychopharmaceutical industry
children’s behavior has changed in recent years, earned $24.2 billion in sales of antipsychotics and
the response of mental health professionals to antidepressants. They benefit when more people
problematic children has altered. are diagnosed with bipolar illnesses, which often
receive prescriptions for expensive antipsychotic
Role of the Pharmaceutical Industry medications. Bipolar patients frequently take mul-
Drugs that were oriented to specific psychiatric tiple drugs, which is also beneficial to the psycho-
conditions were first marketed in the mid-1950s, pharmaceutical industry. One month of a single
with the advent of Thorazine, and in the 1960s patented antipsychotic medication can cost more
with Haldol. The success of these drugs was par- than $1,200. Drug companies give samples to phy-
tially responsible for the deinstitutionalization sicians and psychiatrists, hoping to induce them to
of the mentally ill and the establishment of com- prescribe that drug rather than competing drugs.
munity treatment. The older antipsychotics such An important reason for the upsurge in sales
as Thorazine and Haldol were associated with of medications for the treatment of bipolar
 Board and Care Homes 85

conditions is the expiration of the patents of are seen as at risk of developing bipolar condi-
many of the selective serotonin reuptake inhibitor tions has expanded. This is partially a result of
(SSRI) medications in the early 2000s. This class the inclusion of bipolar II as a “less severe” ver-
of medication was primarily oriented toward the sion of bipolar disorder in the DSM-IV. Bipolar
treatment of conditions such as depression and has become less stigmatized because there is a less
anxiety. Once these drugs could be replaced by severe version of it. The DSM-5 is expected to
generic equivalents, they became far less profit- carry on this process through further decreasing
able. This was a strong inducement for drug com- the thresholds for bipolar diagnoses.
panies to search for new, more lucrative markets.
The pharmaceutical industry began widespread Kathryn Burrows
advertising campaigns for their patented anti- Allan V. Horwitz
psychotic medications. This advertising strove to Rutgers University
normalize bipolar disorder by featuring attrac-
tive people who took antipsychotics to achieve a See Also: Emotions and Rationality; Lithium; Mania;
successful life. Mood Disorders; Pharmaceutical Industry; Unquiet
The result of these extensive advertising cam- Mind, An.
paigns was to appeal to the broadest possible mar-
ket by associating mood swings with a frequently Further Readings
occurring disorder that could be controlled Healy, David. Mania: A Short History of Bipolar
through medication. This strategy simultaneously Disorder. Baltimore, MD: Johns Hopkins
normalized and pathologized bipolar behaviors. University Press, 2011.
On the one hand, they redefined seemingly nor- Horwitz, Allan. Creating Mental Illness. Chicago:
mal mood swings as abnormal in order to broaden University of Chicago Press, 2002.
their market. On the other hand, they normalized Jamison, Kay Redfield. An Unquiet Mind. New York:
bipolar conditions by connecting taking medica- Vintage, 1997.
tion for them with attractive and ordinary people.
Antipsychotic medications are now the single most
profitable class of psychotropic drugs, a result that
would have been unthinkable in previous decades,
when psychotic conditions were thought to affect Board and Care Homes
a small minority of the population.
Board and care homes, often called group homes,
Cultural Trends are small-scale residential facilities serving the
Several broader cultural trends have increased mentally ill, developmentally disabled, or older
the number of people who are diagnosed with adults. These facilities typically have small num-
bipolar disorder. These processes have lowered bers of on-site staff. They serve meals and provide
the thresholds of when both professionals and assistance with daily living activities but seldom
laypeople consider a disorder to be present. This provide the level of medical services associated
has not largely been a coercive process, because with nursing homes. These facilities, if regulated,
the growth of a therapeutic culture has led people are governed by state and local rules. Residents
to be more and more willing to adopt a bipolar typically pay for “room and board” with their
label. The economic interests of the pharmaceuti- public benefit checks. Some states provide supple-
cal industry have promoted antipsychotic medica- mental funding. The facilities and services vary in
tions to far broader groups of people. Direct-to- quality. They receive the lowest level of oversight
consumer advertising has spread the notion that by state authorities.
bipolar conditions are widespread, nonstigma- Board and care homes fill an important hous-
tizing, and amenable to treatment. At the same ing niche for people who need some level of
time, the boundaries of what is considered bipo- supervision and support. People with mental
lar disorder have been lowered while the types of illness require access to inexpensive housing.
people, especially children and adolescents, who Supplemental Security Income (SSI), the primary
86 Board and Care Homes

New Jersey Governor Chris Christie (left) talks with resident Denise Parno at Hilltop Group Home, a community-based program for
residents with developmental disabilities in Robbinsville, March 7, 2013. Each state has its own set of regulations for the care and
safety of residents in group homes. Board and care homes usually have requirements in terms of minimal private space for residents,
shared facilities for meals and socializing, and staffing. State law also governs the rights of people living in these facilities.

source of income for people with disabilities and Regulation and Operation
little work history, does not pay enough to cover Each state has a different way to regulate care and
the cost of market rate housing. Medicaid, which safety of group homes. Sometimes, these homes
pays for treatment, does not ordinarily pay for are just part of a catchall category of facilities not
housing. regulated by other entities. Nursing homes, men-
Most board and care homes are small-scale tal health residential treatment facilities, drug and
facilities because neither Medicaid nor SSI is alcohol addiction programs, and halfway houses
payable when individuals live in mental health have much stricter regulation than board and care
facilities with more than 16 beds. A 2006 fed- homes. Board and care homes are usually required
eral survey of mental health residential treatment to provide minimal private space for residents,
facilities revealed that approximately 39 percent shared facilities for meals and socializing, and a
of residential facilities averaged between three minimum of staffing. The quality of board and
and eight residents; another 40 percent of the care homes varies widely. Inspections rarely result
facilities had an average of nine to 16 residents. in fines against unscrupulous operators. Rules
Only about 19 percent of facilities averaged 17 that protect vulnerable people from exploitation
or more residents (these were usually classified as vary in effectiveness from state to state. Continu-
“treatment centers”). These facilities are usually ity of care can be a problem, especially when an
not secure, in the sense that residents are permit- agency in one county places an individual in an
ted to come and go as they would in any home. out-of-county group home.
The smallest regulated facilities are rarely, if ever, Ideally, when a person is referred to a group
permitted to have locked units. The largest facili- home by a mental health agency, the agency should
ties may have some locked units. develop a written, individual mental health plan
 Brazil 87

to help make sure that the placement is safe and rules and procedures. In addition to day-to-day
supportive. The plan should address medication rules for meals, sleeping arrangements, and fire
and possible adverse side effects, personal care safety, the written material should include the pro-
services, and other assistance the person needs, cess that the facility uses when making referrals
and the entity that is to provide these services. The for mental health and medical evaluations.
plan should ensure that the person remains con- The authors of the 2006 federal survey noted
nected to services and his or her family. The plan that many states lack ready access to important
should also address what will happen in the event data about residential facilities for adults with
of emergencies, including advance directives such mental illness. About 40 percent of state regula-
as living wills or powers of attorney for health tors were unable to provide information on the
care. The plan should be updated at least once average length of stay in the facilities they were
a year. Friends and family members of people overseeing. They could not provide ownership
referred to a group home can become involved in information for about 10 percent of facility types,
the process and advocate for their friend or rela- accounting for almost 30 percent of facilities.
tive during the preparation of the plan for care. Moreover, the federal survey respondents often
Group home operators receive rent payments indicated that they were relying on administra-
from residents, and sometimes money from sup- tive estimates, rather than specific records or
plemental state funding programs. The amount of documents to report on certain types of descrip-
pocket money remaining available to a resident tive data such as average number of residents per
varies widely within each facility, based on state facility, frequency of announced visits, or Medic-
rules. Some residents may be able to keep nearly aid per diems.
all of their income, while others struggle to keep
small amounts of cash for cigarettes and snacks. Paul Komarek
Friends and relatives can help ensure that resi- Independent Scholar
dents retain access to personal resources.
The best facilities maintain close ties with com- See Also: Group Homes; Mental Institutions, History
munity mental health treatment agencies that of; Nursing Homes.
provide case management and other services for
residents. Good case managers visit regularly, Further Readings
inspect living quarters, and speak with their cli- Frank, R. G., H. H. Goldman, and M. Hogan.
ents privately on a regular basis. People who “Medicaid and Mental Health: Be Careful What
require group home placement are vulnerable You Ask For.” Health Affairs, v.22/1 (2003).
to abuse and exploitation. Resident-to-resident Ireys, H., L. Achman, and A. Takyi. “State Regulation
abuse can be a very serious problem. Sometimes, of Residential Facilities for Adults With Mental
residents loan others cigarettes or snacks and then Illness.” DHHS Pub. No. (SMA) 06-4166.
take the resident’s checks at the beginning of each Rockville, MD: Center for Mental Health Services,
month or steal property. Sexual abuse sometimes Substance Abuse and Mental Health Services
occurs. There may be no planned activities. Some Administration, 2006.
case managers seldom visit. Komarek, P. Defying Mental Illness: Finding Recovery
State law governs the rights of people living in With Community Resources and Family Support.
board and care homes. There are some common Cincinnati, OH: Church Basement Press, 2013.
elements. Before admission, the resident should
sign, and the facility should explain, the terms
of a resident agreement that sets out all charges
that apply. The resident should have a copy of the
signed agreement. Arrangements should be made Brazil
concerning how the resident will continue to con-
nect with mental health and medical services. The The name Brazil was derived from the Portuguese
operator should explain its resident’s rights poli- and Spanish word brasil, the name of an east
cies and procedures and provide written copies of Indian tree that was found on the landmass by
88 Brazil

early settlers. The tree produced a reddish-brown historically characterized by extremes of poverty
wood, from which a red dye was extracted. Brazil and affluence.
is the largest country in South America, compris- Brazilian assets such as a sunny, agreeable climate
ing the majority of the continent’s total landmass, throughout the year, a beautiful coastline, and the
and is the largest Portuguese-speaking country Amazon rain forest promote a robust ecotourism-
in the world, with a population estimated at 193 based economy, even in the context of relatively
million (São Paulo has over 11 million, and Rio high crime rates in many impoverished areas that
de Janeiro over 6 million inhabitants). border ecotourism sites. Brazil ranks 52nd as an
Brazil was formally discovered and recognized international destination and is third among Latin
as habitable around 1500 c.e., when the caravels American countries, after Mexico and Costa Rica.
of a Portuguese sailor, the Santa Maria, Pinta, Poverty is defined in Brazil as a monthly per capita
and Nina, landed at Porto Seguro (Safe Port) in income under $151 reals ($75.50). Poverty levels
an attempt to find a new route to India. Explorer in Brazil dropped by about half between 2002
Pedro Álvares Cabral was astonished at the and 2010 as the country’s growth accelerated and
beauty of the land, and he claimed it for Portugal; more Brazilians participated in education, social
it was ruled by the King Dom Joao VI from 1500 programs, and economic gains. Over 16 million
to 1822, and then it became a separate empire Brazilians live below the poverty line.
ruled by Pedro I, son of King John VI of Portugal. The Brazilian constitution has guaranteed
Cabral first named the new land Ilha de Vera Cruz freedom of religion since 1988. African slaves
(Island of the True Cross) in honor of the Feast brought religious practices such as Umbanda and
of the Cross. After discovering that it was not an Candomble, which are widely practiced. How-
island, it was named Terra de Santa Cruz (Land ever, most Brazilians practice Catholicism.
of the Holy Cross), and then only Brasil because
of the abundance of the brasil tree. Culture and Mental Health in Brazil
Brazil’s population is diverse and represents Brazilian mental health policies reflect a diverse
descendants of Portugal, various European coun- culture, rapidly changing economy, and culture
tries, African slaves, and, in smaller numbers, with multiple conceptualizations and remedies
Japanese, Arabs, and Amerindian. The language for mental illness. Recent laws in Brazil guarantee
spoken in Brazil is Portuguese, inherited from equality, protections, and civil rights to patients
Portugal and the proclamation of the Brazilian with mental health issues. Traditionally, men-
Republic on November 15, 1889. Brasília has tal illness was managed with institutionalization
been the country’s capital since 1960, replacing in asylums, where the quality of care was often
Rio de Janeiro, which was the country’s first capi- unpredictable and living and work conditions
tal after it became a republic in 1889. were poor. Reforms have been slow and are often
Brazil’s economy is rapidly expanding and has incited by neighboring countries, influential trad-
been recognized for its growth and competitive- ing partners, and providers of psychiatric care.
ness. Increased worker productivity accounts The Brazilian Psychiatric Association, the Brazil-
for a significant portion of the country’s recent ian Federation of Hospitals, and many families of
growth and development. Brazil competes patients have vocally opposed efforts to deinsti-
directly with Russia, India, and China for exports tutionalize the mental health care system. Recent
and intellectual capital. Recently, the Brazilian studies suggest that Brazilian mental health care
government has begun to focus on fiscal sus- providers favor community-based models of psy-
tainability, decreased dependence on imported chiatric care.
energy, and developing domestic energy produc- Brazil has approximately 1,153 psychosocial
tion, including hydroelectric power. Although care facilities for outpatients affected by mental ill-
varying significantly from region to region, ness, constituting 486 home care providers assist-
increased exports require governmental invest- ing 2,499 people, 862 facilities for inpatient mental
ments in transportation infrastructure, and these health, 60 centers of companionship and culture,
investments account for increasing numbers of and 239 social inclusion programs providing job
jobs and a growing middle class in a country placement. Approximately 23 million people suffer
 Burma (Myanmar) 89

a mental illness in Brazil, and approximately 5 mil- Candiago, R. H., S. D. S. Saraiva, V. Goncalves,
lion have reduced quality of life because of deterio- and P. Belmonte-de-Abreu. “Shortage and
rating mental health and limited access to adequate Underutilization of Psychiatric Beds in Southern
mental health care. Brazil: Independent Data of Brazilian Mental
The most frequent mental health presentations Health Reform.” Social Psychiatry and Psychiatric
in Brazil are anxiety and depressive-related condi- Epidemiology, v.46 (2011).
tions, but public policies for mental health give Courts, N. D., C. Lauber, C. T. Costa, and K. C.
priority to patients who are experiencing bipo- Ludewig. “Beliefs About the Mentally Ill: A
lar disorder and schizophrenia. Many parents of Comparative Study Between Healthcare
children with unmet mental health needs attribute Professionals in Brazil and in Switzerland.”
their suffering to a lack of governmental support, International Review of Psychiatry, v.20/6 (2008).
and exposure to social environments plagued by Moreira-Almeida, A. and J. D. Koss-Chioino.
poverty and violence. Many have advocated an “Recognition and Treatment of Psychotic
expanded role for primary care medicine to better Symptoms: Spiritists, Compared to Mental
address the mental health needs and support par- Health Professionals in Puerto Rico and Brazil.”
ents in a future deinstitutionalized mental health Psychiatry, v.72/3 (2009).
system. Others have argued that the primary care Paula, C. S., E. Nakamura, L. Wissow, I. A. Bordin,
model of mental health care is an exportable R. D. Nascimento, A. M. Leite, A. Cunha, and
strategy for other poorly resourced but highly D. Martin. “Primary Care and Children’s Mental
populated countries. Health in Brazil.” Mental Health and Child
The Brazilian mental health system is a diverse Development, v.9 (2009).
experiment in culture, where historical and con-
temporary thinkers work diligently to resolve
complex, difficult to conceptualize pathologies
and resolutions. Growth and maturation of the
Brazilian economy continues to influence policy Burma (Myanmar)
and behavior of patients and providers. Although
debates about how to best react to mental health There is documentary evidence of mental illnesses
issues dominate the current discourse, the future in Burma (also called Myanmar) from medieval
lies in proactive approaches that prevent vio- and early modern times, through references in
lence, address poverty, and reduce exposure to chronicles and allusions in some inscriptions.
factors that most contribute to the current men- King Tabinshweti of the Toungoo dynasty, after
tal health crisis. his military invasion of Thailand, failed to capture
the Thai capital of Ayutthaya in 1548 and suf-
Christopher Edwards fered from depression. On his return to his capi-
Duke University tal, Pegu, he started a search for a white elephant
Vania Regina De Angeli Wood that was so obsessive that it has been highlighted
North Carolina Central University by historians as a sign of mental illness.
Ricardo Pietrobon From 1824 to 1826, taking advantage of a
Duke University Medical Center weak Burmese empire, the British invaded and
Malik Muhammad (at great cost) won the First Anglo–Burmese War,
Elite Biobehavioral Health annexing the territories bordering India, and Ara-
kan and Tenasserim in southern Burma. A sec-
See Also: Homelessness; Policy: Federal Government; ond war, from April until December 1852, saw
Social Class. the British take Lower Burma, leaving the king-
dom landlocked; and in November 1885, in the
Further Readings Third Anglo–Burmese War, the British seized the
Andrade, L. H., et al. “Mental Disorders in Megacities: remaining part of the country.
Findings From the São Paulo Megacity Mental From the taking of Arakan and Tenasserim,
Health Survey, Brazil.” PLOS ONE, v.7/2 (2012). Burma was ruled from British India, and after the
90 Burma (Myanmar)

taking of Lower Burma in 1852, with the Brit- The series of civil wars that have been fought
ish in control of Rangoon (now Yangon), there in border regions of Burma involving the Karens,
was the need to provide a degree of health care Shans, and other ethnic groups, as well as against
for the new subjects of the British. The British the Communist Party of Burma, resulted in the
established a lunatic asylum north of Rangoon at dislocation of large numbers of refugees and great
a place called Tadagale (sometimes called Tadag- trauma suffered by many families. Some have
aly), and this was officially known as the Rangoon gained refugee status in other countries, where
Lunatic Asylum, although it appeared in some these mental illnesses are treated far more effec-
contemporary records as the Tadagale Lunatic tively than in Burma or in refugee camps.
Asylum. From June 1871 until his retirement in Fueling part of the conflict in Burma was the
May 1890, Brigadier-Surgeon Hugh Griffith was illegal trade in narcotics. From early modern soci-
the superintendent of the Rangoon Lunatic Asy- ety in Burma, there are folktales involving wealth-
lum. By 1905, it cared for 427 inmates, the only ier people taking narcotics—especially opium—to
asylum for mentally ill patients until the Minbu treat nervous anxieties and mental instability.
Lunatic Asylum was built by the early 1920s. In Under the British, the smoking of opium was seen
1926, a female wing of the Rangoon Lunatic Asy- as the cause of emotional and mental problems.
lum was completed. With cheap narcotics, some disenchanted and
The traditional method of treating the mentally marginalized youth in Burma turned to drugs,
ill at that time was to have patients at the asy- contributing to mental health problems.
lum undertake simple tasks, such as maintaining The former Rangoon Lunatic Asylum is now
a small dairy herd of cows to provide fresh milk the Yangon Psychiatric Hospital, albeit in a differ-
to the European population in Rangoon. ent location. Doctors working there and elsewhere
The outbreak of the Pacific war in December in the country include Cho Nwe Zin, Irene San
1941 saw the Japanese attack British Burma. In Min, Joyce Khaing, Khin Ko Ko Thu, Khine Khine
February 1942, as the Japanese army approached Mar, Mya Mya Win, and Myint Myint May. They
Rangoon, the British and many Anglo-Indians have done their best to publicize psychiatric prob-
fled. With nobody to care for them, the inmates lems and promote mental issues to the public.
of the Rangoon Lunatic Asylum were released,
but many were shot as suspected looters as Justin Corfield
they roamed the streets in search of food and Independent Scholar
sustenance.
By the time the British returned in 1944, the See Also: Drug Abuse; Drug Abuse: Cause and
Japanese occupation had seen the ill-treatment of Effect; India; Japan; Thailand; War.
many Allied prisoners of war and great hardships
of the Anglo-Indians who had tried to reach Brit- Further Readings
ish India, and deprivations were suffered by the Appleton, Kathleen. Burmese Political Dissidents in
local people. There was some research into men- Thailand: Trauma and Survival of Young Adults in
tal illnesses suffered by these three groups. Exile. Brighton, MA: Harvard Program in Refugee
After Burma gained independence in 1947, Trauma, Indochinese Psychiatry Clinic, 1994.
it had a relatively small number of rulers, and Houtman, Gustaaf. Mental Culture in Burmese
there were many accusations in foreign books on Crisis Politics: Aung San Suu Kyi and the National
Burma that Ne Win, the country’s prime minister League for Democracy. Tokyo: Institute for the
from 1958 until 1960, president from 1962 until Study of Languages and Cultures of Asia and
1981, and chairman of the Burmese Socialist Pro- Africa, Tokyo University of Foreign Studies, 1999.
gramme Party until 1988, suffered from mental van Wyk, S., R. Schweitzer, M. Brough, L. Vromans,
problems. This was especially evident when he and K. Murray. “A Longitudinal Study of Mental
started following the advice of astrologers and Health in Refugees From Burma: The Impact of
numerologists, changing the currency in 1988 to Therapeutic Interventions.” Australian and New
denominations of 45 and 90 kyat because these Zealand Journal of Psychiatry, v.46/10 (October
were divisible by nine. 2012).
 Business and Workplace Issues 91

Business and 55 and 70 percent. At the same time, people with

mental disorders are two to three times more likely
Workplace Issues than healthier individuals to be unemployed.
Approximately one in five workers suffer from
People with mental disorders participate in the a mental disorder. Research indicates that many
labor force in large numbers but face unique chal- individuals will be unable to find employment,
lenges in functioning productively. not seek employment, or lose employment in any
Mental illness affects a person’s ability to find given year due to mental illness. Those who are
and keep a job, attendance at work, performance employed experience a loss of annual income
on the job, and advancement opportunities. The between $3,500 and $6,000 due to their men-
extent to which a person can participate produc- tal illness. Among U.S. disabled workers (those
tively in the workforce depends upon the type receiving social security income), 29 percent had
and severity of mental illness, the coping response a mental disorder other than an intellectual dis-
of the employee with mental illness, and the ability. Worldwide, between 30 and 50 percent of
employer’s response and willingness to modify new disability benefits claims are due to mental
work expectations and the work environment. illness. Across advanced nations, individuals with
Although factors outside the workplace influ- mental illness rely on a variety of different types
ence an employee’s ability to function well on the of benefit mechanisms, including unemployment
job (such as availability of treatment), workplace benefits, social assistance, and lone-parent ben-
issues and employers have a role in either exac- efits instead of or in addition to disability benefits.
erbating or helping alleviate symptoms of mental Consequently, mental illness exacts an eco-
illness that in turn affect the workplace. In par- nomic and social toll on society, individuals, and
ticular, research has found a strong link between their families through reduced workforce partici-
workers’ difficulty coping with work stress and pation, resulting in loss of income and disengage-
the onset or exacerbation of depression, anxiety, ment with mainstream society. Employees with
and other mental disorders. mental illness can experience several types of
This article first describes the difficulties and functional limitations that affect their ability to
challenges faced by individuals and organiza- attend work consistently and perform well on the
tions. It then addresses the role of the workplace job. Functional limitations vary by type of mental
environment in producing and mediating patterns disorder and can include difficulty concentrating
of mental illness and describes coping and accom- and general cognitive deficits, fatigue and sleeping
modation strategies that help workers with mental problems, difficulty interacting with coworkers
illness participate more productively. Employers and customers, memory problems, organizational
influence the patterns of mental illness and effects skill deficits, difficulty with emotional control,
of mental illness on the workplace in two ways: as and panic attacks. Seventy-four percent of work-
agents (such as managers or supervisors) and as ers with mental illness report productivity loss at
institutions or environments (such as workplaces work compared to 26 percent of workers without
and benefit policies). While some research has a mental disorder. These functional limitations
demonstrated potential positive effects of mental can greatly affect the individual’s advancement
illness in the workplace, particularly in creative opportunities in an organization.
professions, this article deals with mental ill- While milder forms of mental illness (such as
ness as a disorder, the workplace’s response, and anxiety, mild depression, and panic disorders)
employment consequences. exhibit less severe symptoms than more disabling
forms of mental illness (such as major depres-
Individual Challenges sion, bipolar mood disorder, and schizophrenia),
In advanced nations, most adults of working age the higher prevalence of the milder forms in the
who have mental illness are actively employed. working population can result in high overall pro-
Although they are less likely than the general popu- ductivity losses. Mental health treatment (includ-
lation to be employed, employment rates for people ing but not limited to medication management)
with mental illness have been estimated between can alleviate some of these symptoms but can also
92 Business and Workplace Issues

exacerbate others (such as through fatigue or gen- coworkers understand the signs and symptoms of
eral malaise). However, research is clear that ade- mental illness and are aware of available resources
quate mental health treatment greatly improves can also help employees self-identify their need
the chances of workers with mental illness stay- for mental health services and increase the likeli-
ing in or returning to work. Unfortunately, across hood that they will receive timely treatment.
advanced nations, about 50 percent or more of In many cases, mental health benefits offered
individuals with mental disorders do not receive by employers are poorly structured and inad-
any treatment for their illness. equately comprehensive. It has been shown that
The employer’s ability to offer job accommo- when benefits include early intervention and high-
dation (such as altering an employee’s duties, quality treatment, employers can minimize epi-
workspace, or expected hours) for workers with sodes of recurrent absence and performance loss
mental illness and access to adequate treatment due to mental illness. Cognitive behavior therapy
can greatly influence how these functional limi- or other types of counseling or skills-training
tations affect work attendance and performance therapies for milder forms of mental illness, with
patterns. or without prescription medication, can often be
effective in absence prevention and/or returning
Business Challenges people to work. For more severe forms of mental
The costs of mental illness include lost productiv- illness, such as schizophrenia, medication might
ity, mental health treatments (particularly where help address symptoms such as hallucinations
health care coverage is employment based), and and delusions but do little to reduce the negative
sick pay or disability payments to compensate effects of cognitive deficits. Because these more
lost wages when employees are absent from work severe forms result in higher dysfunction in the
because of poor mental health. There may also be workplace, less than a third of individuals with
productivity losses among coworkers who are in more severe mental illnesses are actively employed.
teams or dependent on service or product delivery These cognitive deficits can affect attention span,
from these same employees. memory, and ability to organize and plan.
Employers often are unaware that some of Current labor laws in many countries prevent
their employees suffer from mental disorders. It employment discrimination against individuals
is also difficult for employers to understand how with mental disorders. For example, in the United
a person’s mental disorder might influence their States, the Americans with Disabilities Act (ADA)
productivity and what the employer can do to requires job accommodation for individuals with
ameliorate the problems. With appropriate iden- mental disorders who could perform their usual
tification, treatment, and ongoing support, the job functions if provided reasonable adjustments
vast majority of employees with mental illness such as time schedule flexibility, modified work
will return to high levels of functioning, both at duties, or other supports. With proper treatment
home and at work. The challenge to employers and accommodation, many workers with mental
is understanding the nature of their employees’ illness can be retained on the job, thus minimizing
mental illnesses so that early identification and undesirable turnover and leaves of absence.
treatment services can be provided. However, in
many places, workers’ rights to privacy prevent The Workplace Environment
employers from understanding the nature of their Unfavorable work environments (such as lack of
employees’ mental illnesses. This makes it difficult job autonomy, difficult relations with managers or
to identify workers who could benefit from men- coworkers, unclear job demands) generally have
tal health services and connect them with avail- lower worker productivity, but they are particu-
able resources. Employers must instead rely on larly challenging for employees with mental ill-
third parties, such as health insurance companies ness. Negative work environments exacerbate the
and other health-related and employee assistance effects of mental illness on attendance and job per-
providers, to steer employees with mental illness formance by sapping energy, increasing fatigue,
into timely and appropriate treatment. Creating a and heightening symptoms and behaviors related
trusting work environment where managers and to emotional problems. Job strain as assessed
 Business and Workplace Issues 93

by both psychological demand and control over social contact, contribution to collective work,
work is associated with higher levels of absence and regular participation in a prosocial activity
and lower levels of job performance. Recent that also results in a direct financial benefit to the
research has found a strong link between workers’ employee.
difficulty coping with work stress and the onset
of depression, anxiety, and other mental illnesses. Conclusion
Job accommodation strategies aimed at The prevalence of mental disorders in the work-
improving attendance include flexible work place and their impact on organizational func-
scheduling, allowing time off for treatment, and tioning can be lessened if appropriate treatment
adjustments to break schedules. These same strat- is available and utilized and employers are able
egies combined with the reduction of physical and to modify work stressors and support improved
emotional stressors can also reduce fatigue and coping skills among workers with mental illness.
sleeping problems, concentration deficits, and When equipped with disability awareness train-
negative reactions to work stress associated with ing and knowledge about employer supports,
many mental illnesses. managers and coworkers can better help persons
For memory deficits and difficulties organizing with mental illness remain healthy and productive
work, lists of step-by-step procedures, maps iden- on the job. To the extent that workplaces offer
tifying storage locations of tools and supplies, good working conditions with high-quality stress-
written summaries of meetings, planners, check- management strategies, a preventive approach
lists, and assistance prioritizing and dividing tasks (including treatment when needed), and positive
can be helpful. Some strategies aimed at emotional managerial and structural changes, the potential
coping deficits include training in stress manage- negative effects of mental illness on attendance
ment techniques, flexible scheduling, and referral and job performance in the workplace can be
to employee assistance programs for additional diminished.
support. Even with supports, some employees
with mental illness will experience panic attacks Kimberly Jinnett
or difficult interactions with coworkers. In both Brian Gifford
cases, employees should be encouraged to take a Integrated Benefits Institute
break and walk away from the difficult situation,
going to a more comfortable area or contacting a See Also: Costs of Mental Illness; Creativity; Life
support person. Sometimes smells or noises can Skills; Stress; Work–Family Balance.
trigger panic attacks; such triggers should be iden-
tified and removed if possible, or the employee Further Readings
relocated. Bhui, K. S., S. Dinos, S. A. Stansfeld, and P. D. White.
The continuum of employer-based programs “A Synthesis of the Evidence for Managing Stress
includes early interventions to prevent disabling at Work: A Review of the Reviews Reporting on
mental health episodes, disease management for Anxiety, Depression, and Absenteeism.” Journal of
known conditions, and return-to-work strategies Environmental and Public Health (2012).
in the event of a disabling episode. Some effective Dewa, C. S., A. Lesage, P. Goering, and M. Caveen.
strategies to prevent depression in the workplace “Nature and Prevalence of Mental Illness in the
include resilience training, screening for depres- Workplace.” Healthcare Papers, v.5/2 (2004).
sion risk with treatment follow-up, improving Kessler, R. C., S. Heeringa, M. D. Lakoma, M.
managers’ and coworkers’ understanding of the Petukhova, A. E. Rupp, M. Schoenbaum, P. S.
signs of depression and anxiety and follow-up Wang, and A. M. Zaslavsky. “The Individual-Level
options, and integrating workplace interventions and Societal-Level Effects of Mental Disorders
with provider-based services. on Earnings in the United States: Results From
It is also possible for work to positively affect the National Comorbidity Survey Replication.”
mental well-being because it promotes a wide American Journal of Psychiatry (2008).
array of psychological, social, and economic Lerner, D. and R. M. Henke. “What Does Research
benefits. Employment can offer time structure, Tell Us About Depression, Job Performance, and
94 Business and Workplace Issues

Work Productivity?” Journal of Occupational and Realities About Mental Health and Work.” http://
Environmental Medicine, v.50/4 (2008). www.oecd.org/newsroom/employmentmentalhealth
Organisation for Economic Co-operation and issuesrisinginworkplacesaysoecd.htm (Accessed
Development. “Sick on the Job? Myths and May 2013).
 C
Canada territories. It boasts many natural resources as
well as varied terrain and climate. While English
In 2012, Canada launched its first national men- and French are the nation’s two official languages,
tal health and addictions strategy. Almost 7 mil- the country is very diverse. In addition to Aborigi-
lion people in Canada live with a mental illness nal Peoples (First Nations, Inuit, and Métis, 2 per-
or mental health problem. However, only half of cent) and those of European descent (66 percent),
those with a current diagnosis of mental illness Canada hosts the second-largest foreign-born
actually seek care. In Canada, despite mental ill- population in the world (19 percent). The current
nesses accounting for the highest total direct and immigration wave predominantly originates from
indirect costs on the nation’s health care system, Asia and Africa, while earlier waves were primar-
less than 5 percent of the nation’s health budget ily European in origin.
is directed toward mental health care delivery, Canada’s Aboriginal Peoples lived in the
placing it at the bottom of the list of developed country for millennia before European settlers
nations in terms of national mental health expen- arrived. The Vikings, British, and French all
ditures. Research has shown that promotion, arrived in Canada during the Age of Exploration
prevention, and early intervention can make sig- (985–1909 c.e.). Canada became the Dominion
nificant improvements in a person’s mental health of Canada in 1876.
and well-being and increase their quality of life.
Social determinants of mental health such as gen- Mental Illness: Prevalence Rates
der, age, income, education, area of residence, and Risk Factors
migration, and Aboriginal status all need to be One in five Canadians will experience a mental
considered in the development and delivery of illness or addiction in their lifetime. Anxiety dis-
mental health services in Canada. orders and mood disorders are the most prevalent
mental illnesses affecting Canadians (12 percent
An Overview and 10 percent of the population, respectively).
With a population of 34.3 million, Canada is the Women have a twofold greater risk of depression
second-largest country by lande area in the world. than men. Schizophrenia affects about 1 percent
A British Commonwealth country, Canada shares of the population. About 14 per 100,000 of the
borders with the United States, its strongest population commit suicide every year. In addi-
ally, and is comprised of 10 provinces and three tion, about 3 percent of women and 0.3 percent

95
96 Canada

of men will be affected by an eating disorder in health stressors. Rates of psychological distress
their lifetime. are higher among low-income populations (29
Mental health encompasses more than the percent) compared to non-low-income communi-
absence or presence of mental illness. Positive ties (19 percent). About 86 percent of the home-
mental health and well-being includes factors less population have a mental illness or substance
such as emotional well-being, coping ability, spiri- abuse diagnosis. High rates of substance abuse,
tual values, and social connectedness. About 37 suicide, and mental illness can be found among
percent of Canadians rate their mental health as those incarcerated in correctional facilities. The
excellent, 24 percent have high emotional well- majority of offenders (50–80 percent) have a his-
being, and 45 percent experience high levels of tory of mental illness or addiction.
social connectedness. Immigrants, refugees, ethnocultural, and racial-
Across the life span, youth and older adults are ized populations, those living in northern and
particularly at risk in terms of mental health. Sui- remote settlements, and Aboriginal Peoples have
cide accounts for almost a quarter of all deaths been identified as at-risk populations in terms of
among youth and young adults aged 15 to 24. mental health due to disparities in social deter-
Men over the age of 80 have the highest suicide minants of health. There is a “healthy immigrant
rate in Canada. effect” for mental health in Canada, where immi-
Those encountering systemic barriers and fac- grants enjoy better levels of mental health than
ing low-income situations, precarious employ- their Canadian-born counterparts. Unfortunately,
ment and housing, and persons in custody in the this mental health advantage deteriorates upon
criminal justice system deal with unique mental arrival, and immigrant mental health converges

Children of the Tsuu T’ina Nation, a First Nation in Canada, ride in traditional costume at a Stampede Parade in Calgary, Canada,
July 2005. In the past, Aboriginal children were forcibly put into government-run schools in order to assimilate them, but the mental
health results were devastating. A British Columbia study found that 98 percent of survivors of residential school system suffer from
mental illness. Today, Aboriginal youth have suicide rates five to six times higher than non-Aboriginals.
 Canada 97

to Canadian-born levels within 10 years of living Less than half of those with a current mental ill-
in Canada. ness (40 to 50 percent) seek mental health care in
The residential school system in Canada, where Canada. The majority of Canadians seek mental
Aboriginal children were forcibly put into gov- health care from their family physician, and those
ernment-run schools with the intent of bringing who seek both primary care services and special-
about complete assimilation, has had profound ized mental health services report the greatest
repercussions. A British Columbia study found perceived effectiveness of care received. Canada’s
that 98 percent of residential school system survi- mental health strategy proposes the integration of
vors suffer from mental illness. Aboriginal youth mental health services across primary and special-
have suicide rates five to six times higher than ized care sectors to improve continuity of care to
their non-Aboriginal counterparts. address this service gap.
Men are less likely to seek mental health care
Canada’s Mental Health Strategy and System compared to women. Those living in low-income
To address these concerns, Canada unveiled its situations and with low education levels are also
national mental health strategy in 2012. The less likely to seek care. In addition, visible minor-
strategy calls for improvements in mental health ity communities (nonwhite and non-Aboriginal)
promotion and awareness programs, strengthen- and immigrant populations underutilize mental
ing of the present body of mental health research, health services in Canada. The presence of a men-
integration of primary care services with special- tal disorder and self-reported poor health status
ized mental health services, and a dedicated focus are consistent predictors of mental health service
on at-risk populations. use. Lack of access to mental health care and long
Canada has a publicly funded universal health wait times are barriers experienced by those living
care system (Medicare). The direct and indirect in rural, remote, and northern settlements.
costs of mental illness in Canada have been esti-
mated at $48 to $51 billion. However, Canada Mental Health Promotion and Best Practices
directs only about 4.8 percent of its health bud- Mental health promotion interventions aim to
get ($6.6 billion) toward mental health care. build individual and community-level capacity by
Among developed nations, this places Canada enhancing protective factors and reducing barri-
at the bottom in terms of national mental health ers to good mental health. Mental health promo-
expenditures. tion combines a population health approach with
Visits to the family physician (the most com- evidence-based decision making. The promotion
monly sought health care professional for mental of good mental health begins in early childhood
health) are covered by Medicare. A referral from with parent training programs, home-based sup-
a family doctor is needed to visit a psychiatrist. port, and school-based interventions. Programs
Psychologist fees can be paid out-of-pocket or to address self-esteem and the building of emo-
be covered by third-party health insurance (often tional and social skills are important for youth.
provided by one’s employer). Community health For adults, work-related stress is a signifi-
centers can also provide referrals. Telemental cant determinant of mental health. To reduce
health, which uses videoconferencing and other the strain of unemployment, programs for skill
technologies to connect health professionals to development, adult literacy, and job placement
clients in underserved areas, is especially help- are crucial. The workplace can also be a site of
ful in reaching rural, remote, and Aboriginal stress, bullying, and burnout, leading to absen-
populations. teeism and lost productivity. Mental health pro-
About 9.5 percent of Canadians report past- motion interventions that provide counseling
year mental health consultation. About 5 percent services and educate employers and employees
consulted a general practitioner or family doctor, about mental health issues are essential in ensur-
3.5 percent sought specialty mental health care ing workplace mental health. As physical and
from a psychiatrist or psychologist, and 4 per- cognitive changes can accompany older age and
cent got advice from other professionals (such older adults face loneliness and social exclu-
as a nurse, social worker, or religious adviser). sion, interventions that aim to enhance coping
98 Canada

skills and develop social networks are especially (1994). http://www.phac-aspc.gc.ca/mh-sm/pdf/

important for older adults. suicid_e.pdf (Accessed December 2012).
Health Canada. “Telemental Health in Canada: A
Future Directions Status Report.” (2004). http://www.hc-sc.gc.ca/hcs
For many years, Canada was the only G8 country -sss/pubs/ehealth-esante/2004-tele-mental/index
that did not have a national mental health strat- -eng.php#4.4 (Accessed December 2012).
egy. With the launch of Canada’s Mental Health Lesage A., H. M. Vasiliadis, M. A. Gagné, S.
Strategy in 2012, there is a hope that the burden Dudgeon, N. Kasman, and C. Hay. “Changing
of mental illness and gaps in service delivery will Directions, Changing Lives: The Mental Health
be addressed. Research into the social determi- Strategy for Canada.” Calgary: Mental Health
nants of mental health, the integration of pri- Commission of Canada, 2012.
mary care service with specialized mental health Mental Health Commission of Canada. “Why
services, the expansion of telemental health ser- Investing in Mental Health Will Contribute
vices, and increased health care dollar spending to Canada’s Economic Prosperity and to the
on mental health will contribute to improvements Sustainability of our Health Care System” (2012).
in the mental health of Canadians. http://strategy.mentalhealthcommission.ca/pdf/case
-for-investment-en.pdf (Accessed December 2012).
Farah Islam Mood Disorders Society of Canada. “Quick Facts:
Nazilla Khanlou About Mental Illness and Addiction in Canada.”
York University 3rd ed. (November 2009). http://www.mooddisor
derscanada.ca/documents/Media%20Room/Quick
See Also: Medicare and Medicaid; Public Education %20Facts%203rd%20Edition%20Referenced%20
Campaigns; Racial Categorization; United States. Plain%20Text.pdf (Accessed December 2012).
Pollet, Heather. “Mental Health Promotion: A
Further Readings Literature Review” (2007). Mental Health
Canadian Collaborative Mental Health Initiative. Promotion Working Group of the Provincial
“Mental Illnesses and Related Service Utilization in Wellness Advisory Council. http://www.cmhanl.ca/
Canada: An Analysis of the Canadian Community pdf/Mental%20Health%20Promotion%20Lit
Health Survey” (2006). http://www.ccmhi.ca/ .%20Review%20June%2018.pdf (Accessed
en/products/documents/09_Prevalence_EN.pdf December 2012).
(Accessed December 2012). Sareen, J. and B. J. Cox, et al. “Mental Health Service
Canadian Encyclopedia. “Timeline.” http://www.the Use in a Nationally Representative Canadian
canadianencyclopedia.com/index.cfm?PgNm=TCE Survey.” Canadian Journal of Psychiatry, v.50
Timeline&Params=A1 (Accessed December 2012). (2005).
Canadian Institute for Health Information. Smetanin, P., D. Stiff, C. Briante, C. E. Adair, S.
“Improving the Health of Canadians: Exploring Ahmad, and M. Khan. “The Life and Economic
Positive Mental Health” (2009). http://www.cpa Impact of Major Mental Illnesses in Canada: 2011
.ca/cpasite/userfiles/Documents/Practice_Page/ to 2041.” Calgary: Mental Health Commission of
positive_mh_en.pdf (Accessed December 2012). Canada, 2011.
Caron, J. and A. Liu. “A Descriptive Study of the Statistics Canada. “Health at a Glance: Suicide Rates:
Prevalence of Psychological Distress and Mental An Overview.” http://www.statcan.gc.ca/pub/82-6
Disorders in the Canadian Population: Comparison 24-x/2012001/article/11696-eng.htm (Accessed
Between Low-Income and Non-Low-Income December 2012).
Populations.” Chronic Diseases in Canada, v.30 Vasiliadis, H. M., A. Lesage, and C. Adair. “Service
(2010). Use for Mental Health Reasons: Cross-Provincial
Health Canada. “Health Care System.” http://www Differences in Rates, Determinants, and Equity
.hc-sc.gc.ca/hcs-sss/index-eng.php (Accessed of Access.” Canadian Journal of Psychiatry, v.50
December 2012). (2005).
Health Canada. “Suicide in Canada Update of the Vasiliadis, H. M., R. Tempier, A. Lesage, and N.
Report of the Task Force on Suicide in Canada” Kates. “General Practice and Mental Health
 Care, Sociology of 99

Care: Determinants of Outpatient Service Use.” socially constructed. One factor that influences
Canadian Journal of Psychiatry, v.54 (2009). the type of care that a society can provide is the
Wang, J. and B. Patten. “Perceived Effectiveness degree to which a social group is communal as
of Mental Health Care Provided by Primary- opposed to individualistic. Communal groups
Care Physicians and Mental Health Specialists.” and societies have generally been more able to
Psychosomatics, v.48 (2007). integrate individuals with severe mental illnesses
World Factbook. “Canada.” https://www.cia.gov/ and to provide needed social supports, whereas
library/publications/the-world-factbook/geos/ individualistic societies are more likely to exclude
ca.html (Accessed December 2012). those with severe mental illnesses and to provide
more coercive forms of social control.
Communal systems of care include home-based
care as well as care in therapeutic communities.
With family-based care, such as in colonial Amer-
Care, Sociology of ica, there is often no real distinction between
mental and physical illness; individuals are simply
In addition to the long-term nature of their illness, sick and cannot support themselves. Families pro-
those with severe mental illness face functional vide social supports including a place to live and
limitations and need a great deal of social support. assistance with daily activities. Sometimes, this
There have been four major phases of care, each care can involve primarily social control, when
shaped by different societal values, political pref- an individual with severe mental illness is locked
erences, and economic priorities. The first phase, away, but more often the care is merely custodial.
involving institutionalized care, was dominant Other types of communal systems can provide
in the United States from the 1800s to the mid- therapy, such as the contemporary therapeutic
1900s, during which the primary locus of care was communities of Italy. Another model is Foun-
the mental hospital. The second phase involved a tain House in New York City. These communi-
period of deinstitutionalization, with the removal ties have emphasized empowerment and recovery,
of patients from state hospitals to the community. and serve as important models for advocates of a
The third phase, community-based care, had an patient’s rights to self determination.
emphasis on the integration of the diverse com-
munity services and support needed for individuals Institutionalization and
with chronic mental illness to live in communities. Deinstitutionalization
Finally, mental health care was privatized, with an As societies developed and underwent the early
emphasis on cost containment and efficacy. While stages of industrialization with migration to
the timeframes vary, other countries have expe- the cities, institutionalized systems of care were
rienced these major cycles of mental health care, developed. Mental illness was still not viewed as a
with forms of institutionalized care still persisting disease but as undesirable behavior that could be
in many places, including the United States. changed. Treatment was provided by psychiatrists
Diverse systems of care have emerged to deal in psychiatric institutions. As “total institutions,”
with individuals with chronic mental health prob- mental hospitals provided for all of the patient’s
lems that result in functional disability. In addi- needs. including housing, food, treatment, medi-
tion to needing formal mental health care for their cal care, and social interaction. Such “total insti-
mental health problems, these individuals need a tutions” served primarily custodial functions,
wide variety of social supports in order to deal involving social control over patients’ behavior
with aspects of daily living. Communal systems, rather than therapeutic care. One of the first soci-
institutionalized care, community-based care, ological critiques of such institutions was Erving
and managed care have served both therapeutic Goffman’s Asylums (1961), in which he analyzes
and social control functions. Not only should the conflict between staff and patient perceptions
mental health care be understood historically, it of the institution and describes how patients must
also has important cross-cultural diversity, which conform to medical definitions and accept their
helps show the ways in which mental illnesses are mental illness. The same general logic is seen in
100 Care, Sociology of

contemporary discussions of “normality,” where of those with chronic mental illnesses. Further-
patients must first gain insight into their mental more, communities were (and still are) unwilling
illness (i.e., accept that they are not normal) in to accept those with severe or chronic illness, who
order to move beyond the institution to life in need a variety of supports to live in the commu-
the community. Acceptance of medical interven- nity. Stigma has remained a formidable barrier to
tion and medications is central to such insight and community acceptance and tolerance.
acceptance of the mental illness. Funding for community-based care began to
Institutions received widespread social criti- decline in the 1980s with Reagan’s Omnibus Rec-
cism for their primarily social control functions onciliation Act of 1980, although efforts to coor-
as hospital censuses grew throughout the first dinate community care continued. At the individ-
half of the 1900s and housed far too many indi- ual level, case management and multidisciplinary
viduals to be able to provide therapy. Hospitals treatment teams worked to integrate care for each
were depicted in both the academic and popular patient. At the organization level, community sup-
press as warehouses for the poor and immigrant port programs were certified to provide targeted
insane. Deinstitutionalization began in the 1950s, coordinated care to those with chronic mental
and was the result of fiscal conservatives who health care needs, generally following the criteria
wished to save public monies, civil libertarians developed by programs for asserted community
concerned with patient liberty and rights, and treatment. In the late 1980s, the Robert Wood
community health advocates. Psychiatric medica- Foundation funded the Program for Chronic Men-
tions provided one mechanism for the transfer of tal Illness, which sought to coordinate care at the
care from the hospital to the community, reduc- systems level, including housing supports, social
ing florid symptomatology and persuading psy- supports, and medical care. While some were par-
chiatrists that extrainstitutional care could work. tially effective, funding for mental health care in
Over 400,000 patients were released from the late the United States has never met the demand.
1950s to the early 1980s. Communities struggled Community-based systems of care remain
to meet the demand for sheltered housing for dis- highly fragmented and underfunded. Rather than
charged patients, and many ended up homeless. providing integrated community-based treatment,
While the number of patients residing in mental systems of mental health care have responded to
institutions declined significantly, the number of wider institutional demands for cost contain-
mental hospitals remained stable, and diverted ment. Beginning in the 1990s, both private and
resources from necessary community supports. public systems of mental health care have moved
to privatization and managed care, resulting in a
Community-Based Care commoditization of care. Furthermore, psychi-
Concurrent with deinstitutionalization was the atric medications are increasingly relied upon to
demand for community-based care and integra- control the symptoms of mental health problems,
tion. Care had moved from the province of psychi- with less and less emphasis on therapy or rehabili-
atrists operating in hospitals to social workers in tation. Mental health care has been medicalized
the community. Community mental health centers and criminalized, with few individuals receiving
(as authorized by the Community Mental Health adequate social supports to address their social
Centers Act of 1963) were supposed to develop welfare. With the decline of public sector men-
both the adaptive capabilities of the patient and tal health programs, those with serious mental
to promote community integration. However, illness find themselves in jails or prisons, where
funding for community-based care never met the they do not receive adequate treatment for their
demand, and very few state mental hospitals actu- mental health problems. With the criminaliza-
ally closed. Instead, community mental health tion of the mentally ill, care has returned to the
centers primarily served the needs of the “worried worst excesses of institutionalized care, with the
well,” those with acute mental health disorders primary focus on social control.
such as depression or anxiety. The basic failure
was the inability to develop integrated systems of Teresa L. Scheid
community-based care that met the many needs University of North Carolina, Charlotte
 Case Managers 101

See Also: Chronicity; Community Mental training, medication, and therapy; in many cases,
Health Centers; Community Psychiatry; the case manager is the only person available to
Deinstitutionalization; Family Support; Integration, an individual living with a serious mental illness.
Social; Law and Mental Illness; Social Control; Social Case management may be performed by any
Support. mental health professional, nurse, social worker,
psychologist, or counselor. While some univer-
Further Readings sities offer specialized tracks or degrees in case
Carlat, Daniel J. The Trouble With Psychiatry: A management, generally a master’s degree in a
Doctor’s Revelation About a Profession in Crisis. social welfare field is all that is required. Certified
New York: Free Press, 2010. community support programs require that case
Early, Pete. Crazy: A Father’s Search Through managers have a master’s degree and experience
America’s Mental Health Madness. New York: C. P. working with individuals with mental illnesses,
Putnam’s Sons, 2006. and Medicaid reimbursement for case manage-
Grob, Gerald N. and Howard H. Goldman. The ment also now requires a graduate degree. While
Dilemma of Federal Mental Health Policy: Radical case management may seem to be less emotion-
Reform or Incremental Change? New Brunswick, ally demanding than therapy, case managers are
NJ: Rutgers University Press, 2006. intimately connected to their clients because they
Scheid, Teresa L. Mental Health: Major Themes in provide emotional supports as well as assistance
Health and Social Welfare. London: Routledge, with the many demands of living in the com-
2009. munity. However, case management is often not
Whittaker, Robert. Anatomy of an Epidemic: Magic deemed as professionally challenging or reward-
Bullets, Psychiatric Drugs, and the Astonishing ing as therapy.
Rise of Mental Illness in America. New York: When case management models were first
Broadway Paperbacks, 2010. developed in the 1980s, social work students
showed little interest in either working with those
with chronic and severe mental illnesses or case
management. This reflects the wider cultural
belief that medical care and therapy can lead to
Case Managers cure, whereas the social supports offered by case
managers focus upon rehabilitation and improved
Historically, a dividing factor between mental levels of functioning. Specialized graduate train-
health care providers has been whether they work ing in psychosocial rehabilitation helped improve
in the private or the public sector. Those operat- the status of case managers, at least for a short
ing in the private sector generally operate out of period of time.
office-based practices and provide therapy to cli- Most case managers work in public mental
ents who pay either out-of-pocket or via private health organizations. Caseloads and budgetary
health insurance. These providers refer to them- constraints mean that these are extremely busy
selves as therapists. Providers who work in the places, with clients always present and case man-
public sector serve the needs of uninsured clients agers kept constantly busy with team meetings,
and those with serious mental illness who also staff meetings, meetings with the client, the cli-
experience functional limitations or disabilities. ent’s family, Department of Social Services work-
These individuals need a great deal of ongoing ers, and efforts to develop the social supports
social support in order to meet their basic needs. for clients to live in the community. Complicat-
Rather than therapy, individuals with serious ing the typical day are the ongoing crises with
mental illnesses benefit from case management, clients, including suicide attempts, emergency
whereby a case manager helps to meet the basic hospitalizations, arrests, and cases of drug over-
needs of the client and to coordinate the diverse doses. Routine problems of daily living are often
services and supports needed for the individual experienced as a crisis by many clients. These
to live in the community. These services and sup- include conflicts with landlords, other clients, or
ports include income, housing, medical care, skills family members.
102 Case Records

Oftentimes, case managers operate in teams, services, except for very short periods of time fol-
with four or five case managers sharing caseloads lowing hospitalization. It is unclear what effects
of anywhere from 10 to 35 clients each. Case man- these limitations on case management will have
agers have supervisors, who are often also case on the long-term outcomes of those living with
managers or mental health professionals. While severe mental illnesses, but levels of community
case managers have a great deal of flexibility in integration will decline, and mental health care
their work, there is still a high degree of bureau- has already moved from the community to jails
cratic control, largely because of the requirements and prisons.
of public-sector bureaucracies, which require
extensive documentation of the work done by a Teresa L. Scheid
case manager in order to verify that services ren- University of North Carolina, Charlotte
dered are worthy of reimbursement.
With the growth in managed care (the 1990s See Also: Care, Sociology of; Community Mental
in the United States), the work of case managers Health Centers; Psychiatric Social Work; Social
has been subject to increased bureaucratic control Support.
and scrutiny.
With managed care, the role of case managers Further Readings
has changed from linking clients to needed ser- Dill, Ann P. Managing to Care: Case Management
vices (thereby improving access and coordination and Service System Reform. Hawthorne, NY:
of care) to keeping costs down in the face of man- Aldine de Gruyter, 2001.
aged care constraints. Case managers are no lon- Harris, Maxine and Helen C. Bergman. “Case
ger able to advocate for their clients; instead, they Management With the Chronically Mentally Ill:
must limit the services provided to their clients in A Clinical Perspective.” American Journal of
order to keep down the costs of care. Managed Orthopsychiatry, v.57 (1987).
care arrangements determine who may receive Mechanic, David. Mental Health and Social Policy:
mental health care services, what types of services The Emergence of Managed Care. Boston: Allyn
will be offered, and how long an individual can and Bacon, 1999.
receive care. Services to those with chronic and Scheid, Teresa L. Tie a Knot and Hang On: Providing
serious mental illness are in an especially precari- Mental Health Care in a Turbulent Institutional
ous position because these individuals generally Environment. Hawthorne, NY: Aldine de Gruyter,
require long-term care and community supports. 2004.
Managed care reifies a view of mental illness as
a disease entity and promotes a view of mental
health treatment as a technical procedure that
produces predictable client-level outcomes. Fur-
thermore, managed care only reimburses those Case Records
services with scientific evidence of clinical effi-
cacy, favoring medications over both therapy and Case, medical, and health records refer to the
case management. systematic documentation of a patient’s medi-
Recent modifications of Medicaid case manage- cal history and care. Differences between health
ment have tightened the definitions of what con- and medical records lie in the extensiveness of
stitutes case management and who may do case documentation. Mental health case records, like
management, reflecting an increasing preference other medical and health records, systematically
for medical care and a de-emphasis on social sup- describe a patient’s medical history and care,
ports and the integration of social services. Case including mental and physical conditions, his-
management must enhance cost effectiveness, it tory of illness and care, family history, social his-
must be goal oriented, and it must be short term, tory, habits, immunizations, and developmental
even in the case of chronic illnesses. Managed care processes. Mental health records are legal docu-
and increased funding restrictions have almost ments and are subject to national, state, and local
eliminated the provision of case management laws. As a result, there is considerable variability
 Case Records 103

in their ownership, access, and availability. Vari- History

ability in the legal context of ownership, access, Early medical records were developed so that hos-
and availability of medical records is an espe- pitals and clinics could keep track of admissions
cially important consideration with regard to and discharges. The College of Surgeons in 1913
mental health records because the social stigma spearheaded a movement to maintain detailed
attached to behavioral disorders means that pri- and comprehensive records. This fostered profes-
vacy and confidentiality are a paramount concern sionalism and improved patient care. In 1928,
of patients and their families. the American Medical Records Association was
For example, in the United States, pertinent to founded to promote the professional maintenance
the Health Insurance Portability and Account- of health records. The maintenance of medical
ability Act (1996), information contained in case records became an essential component of insti-
records belongs to the patient, but the physical tutional accreditation. This required hospitals to
record is the property of the institution generat- keep track of a number of documents, such as
ing the record. Consequently, access to patient admissions, patient consents, physician attesta-
records is restricted, and information may only tion statements, patient medical history, physician
be made available to others with the patient’s orders, progress notes, pathology/radiology/anes-
consent, although some exceptions may be made thesia reports, doctor and nurses’ notes, medi-
under narrowly defined circumstances, such as cations, laboratory reports, vital sign graphics,
when the patient is incapacitated. As paper-based physical and respiratory therapy, special reports,
systems are converted to electronic systems, with and discharges. Medical records that refer to
increased risk of unauthorized access, the need mental health conditions have unique stipulations
to guard the privacy and security of informa- that are continually changing under various legis-
tion contained in mental health records becomes lative regimes.
essential. Electronic health records initiatives, The National Mental Health Act (1946), the
guidelines, policy, and law are therefore key to Mental Health Study Act (1955), and Com-
maintaining the privacy and confidentiality of munity Mental Health Centers Act (1963), for
patient records. example, established special standards of care,
privacy, and confidentiality that serve as the basis
Definitions for improved mental health care services. Mental
While case, medical, and health records are used health records contain an evaluative component
interchangeably to refer to the systematic docu- that covers patients’ physical, emotional, behav-
mentation of a patient’s medical history and care, ioral, social, recreational, legal, vocational, and
medical records tend to be less extensive than nutritional status. They contain a treatment plan,
health records. Medical records detail physical its modalities, progress notes, discharge notes,
and mental conditions that are salient to prac- plans for special therapies such as electroconvul-
titioners within a practice, institution, hospital, sive therapy, medication regimes, and any other
or clinic. They are typically compiled and main- relevant documentation. Mental health records
tained by the health care provider, and as such are also contain a utilization review protocol that
subject to strict privacy considerations. Health establishes the appropriateness of admission, dis-
records include a broader array of information charge factors, plans for continued care and reha-
detailing patients’ medical history and chroni- bilitation, and plans for support services. There is
cling illnesses, immunizations, family medical also the matter of consent. Patient consent state-
history, patients’ social history and habits, and ments become a part of the case record. Where
developmental processes. Mental health records state law permits, family members or legal guard-
exist within the same framework and serve a vari- ians may serve as proxies for patients who are
ety of functions such as care management, qual- unable to provide consent.
ity review, claims filing, and legal and educational
purposes. They are intended to provide better Privacy and Confidentiality
quality care, advance medical knowledge, and The medical record is a legal document, and as
lead to better financing policy and practices. such the law determines ownership, access, and
104 Children

availability. The general principle guiding own- and Reinvestment Act and the Affordable Care
ership is that the medical record is the property Act seeks to provide incentives for further expan-
of the institution generating it. The patient does sion of the digital medical records system to
not own his or her record, although the informa- facilitate the integration of mental health and
tion contained therein belongs to the patient. The primary care.
basic rule derived from the Health Insurance Por-
tability and Accountability Act (HIPAA) dictates Matthew E. Archibald
that only the patient and his or her health care Colby College
provider have a right to view the record. The pri-
vacy rule in HIPAA permits the disclosure of pro- See Also: Patient Rights; Policy: Federal Government;
tected information only for treatment, payment, Policy: Medical; Policy: State Government.
and health care operations.
Under some state policies that are more strin- Further Readings
gent than the federal floor provided by HIPAA, Clark, H. Westley. “Substance Abuse and Mental
mental health professionals are limited in the Health Services Administration, Leading Change:
extent to which they can share patient informa- A Plan for SAMHSA’s Roles and Actions 2011–
tion with other providers. In this case, the patient 2014.” Rockville, MD: Substance Abuse and
retains the right to grant access to proxies, legal Mental Health Services Administration, 2011.
guardians, and other providers, including indi- International Foundation of Employee Benefit Plans.
viduals involved in medical research, financial “Medical Records Guide” (2003). http://www.if
or management audits, and program evaluation. ebp.org/pdf/harker/Medical_Records_Guide.pdf
Complications arise when patients have been (Accessed April 2013).
determined to lack the capacity to make decisions Knowles, Philip. “Collaborative Communication
concerning their care, during medical emergencies Between Psychologists and Primary Care
when the patient cannot communicate a decision, Providers.” Journal of Clinical Psychology in
or during times when death or harm is imminent. Medical Settings, v.16/1 (2009).
The Code of Ethics of the American Medical
Record Association supports these tenets while
emphasizing that adequate security of medical
records is essential to patient care.
Children
Electronic Records and Policy
The increased portability and accessibility of Mental illness in children is a common and treat-
electronic mental health records translates into able public health concern. Across the United
an increased risk that the records can be accessed States, approximately 15 million children and
by unauthorized persons. HIPAA was passed to adolescents have a diagnosable mental health dis-
establish rules for access, authentication, storage, order and substantially more demonstrate risk
auditing, and transmission of health information. factors for developing future disorders. Only
The increased security requirements addressed about 7 to 10 percent of them receive appropri-
in HIPAA and other legislation underscore the ate therapeutic intervention from mental health
vulnerability of electronic systems to large-scale professionals. Medication is the single most
breaches in confidentiality. This underlying con- common treatment used with this population,
cern is counterbalanced by benefits that accrue with little emphasis on psychosocial support for
to the interoperability—the ease of information behavioral and emotional factors. This may be
exchange between users—of electronic mental because an estimated 60 percent of young people
health records, given that most mental health ser- receive initial mental health care only from their
vices are provided by a number of different prac- primary health care providers and frequently are
titioners in a variety of contexts ranging from not referred to qualified mental health specialists
hospitals to community-based clinics. Current for assessment and follow-up care. To complicate
legislation in the form of the American Recovery that matter even further, only between 10 and 25
 Children 105

commit suicide are believed to have a diagnosable

mental disorder that often manifests during child-
hood. School failure is frequent in children who
do not receive adequate support for their mental
health struggles, with approximately 50 percent
of young people with behavioral and emotional
disturbances not completing high school. Crimi-
nal justice involvement is likely in this popula-
tion, as it is estimated that 65 to 75 percent of
young people in juvenile detention have at least
one mental illness, occurring as young as 8 years
old. Health care costs can be steep for children
without appropriate mental health support, as
they tend to utilize more frequent emergency ser-
A Pakistani child reflects the fear and grief of losing his family, vices and primary care services for undiagnosed
friends, and home during the floods that struck the country in July and untreated medical issues that are related to
2010. Psychological trauma and environmental stress are among behavioral health. These issues reflect that chil-
the most common factors causing childhood mental illness. dren’s mental health places a significant burden
upon the social fabric of community resources.
Considering the problems identified in research
about children’s mental illness risk and burden,
percent of the known cases of mental health dis- the early identification and treatment of such
orders in children are recognized and diagnosed concerns are absolutely essential to recovery.
by their primary health care providers, making Early identification of mental illness is impera-
this one of the least commonly treated health tive, given that most childhood mental disorders
risks in our nation’s youth. Thus, understanding begin to manifest in early childhood and young
the needs for mental health support for the young school ages. Developmental stability is depen-
population is one of the most pressing issues for dent upon adequate promotion and protection of
child and family advocates today. social and emotional assets that children use for
Like adults, children suffer from mental ill- coping and self-management in day-to-day rou-
nesses in ways that compromise the functional tines. The most optimum experience of childhood
independence of daily routine. Social by-products must be supported by adequate mental health
such as academic failure, arrested development, resources, which include community-based and
distressed socialization, negative self-efficacy school-based opportunities for success. Families
and esteem, ineffective problem-solving and self- of at-risk children can be supported by services
advocacy, and unrealized personal goals are but a and models for intervention across individual and
few of the burdensome impacts that poor mental social levels.
health status can have upon the typical childhood
experience. For families, this can present a sub- Childhood Disorders
stantial difficulty for support and maintenance According to the National Institute of Mental
of children’s health and socialization. Medical Health, the five most common mental health and
intervention, school support, and social bolster- behavioral disorders affecting children’s well-
ing are critical aspects of the general response to being include attention deficit hyperactivity dis-
children’s psychological dysfunction, and the pre- order, depression, conduct disorder, anxiety, and
vention and intervention cycle can sometimes be autism. First symptoms and eventual diagnosis of
difficult to manage. these disorders typically occur by age 10, suggest-
In light of these issues, untreated mental illness ing that substantial segments of childhood devel-
in children can be a devastating occurrence. Sui- opment are eclipsed by the serious nature of these
cide is the third leading cause of death in youth problems. Less than 20 percent of children with
ages 15 to 24, and over 90 percent of those who those disorders receive appropriate treatment,
106 Children

and less than 15 percent have parents who hold not as likely as adults to be diagnosed and treated
active discussions with medical providers and within the early stages of their symptom experi-
school personnel about identification and treat- ence. Therefore, it is believed that children expe-
ment of the disorders. Thus, the importance of rience distressing symptoms of mental illness for
diagnosis and support during childhood is high. longer periods of time than adults before they
Most commonly, childhood mental illness is are diagnosed and supported with therapeutic
caused by factors such as heredity, systemic bio- management.
logical abnormality, psychological trauma, and Generally, children’s mental illnesses can be
environmental stress. While the exact causal pat- categorized into two primary areas: internaliz-
tern is unknown, and is unable to be manipulated ing and externalizing problems. The internalizing
in clinical practice, certain combinations of these problems are those that manifest within the self,
contributors are known to manifest because of such as fears, worrying, depression, shyness, and
developmental stability and trajectory during thought impairments. These are disorder charac-
early years. Biological predispositions and expo- teristics that are dealt with internally, rather than
sure to environmental cues often combine to set being acted out in the context of the environment.
these mental health problems into motion for The externalizing problems evidence themselves
young people, thereby making them susceptible in interaction with others and within the environ-
to a host of behavioral, emotional, and social dif- ment, often resulting in inappropriate behavior
ficulties throughout the most impressionable seg- and/or conflicts with others. Examples include
ments of their development. aggression, hyperactivity, delinquency, and inap-
Because children and adults differ with regard propriate conduct. Like adults, children are more
to developmental characteristics and competen- frequently distressed by internalizing issues than
cies, the features of mental health disorders that by externalizing ones. But unlike adults, chil-
they demonstrate are also varied. Bound by their dren are more likely to demonstrate internalizing
developmental context, young people’s disorders symptoms with external cues. Because of their
are marked by the specific neurophysical, cogni- developmental limitations in areas such as com-
tive, social, and emotional features that limit the munication, cognitive insight about mental ill-
developmental maturity in childhood. Children ness perspectives, and general self-management,
are coping with the developmental tasks of learn- behavioral manifestations of mental illness are the
ing to navigate their social and cultural environ- more frequent means of expression of abnormal-
ments, using communication to their advantage, ity and distress. Therefore, mental health prob-
demonstrating appropriate emotional responses lems among children are more driven by environ-
to everyday occurrences, and solidifying identity. mental cues and interactions.
The types of disorders that affect children are dif-
ferent from those that impact adults, and their Risk and Resilience
degree of severity upon daily functioning may be Risk factors for child psychopathology are inclu-
more pronounced. sive of biological and genetic predispositions but
Given this substantial difference between the also are reflective of stress and temperament. The
ways in which children and adults manifest men- diathesis-stress model of considering and describ-
tal illness, the diagnosis of such concerns may be ing the presence of abnormality prompts think-
of particular interest. Developmentally, children ing along the dimensions of what is happening
are less likely than adults to cognitively evaluate within a person’s environmental context in order
their mental health symptoms with accuracy, less to reflect upon the likelihood of a disorder. This
likely to communicate their distress in terms that problem is true for childhood mental illness in
are compatible with adult functioning, less likely much the same way as it is applied to adult psy-
to recognize a need for intervention and advo- chopathology. Risk factors are induced by both
cacy, and less likely to engage parents and help- physical and environmental contexts, but those
ing professionals in ongoing exchanges that lead environmental phenomena are much more likely
to coping and symptom management. Because to influence mental health disorders via their
of those developmental limitations, children are direct shaping effects on maturity and coping.
 Children 107

Emotional stress in early years is solidly linked to children possess, the more likely they are to thrive
the development of psychological abnormality in in the face of adversity and distress. Levels of
children and adolescents. During early childhood, assets have been shown to be better predictors of
issues such as separation anxiety, abuse/neglect, insulation and recuperation from risk factors than
unstable attachment with caregivers, and environ- actual intervention methods provided by sources
mental safety/security are well known sources of of mental health treatment.
distress that lead to disordered thought, behavior, Based on the balance of risk and resilience, the
and emotionality. Developmental psychopatholo- most effective way to manage children’s mental
gists estimate that over one-half of young children health is to seek a hierarchy of promotion, pre-
who live in stressful environments meet the diag- vention, and treatment. Promotion refers to the
nostic criteria for behavioral, thought, and mood encouragement and support of stable and secure
disorders by the onset of puberty. mental health status through education, modeling,
Temperament, or a child’s natural social and and marketing of asset building and risk reduc-
emotional predisposition, is also directly impact- tion. For instance, social marketing messages and
ful upon psychological disorders in childhood. campaigns frequently are aimed at instilling posi-
Emotional stability and freedom from distress tive behaviors and approaches to children’s men-
are largely based upon children’s ability to cope tal health by communicating the effective ways
with what occurs within the day-to-day rou- in which children’s experiences can be enriched,
tine, and therefore is related to how children are protected, and safeguarded for optimum benefit.
naturally inclined to interact productively with Beyond promotion, prevention activities are
the environment. Psychologists have known for designed to bring targeted support to populations
quite some time that vulnerability to mental ill- who are at greater risk and who sometimes do
ness is strongly correlated with one’s inability to not respond as favorably to promotion methods.
negotiate the boundaries of healthy contextual Prevention involves direct interaction with at-
interactions. The degree to which children char- risk children and their families in activities that
acteristically seek stability and predictability in reduce impact of risk factors and increase effects
their social environments (e.g., respond to parent of developmental assets in order to prevent dis-
interactions, cope with frustrating events, and orders from occurring in the first place. Finally,
manage self-reliance and self-esteem) is a keen treatment is designed to ease distress and suffer-
indicator of how they will avoid behavioral and ing caused by the actual onset of symptoms and
emotional disorders throughout the life span. But diagnosable disorder conditions. Risk factors and
the degree to which temperament is resistant or resilience assets typically are addressed through a
reactive is related to the likelihood that a child combination of the promotion, prevention, and
will be prone to faulty coping and self-manage- treatment opportunities provided through a bal-
ment, thereby predicting the viability of mental anced approach of community-based and school-
health concerns. based resources in order for children’s mental
Resilience or protection from such risk factors health to be safeguarded.
begins with developmental assets. According to
the Search Institute in Minneapolis, Minnesota, Community-Based Approaches
a core group of developmental assets serve as Meeting children’s mental health needs within
the characteristic relationships, opportunities, the community setting has changed substantially
and personal characteristics that children need over the past few decades. Intensive reform in the
in order to thrive and to avoid risk of behavioral health care system (i.e., managed care) has brought
and emotional distress. Thus, in resilience terms, a variety of options that did not always exist in
young people can be free from mental health con- the community setting in order to address the
cerns through the adoption and integration of a myriad of concerns expressed in children’s men-
host of developmental assets. Building assets for tal health cases. More comprehensive care pro-
good mental health should be the primary goal grams have begun to emerge. Frequent collabora-
of treatment and support for children and ado- tion and wraparound between service providers
lescents. Research has shown that the more assets have made the current state of community-based
108 Children

treatment more desirable, and even functional. School-Based Approaches

Years ago, the standard one-hour dose of regular Because children frequently demonstrate symp-
outpatient individual time with a mental health toms of mental illness within the school setting,
service provider was the only alternative to insti- schools have become a primary backdrop for
tutionalized inpatient services. Today, however, the provision of mental health services. Beyond
a host of options are available in comprehensive teaching academic skills and processes, schools
and coordinated care models for children and have recently begun to adopt a mental health
their families. treatment model in order for children to find
Research sponsored by the federal-level Sub- and sustain success in the academic setting. Pub-
stance Abuse and Mental Health Services Admin- lic policy and educational culture have shifted
istration has demonstrated that a system of during the past decades, with schools becoming
coordinated care for young people using commu- more frequently concerned with the mental health
nity-wide resources yielded impressive results in functioning of their students. Mental health issues
the outcomes of children’s mental health support. such as depression, anxiety, disordered conduct,
Participating youth increased school attendance, stress, poor self-control, and suicide risks gen-
with 81 percent of youth attending school regu- erally manifest within schools as behavior and
larly after six months of services, reducing their discipline problems, poor school climate, disen-
school absences by over 20 percent. In addition to gagement, attendance risks, and academic failure.
attendance improvements, suspensions and expul- Therefore, mental health has become recognized
sions decreased by 44 percent, and more than as central to children’s learning and development.
30 percent of the youth improved their grades. School-based mental health services have become
Depression and anxiety became easier to manage, rich centers of innovation for student success.
and noticeable decreases were observed in suicide Generally, school-based mental health services
attempts and ideation. Children with mental ill- follow a three-tiered system of care. The bot-
ness appear to be well served by this community- tom tier advocates for prevention and wellness
based approach for comprehensive care. promotion programs for all students, facilitating
While there is no single correct definition for the improvement of environment and culture to
community-based support services, such treat- improve adequate achievement and success. The
ment approaches foster strength and resilience in middle tier targets at-risk students with coun-
addressing child and family needs. Needs assess- seling and psycho-educational opportunities.
ments, crisis resolution, case management, clini- The top tier includes the most intensive services
cal counseling, social support, and medical super- offered to individual students suffering from seri-
vision are among the most frequently utilized ous emotional and behavioral problems. This ser-
program options made available in the array of vice design corresponds to the promotion, preven-
community-based services to reduce impacts of tion, and treatment balance sought by all effective
mental illness on children. Having no “one-size- systems of care.
fits-all” model for addressing needs, this approach Within the multitiered system, school-based
encourages various levels of involvement for each services should be offered by professionals who
individual patient and family. This historically has are dually trained within both the mental health
been known as a “wraparound” delivery model, and educational practice settings. Because the alle-
in which a carefully designed planning process viation of mental health concerns in the school is
actively involves teams of collaborative profes- related to improvement of the school experience,
sionals who support various aspects of the treat- the school-based service model for children is
ment process. geared toward increasing success in the curriculum
Provision of these community-based approaches and in the social environment of the educational
generally occurs within community mental health setting. The philosophy behind this movement is
centers and hospital-based entities, in collabora- to assist children with maintaining strength and
tion with school-based professionals. Utilization success within the setting in which they spend
of community resources is critical for quality most of their days. Chances for success in both
improvement in children’s mental health concerns. school and life are considered optimum outcomes.
 China 109

Children’s mental illness is not rare. In fact, it Jensen, P., P. Knapp, and D. Mrazek. Toward a New
is more common than most people may initially Diagnostic System for Child Psychopathology:
recognize. Mental health concerns in childhood Moving Beyond the DSM. New York: Guilford
have a devastating impact upon developmental Press, 2006.
and social outcomes in adolescence and adult- Southwick, S., B. Litz, D. Charney, and M. Friedman.
hood. Particularly when considering the burden Resilience and Mental Health: Challenges Across
of mental illness to children’s daily functioning in the Lifespan. Cambridge: Cambridge University
school and community settings, the importance Press, 2011.
of early identification, treatment, and support is
overwhelming. Despite the number of children
who are supported by prevention and intervention
programs and methods, quality of care often is not
appropriate. A serious deficiency in the number of China
providers, a lack of effective evidence-based prac-
tice, and an underfunded system of care present The incidence of mental illness in China and around
many challenges to adequate support for children the world is increasing. Recent statistics indicate
who cope with mental illness concerns. Financing/ that China has one of the highest rates of mental
spending for children’s mental health initiatives illnesses in the world and has a very high suicide
is devastatingly low, not allowing for adequate rate. The prevalence of emotional and behavioral
exposure to community and school-driven care. problems has been increasing and now represents a
In general, outcomes are increasingly stable and major cause of ill health for the Chinese. A number
encouraging when considering the improvements of reasons explain these trends. The Chinese peo-
made in the care of children with mental health ple are dealing with the demands of China’s fast-
concerns. Equipping children with the optimum paced social change, which has been taking place
success that they need, school and community since economic reforms in the 1980s.
support opportunities are of great interest in col- Over several decades, China has been transi-
laborating for child and family success. tioning from a poor socialist country to a modern
nation, with impressive economic development
Russell Vaden and improvements in health, living standards,
University of Wisconsin, La Crosse and quality of life. However, people find it dif-
ficult to adjust to social transformation and new
See Also: Adolescence; Community Mental Health ways of living, especially the changes in China,
Centers; Diagnosis; Diagnosis in Cross-National such as weakening of traditional family and social
Context; Environmental Causes; Prevention; support networks, incompatibilities between tra-
Vulnerability. ditional and modern ways of thinking and doing;
increasing cost of living, widening inequalities,
Further Readings and competition in society. Myriad social prob-
Adelman, H. and L. Taylor. Mental Health in Schools: lems such as corruption, crime, divorce, social
Engaging Learners, Preventing Problems, and exclusion, substance use and abuse, and urban
Improving Schools. Thousand Oaks, CA: Corwin inequalities add to the pressure.
Press, 2010. Chinese employees face new challenges in the
Doll, B. and J. Cummings. Transforming School workplace as Western business practices and a
Mental Health Services: Population-Based new way of work life have become popular. The
Approaches to Promoting the Competency and job market is now very competitive and unem-
Wellness of Children. Thousand Oaks, CA: Corwin ployment has risen. Research shows that there
Press, 2008. is an increasing prevalence of work-related
Frank, R. and S. Glied. Better But Not Well: Mental stress among Chinese employees that negatively
Health Policy in the United States Since 1950. impinges well-being. Employees who suffer with
Baltimore, MD: Johns Hopkins University Press, stress are more susceptible to ill health, includ-
2006. ing depressive illnesses and anxiety, and physical
110 China

health issues such as heart disease, hypertension, medicine, Miao medicine, and Tibetan medicine.
and acerbation of existing conditions. Rural– TCM is still popular in China today.
urban migrants in cities face challenges in work Modern medicine for mental illness in China is
as they perform roles that locals refuse, with long grounded in the country’s first psychiatric hospi-
hours and low pay, such as laborers on building tals, which were founded in the 1900s by Western
sites and in factories and in the service industry; missionaries. However, developments in mental
also, migrants are not regarded as city residents health care were halted by social disruption and
because their official registration is in their home- war until the founding of the People’s Republic
town, and consequently they are excluded to of China in 1949 by Mao Zedong, which marked
some extent from some health and social welfare the beginning of substantial improvement in
services. A recent spate of suicides in Chinese fac- health services. The number and quality of men-
tories highlights the misery and stress that some tal health facilities increased, and in the 1950s,
employees encounter. the public health system was overhauled in favor
Young people in China also experience mental of the Soviet model. The first National Mental
ill health. Difficulties reported by Chinese adoles- Health Meeting was held in 1958. However, men-
cents include loneliness, relationship problems, tal health services came to a standstill during the
school-related stress, and Internet and video game Cultural Revolution, a political movement from
addiction. There is also increasing recognition of 1966 to 1977. During this period, psychology
attention deficit hyperactivity disorder (ADHD). and mental illness were attributed to incorrect
School-related stress is a particular problem political thinking and were addressed through re-
because Chinese parents maintain high expecta- education, rather than psychiatric care, and diag-
tions for their child’s academic achievement, and nosis and treatment was dominated by political
traditional Chinese philosophy emphasizes edu- control. Since Mao’s death in 1976, the country
cational achievement. As the Internet has gained and its health service have gone through sub-
popularity for entertainment and social interac- stantial economic and social change; the 1980s
tion, there has been an increasing incidence of onward was a period of openness with increased
addictive and maladaptive Internet use. availability of Western models of health care and
There is an increasing prevalence of aging- numerous reforms. Today, China’s health care
associated diseases among the elderly such as system is modern and based on modern medicine,
Alzheimer’s disease, depression, and dementia as with management of mental illness similar to that
the Chinese population ages rapidly because of an of other countries.
increasing average life expectancy and decreased Mental health professionals in China use many
fertility and mortality rates. methods of treatment; they are trained in a similar
fashion to the West and use the same treatment
Treatment of Mental Illness methods such as drugs and behavioral methods.
Medicine and therapy in China date back to ancient Biomedical therapies—such as antidepressants,
times, when early physicians and philosophers anxiolytics, and mood stabilizers—are the core of
recorded accounts of emotional and behavioral mental health treatment and are employed along-
problems in texts such as “The Yellow Emperor’s side counseling and other therapies. In addition to
Canon of Internal Medicine.” For thousands of public and private sectors, an increasing number
years, the philosophical schools of Confucianism, of charitable trusts and voluntary organizations,
Taoism, and Buddhism underpinned traditional as well as professional associations such as the
Chinese medicine (TCM), which includes reme- Chinese Association for Mental Health, play a role
dies for emotional and behavioral difficulties, for in the mental health field. Psychiatrists (doctors
example, acupuncture, dietary recommendations, trained in treatment of psychological disorders)
herbal medicine, massage, moxibustion (therapy are the principal profession involved in mental
using burned mugwort herb), and Qigong. Vari- health care in China. Other mental health profes-
ous branches of TCM have developed, such as the sionals such as counselors, psychologists, nurses,
Jingfang and Wenbing schools, as well as other and social workers play an important role, but
traditional medical systems such as Mongolian there is an acute shortage of staff. The degree of
 China 111

family support when an individual is ill is greater standards for its population. However, mental
in China than in the West because Chinese culture health is still not considered a national priority
emphasizes the role of families in responsibility because China is a developing society and the
and decisions regarding treatment. government’s top priority has been economic
However, Western-based therapeutic methods growth to meet people’s basic needs, which takes
are not always appropriate for Chinese clients and precedence over other issues. Despite a decline in
must be used with care. A solution has been to poverty across the country and improvements in
modify Western counseling approaches for Chi- living standards, there are still poor Chinese who
nese culture and to develop indigenous therapies. lack access to basic necessities.
There are also cultural differences in beliefs about However, there are challenges facing mental
mental illness. This is exemplified by the way that health. There is a severe shortage of health facili-
illness is assessed and classified by psychiatrists in ties, and China’s immense size and uneven pace of
China and the West. The International Classifica- development has led to marked geographic varia-
tion of Diseases (ICD) and Diagnostic and Statisti- tion in availability and quality. Hospitals, staff,
cal Manual (DSM) have become globally accepted and resources are concentrated in big cities and
systems to classify and diagnose mental disorders. along the east coast and there are widening gaps
The Chinese Classification of Mental Disorders between rural and urban China. These disparities
(CCMD), published by the Chinese Society of mean that many people who need medical atten-
Psychiatry (CSP), is used in China alongside the tion are unable to receive help. Economic reforms
DSM as a clinical guide for diagnosis of mental have brought changes in how people pay for their
disorders. Although similar to the ICD and DSM, health care; in a move toward a more market-ori-
the Chinese guide has variations on diagnoses, ented economy, China abandoned financial support
including additional culturally related illnesses, from the state, and few schemes are now available
as well as exclusion of certain Western diagnoses. to assist the poor who cannot afford services.
For example, mental health issues in the CCMD Health care in China can be expensive, and
that are more specific to Chinese and Asian cul- medical expenses have been increasing in recent
tures include koro (genital retraction syndrome), years, alongside the medicalization of society that
which is an episode of sudden and intense anxi- has fueled substantial growth of the pharmaceu-
ety that the genitals (and breasts in women) will tical industry. Conversely, some have claimed
shrink and retract; and qigong deviation, which is human rights abuses in which people not in need
the perception of disrupted and uncontrolled flow of treatment—such as dissidents and outlawed
of qi (life energy in the body). groups—have been labeled mentally ill by Chi-
nese authorities seeking to detain them in men-
Future Challenges and Opportunities tal health hospitals. Another challenge is stigma
There have been significant improvements in the associated with seeking help as mental health
understanding of mental health in China in recent problems shame Chinese clients and their fami-
decades, and the government is currently under- lies, which can include negative reactions such
taking reform of the health care system. Improve- as social disapproval. There is also stigma in the
ments have included advancement of medical medical profession about pursuing psychiatry as a
procedures and allied sectors such as the phar- profession, as well as a growing number of attacks
maceutical industry and health insurance mar- on medical staff by patients, and some medical
ket, increases in government funding, infrastruc- graduates are discouraged from psychiatry as a
ture expansion, and training of mental health career. These reasons have led to frustration and
personnel. The standard of health care in China resentment among both the general population
has improved, and in some cases is on par with and medical staff.
international standards, especially in large cities China faces a heavy illness burden, yet high-
such as Beijing and Shanghai, with Western-style quality data on prevalence and treatment is lim-
medical facilities and international staff. These ited, which makes it difficult to better understand
positive changes are set against a backdrop of the situation. There is also a need to conduct
the government’s determination to improve living more studies, particularly epidemiological
112 Chronic Pain

surveys because there is a paucity of research in or religious affiliation, shared sacrifice, or com-
most provinces and cities that limits understand- mon enemy, or any of a number of other shared
ing. Regular and extensive monitoring will pro- experiences. The term cultural group has been
vide data for analysis and comparison. Mental broadly defined as a super ordinate term that can
health care in China has come a long way in a encompass notions of race or ethnicity to reflect
short time and is still at an early stage of devel- a shared social experience whereby individuals
opment. Despite significant improvements in ser- of similar backgrounds come to perceive and
vices, mental health in China faces a number of respond to events in a similar, culturally defined
challenges in the years ahead. manner, according to V. L. Shavers, A. Bakos,
and V. B. Sheppard. These terms are often con-
Gareth Davey flated in the literature and can take on varying
Hong Kong Shue Yan University meanings depending on context, as discussed by
F. J. Keefe and colleagues.
See Also: Anthropology; Diagnosis; Diagnosis Implicit to the concept of culture is the notion
in Cross-National Context; Epidemiology; of a multifaceted lens through which one views,
Ethnopsychiatry; Mental Illness Defined: Sociological interprets, and interacts with the world and oth-
Perspectives. ers, both within and beyond one’s cultural group.
Culture is a rich and pervasive agent that influ-
Further Readings ences how one perceives and responds to both
Cohen, Arthur Kleinman and Benedetto Saraceno. internal (bodily) and external (worldly) stimuli
World Mental Health Casebook: Social and Mental to include signals obtained from and transmit-
Programs in Low-Income Countries. New York: ted through nociceptive neurons, as well as the
Springer, 2002. sociocultural context in which those stimuli are
Pearson, Veronica. Mental Health Care in China: perceived. The International Association for
State Policies, Professional Services, and Family the Study of Pain (IASP) conceptualizes pain as
Responsibilities. London: Gaskell, 1995. a “sensory and emotional experience” that can
Phillips M., J. Zhang, Q. Shi, Z. Song, Z. Ding, S. differ individually or culturally. Culture, hence,
Pang, X. Li, and Z. Wang. “Prevalence, Treatment, informs how and what members of a group define
and Associated Disability of Mental Disorders as pain; their emotional, physical, and psycho-
in Four Provinces in China During 2001–05: An logical reactions to pain; and how they seek to
Epidemiological Survey.” Lancet, v.373 (2009). resolve or manage their pain.
Ran, Mao. Family-Based Mental Health Care in The influence of culture on reactions to experi-
Rural China. Hong Kong: Hong Kong University mental pain has been noted at both macro and
Press, 2005. micro levels by Rahim-Williams, Riley, Williams,
Selin, Helaine and Gareth Davey. Happiness Across and Fillingim. Less is known about the impact of
Cultures: Views of Happiness and Quality of Life culture and related sociocultural factors on clini-
in Non-Western Cultures. New York: Springer, cal or disease-related persistent or chronic pains.
2012. However, culture, particularly beliefs and behav-
iors, influences the experience of clinical or dis-
ease-related chronic pains.

Cultural Beliefs and Pain Tolerance

Chronic Pain Cultural beliefs about pain shape much of the
associated experience, especially with regard to
Culture represents the accumulation, transmis- coping with persistent pain over time. Under-
sion, and promulgation of knowledge, mores, standing philosophical distinctions between
values, experiences, beliefs, ideas, and behav- cultural groups at the broadest level, such as
iors throughout a group of individuals con- belonging or adhering to Eastern versus West-
nected through common ancestry, geographical ern philosophical traditions, often provides use-
locale of origin or inhabitance, philosophical ful insights into a particular set of beliefs about
 Chronic Pain 113

chronic pain and expectations for treatment expe- absence of suffering, and suffering can occur in the
rienced at the level of the individual. Researchers absence of pain. Coping is most often the media-
have noted the propensity of Eastern cultures to tor between pain and suffering, such that better
define pain as a necessary and expected experi- coping promotes reduced suffering independent
ence in life, and thus a factor to be embraced of the pain intensity, frequency, and duration.
and endured, as well as a path to deeper mean-
ing and understanding of life. In contrast, many Cultural Beliefs and Pain Intensity
Western cultures commonly define and respond Cultural beliefs about pain have also been asso-
to pain as a negative experience to be feared and ciated with pain intensity in U.S. samples. For
avoided, and when avoidance is ineffective, cured example, M. S. Bates and colleagues reported that
as described by S. Nayak and colleagues. an interaction of ethnicity and locus of control
Examples of the difference in perspective are (LOC) significantly predicts pain intensity and
plentiful. Parts of the Old Testament and simi- accounts for almost one-quarter of the variance
lar religious texts sometimes associate pain with in the experience of chronic pain. In their find-
sin and conceptualize pain as a punishment or a ings, ethnic group identification was predictive of
form of discipline as well as an expected expe- locus of control (Hispanics, more than any group,
rience of life. In Eastern religious texts such as reported external locus of control) and pain inten-
the Dharmacakra Pravartana Sutra, the Buddha sity ratings.
explains that suffering comes from the desire to Systematic variation also exists, even within
not experience pain. This text suggests that pain dominant cultures. T. A. Baker, C. R. Green, and
avoidance is unhealthy and a primary cause of other researchers have found that younger (less
distress and suffering. In Eastern cultures, accep- than 50 years old) African Americans and Cau-
tance of the inevitability of pain relieves suffer- casians report greater pain intensity and poorer
ing and is part of a healthy developmental tra- ability to cope with their pains as compared to
jectory. These two cultural perspectives (Western older same-race counterparts. Older age may rep-
and Eastern) on pain anchor the most common resent more traditional cultural values and more
boundaries of the continuum of beliefs about traditional thoughts about tolerating and manag-
pain and help frame the relationship between ing pain. Younger age may represent more con-
cultural factors and beliefs and behaviors associ- temporary cultural values and more of a tendency
ated with possessing and managing and/or curing to seek and expect cure, and to see tolerating pain
chronic pain. as irrational and unnecessary, given today’s tech-
Clinically, American outpatients are often nology and medicine.
noted to be “searching for a cure,” while their There is little data examining the impact of cul-
Indian counterparts seek “meaning” in their tural belief on chronic pain threshold, or the min-
pain. As a consequence of chronic pain, Ameri- imal amount of stimulation that an individual can
cans often report worse interpersonal relation- recognize as pain. Studies have often examined
ships, greater negative affective distress, and differences between ethnic groups in response to
more functional impairment; while their Indian experimentally induced pain, with general find-
counterparts report increased social support and ings that African Americans, for instance, tend
respect from friends and family, feelings of peace- to exhibit lower pain thresholds than whites, as
fulness, greater functionality, and continued pro- researched by B. Rahim-Williams and colleagues.
ductivity as described by M. F. Kodiath and A. However, little has been done to identify differ-
Kodiath. ence in pain thresholds as a function of culture or
Embedded in the discussion of cultural fac- subculture. Some have argued that when factors
tors that influence chronic pain is the distinction such as socioeconomic status are controlled, even
between pain and suffering. Chronic pain is con- differences found among subcultures and racial
ceptualized as an enduring nociceptive experi- group disappear, as shown by R. Edwards and
ence, while suffering is often used to describe the colleagues. Little to no data exists that defines
negative emotional reactions that can accompany clinical chronic pain frequency in terms of ethnic
an enduring stressor like pain. Pain occurs in the or cultural differences.
114 Chronic Pain

Cultural Beliefs and Pain Coping remedies from a pastor versus a physician. Even
Chronic pain coping varies as a function of cul- when seeking physician consultation, compliance
ture. Sociocultural factors like religion, roles in with medical directives such as prescription medi-
interpersonal relationships, and the media influ- cations or deriving satisfaction from the physician
ence pain appraisal—the meaning one attributes interaction may be governed by factors such as
to pain. Pain appraisal influences emotional reac- culture.
tions and ultimately behavioral responses to a Findings regarding religious beliefs and
sustained period of pain, the decision to continue chronic pain are mixed with some indication
working versus work cessation, and acceptance for both positive and negative outcomes. Prayer,
versus seeking a cure. especially, has been noted as a common method
Religious beliefs as representative of a culture of coping, particularly among African Ameri-
shared by a group influence the management of can and Hispanic/Latino subgroups. Prayer has
chronic pain. Shavers and colleagues found that been associated with greater disability across all
pain appraisal may be derived from religious ethnic groups. Prayer has also been linked to an
beliefs and spirituality. For instance, whether the increased likelihood of using medication to man-
experience of chronic pain is viewed as a part of age pain, as well as heightened pain sensitivity in
God’s plan or as punishment may impact treat- African Americans, as described by Shavers and
ment-seeking behaviors such as choosing to seek colleagues.

During a 2008 clinical trial conducted by associate professor of neurology Dr. Jack Tsao (right) at the Walter Reed Army Medical
Center in Washington, D.C., a U.S. Army sergeant attempts mirror therapy to treat the excruciating pain he felt in his amputated
right leg. Every participant who used the mirror experienced relief. Multidisciplinary management programs focus on biological,
psychological, and social aspects of chronic pain management, often with consideration of the patient’s culture.
 Chronic Pain 115

Cultural Beliefs and Pain Treatment their clinicians, have led to less-than-ideal clini-
Considerations cal outcomes and high levels of dissatisfaction in
Multidisciplinary pain rehabilitation programs both groups. Understanding cultural influences
are the gold standard in the treatment of chronic and using them toward better treatment goals and
pain. These programs focus on biological, psy- outcomes and patient and clinician satisfaction is
chological, and social aspects of chronic pain a lofty but necessary goal for the future growth of
management by providing management strategies the science of chronic pain management.
such as medication, physical rehabilitation, cogni-
tive behavioral skills training, and education and Christopher Edwards
support for caretakers. The goal of these centers Duke University
includes facilitation of self-control and self-man- Andrea Hobkirk
agement strategies, often with consideration of LaBarron K. Hill
the patient’s culture. The expectations and goals Duke University Medical Center
of the patient are matched with those of a treat-
ing clinician. In contrast to historical treatment See Also: Anxiety, Chronic; Chronicity; Race; Race
approaches, where patients are passive recipients and Ethnic Groups, American; Racial Categorization;
of health care, multidisciplinary treatment cen- Sadomasochism; Self-Injury.
ters promote patient involvement at all stages of
the evaluation and treatment process. These pro- Further Readings
grams also recognize that many patients prefer to Baker, T. A. and C. R. Green. “Intrarace Differences
remain passive in their care, and they are also able Among Black and White Americans Presenting for
to accommodate that choice. Chronic Pain Management: The Influence of Age,
The integration of sociocultural factors into the Physical Health, and Psychosocial Factors.” Pain
treatment of chronic pain provides an opportu- Medicine, v.6/1 (2005).
nity to emphasize the importance of congruence Bates, M. S., W. T. Edwards, and K. O. Anderson.
between the patient and provider’s cultural con- “Ethnocultural Influences on Variation in Chronic
ceptualization, beliefs about pain, expectations Pain Perception.” Pain, v.52/1 (1993).
for intervention, views and definitions of sup- Campbell, L. C., N. Andrews, C. Scipio, B. Flores, M.
port, and interventional goals toward satisfaction H. Feliu, and F. J. Keefe. “Pain Coping in Latino
for both parties involved. Cultural differences Populations.” Journal of Pain, v.10/10 (2009).
may lead to misperceptions, dissatisfaction, and Edwards, C. L., R. B. Fillingim, and F. Keefe. “Race,
poor clinical outcomes. For example, a patient’s Ethnicity, and Pain.” Pain, v.94/2 (2001).
assumption that finding a “cure” is the only strat- Edwards, R., M. Moric, B. Husfeldt, A. Buvanendran,
egy that their treating clinician is pursuing may and O. Ivankovich. “Ethnic Similarities and
not promote satisfaction and may not be reflec- Differences in the Chronic Pain Experience: A
tive of the total potential range of culturally based Comparison of African American, Hispanic, and
reasons for the clinician to intervene. Similarly, White Patients. Pain Medicine, v.6 (2005).
assuming that all patients seek a cure from clini- Hammond, W. P. “Psychosocial Correlates of Medical
cal interactions opposed to support, guidance, Mistrust Among African American Men.” American
and relief from suffering, not reduced pain, is Journal of Community Psychology, v.45 (2010).
equally problematic. These and many other fac- Keefe, F. J., M. A. Lumley, A. L. Buffington, J.
tors, including “trust,” may divide patients and W. Carson, J. L. Studts, C. L. Edwards, D.
providers of care. Inquiry becomes the tool for J. Macklem, A. K. Aspnes, L. Fox, and D.
the promotion of satisfaction among patients and Steffey. “Changing Face of Pain: Evolution of
their providers of care. Pain Research in Psychosomatic Medicine.”
Culture, although only recently and formally Psychosomatic Medicine, v.64/6 (2002).
introduced into the conceptualization, evaluation, Kodiath, M. F. and A. Kodiath. “A Comparative
and treatment of chronic pain, has always exerted Study of Patients With Chronic Pain in India and
an influence. Too often assumptions of homoge- the United States.” Clinical Nursing Research,
neity among patients, and between patients and v.1/3 (1992).
116 Chronicity

Miles, Donna. “Mirror Therapy Shows Promise in medical community, the depth and breadth of the
Amputee Treatment.” Alaska Post (January 25, definition flourished.
2008). http://www.usarak.army.mil/alaskapost/ In defining the level of mental health chronic-
archives2008/080125/Jan25Story12.asp ity, Leona Bachrach posited the use of three cri-
(Accessed June 2013). teria: diagnosis, durations, and disability, yet
Nayak, S., S. C. Shiflett, S. Eshun, and F. M. Levine. no agreement has been reached with respect to
“Culture and Gender Effects in Pain Beliefs and their interconnections and importance. The word
the Prediction of Pain Tolerance.” Cross-Cultural chronicity, suggestive of irreversibility or unfavor-
Research, v.34/2 (2000). able treatment outcomes, is controversial because
Rahim-Williams, B., J. L. Riley III, A. K. K. Williams, patient advocates continue to question the poten-
and R. B. Fillingim. “A Quantitative Review of tial negative connotations and damaging effect it
Ethnic Group Differences in Experimental Pain carries or implies in a patient’s prognosis. Hence,
Responses: Do Biology, Psychology, and Culture a constellation of other choices of expression such
Matter?” Pain Medicine, v.13 (2012). as “serious” and “prolonged” have also been
Shavers, V. L., A. Bakos, and V. B. Sheppard. used extensively and interchangeably to elucidate
“Race, Ethnicity, and Pain Among the U.S. Adult the long-term effect of mental illness.
Population.” Journal of Health Care for the Poor Many mentally ill patients report that the
and Underserved, v.21 (2010). chronicity of their disease interferes with various
aspects of the quality of their life. But the endur-
ing effect of mental illness also has far-reaching
impact on the patient’s family and society at large.
Strong evidence suggests that chronic mental dis-
Chronicity orders can interfere with one’s capacity to carry
out many crucial daily activities, including self-
Controversy surrounds the term chronicity, which care and work. Treatment does not always equate
implies poor prognosis and persistent expression to the elimination of symptoms for all patients. In
of symptoms. Chronic mental illness can have a some cases, patients have to cope with symptoms
clinically significant impact on the quality of one’s of varying intensity and persistence. Those who
life, which has implications for treatment. The become resistant to psychiatric treatment, in par-
disorder is linked to many demographic charac- ticular, are often shuttled back and forth between
teristics and is complicated by stigma, environ- the psychiatric hospital and the community. Fre-
mental factors, and access to mental health care. quent psychiatric hospitalization and readmission
Early diagnosis and intervention can help reduce can interfere with a patient’s ability to maintain a
the chronicity of mental illness. Treatment out- structured lifestyle.
come can be improved by offering the chronically Chronically mentally ill patients who are
mentally ill education and rehabilitation. socially disadvantaged not only require regular
Chronic mental illness is frequently conceptual- medical attention but are also likely to face dif-
ized as a mental disorder with recurring symptoms ficulties in comprehending social norms because
that persist throughout the course of the disease. of cognitive disorganization. Further, the intensity
Although definitions of severity and persistency of the prolonged care can become a heavy burden
in the area of mental illness characterize the men- to the health care system because of high medical
tal health literature in the early decades, greater expenses and the social aftermath associated with
emphasis was placed primarily on the level of care the health risk. Unlike mental illness with acute
provided by state institutions. Following deinsti- psychotic episodes, chronic mental illness, because
tutionalization, with the establishment of com- of its complex etiology, makes assessment and
munity network centers developed to serve the effective treatment delivery challenging. As such,
needs of the mentally ill, the emergence of a new the treatment approach for this type of mental ill-
philosophical debate centering on more humane ness is likely to focus heavily on maintenance of
patient treatment, and various social change a patient’s psychosocial functioning and reduction
efforts to promote cultural sensitivity among the in their readmissions or length of hospitalization.
 Clinical Psychologists, Training of 117

Chronic mental illness has been linked to many clinicians and medical professionals can help
demographic characteristics and environmen- improve patients’ compliance with medication by
tal factors. Chronicity in certain mental illness, providing insights about their illness and capacity
for example, is more prevalent in female-headed to lead a normal life. Care should focus on devel-
households. Though the causal order of these oping long-term rehabilitative services that help
events is debatable, individuals who are chroni- improve patients’ daily functions.
cally ill are likely to have fewer years of educa-
tion and lower household income. They are also Yok-Fong Paat
more likely to live in poverty and to experience Samuel Terrazas
other physical challenges or medical comorbidi- University of Texas at El Paso
ties. As such, residential care giving is a challenge
for families with members affected by long-term See Also: Community Psychiatry; Costs of Mental
mental illness. Ethnicity and socioeconomic sta- Illness; Diagnosis; Diagnosis in Cross-National
tus are important determinants in one’s utilization Context; Neighborhood Quality.
and access to mental health services.
While individuals with chronic mental illness Further Readings
use health care services more regularly compared Atkinson, Mark, et al. “Characterizing Quality
with those without, cultural perceptions and of Life Among Patients With Chronic Mental
beliefs about medication usage and drug effects Illness: A Critical Examination of the Self-Report
can shape a patient’s recovery pattern and prog- Methodology.” American Journal of Psychiatry,
nosis. Contemporary ecological research has also v.154/1 (1997).
identified a number of neighborhood features that Bachrach, Leona L. “Defining Chronic Mental Illness:
are intimately connected to poor mental health A Concept Paper.” Hospital and Community
outcomes that are above and beyond character- Psychiatry, v.39/4 (1988).
istics of the residents. Neighborhoods featuring Corrigan, Patrick. “How Stigma Interferes With
poor social organization, low social integration, Mental Health Care.” American Psychologist,
and sparse social networks can exacerbate mental v.59/7 (2004).
illness and functional limitations. Lefley, Harriet P. “Culture and Chronic Mental
The general public’s perceptions of the mentally Illness.” Hospital and Community Psychiatry,
ill have been found to foster negative attitudes v.41/3 (1990).
toward the mentally ill, resulting in both individ- Ross, Catherine. “Neighborhood Disadvantage and
ual and structural consequences, especially for the Adult Depression.” Journal of Health and Social
chronically mentally ill. Stigma toward the men- Behavior, v.41/2 (2000).
tally ill can negatively influence their compliance Schinnar, Arie P., et al. “An Empirical Literature
with psycho-pharmaceutical treatment, resulting Review of Definitions of Severe and Persistent
in poor treatment outcomes or persistent symp- Mental Illness.” American Journal of Psychiatry,
toms. The influence of stigma on the mentally ill v.147/12 (1990).
can also exacerbate the chronicity of their disor-
der by creating individual and structural barriers
to the use of mental health care. Early diagnosis
and intervention can help prevent chronicity asso-
ciated with mental illness. Clinical Psychologists,
Individual’s access to community support is
particularly crucial for those with chronic mental Training of
illness. Specifically, to normalize patients’ daily
lives and decrease their reliance on mental health The first training program in clinical psychology
services, mental health advocates can educate in the United States was established at the Univer-
community members about the importance of sity of Pennsylvania in 1904 by Lightner Witmer,
employment opportunities and strengthen emo- a former student of Wilhem Wundt. Witmer also
tional support for the mentally ill. In addition, founded the first psychological clinic in 1986,
118 Clinical Psychologists, Training of

also at the University of Pennsylvania, which was summer conference at the University of Colorado
used as a training facility for students in the clini- at Boulder in 1949 for the purpose of developing
cal psychology program. training standards for clinical psychology gradu-
The two world wars greatly hastened the devel- ate programs (attended by representatives of the
opment of clinical psychology by creating a need VA, PHS, APA, and other groups). The result was
for mental health services to soldiers and veter- a recommendation for a scientist-practitioner
ans that could not be met by psychiatry. World model that would train clinical psychologists to
War II, in particular, greatly changed the nature be both researchers and clinical practitioners. This
of the field. Prior to World War II, the major was a compromise between those who wanted
activity of clinical psychologists was administer- the Ph.D. in clinical psychology to remain a tra-
ing psychological tests. They were rarely involved ditional research degree and those who wanted
in psychotherapy. Because of the unprecedented clinical psychologists to be trained as practitio-
demand for mental health services for military ners who could meet the very real mental health
personnel during and after World War II, psy- provider needs of the VA, which was funding
chologists were allowed to function as indepen- much of the training. As part of this training, stu-
dent psychotherapists. dents were required to complete an empirical dis-
During and after the war, the U.S. Veterans sertation and a one-year, full-time clinical practice
Administration (VA) had a tremendous need for internship. Because of the needs of the VA, psy-
providers of mental health services that could not chotherapy courses became standard in clinical
be met by psychiatry. For example, a 1946 survey programs. The scientist-practitioner model soon
found that 44,000 of the 74,000 patients in the VA became the dominant model in clinical psychol-
system were neuropsychiatric patients. As a result, ogy and counseling and school psychology doc-
the VA not only hired a great many clinical psy- toral programs.
chologists but also decided to begin funding their Another result of the 1948 Boulder Confer-
training. Anticipating this need, in 1942, the federal ence was the development by the APA of stan-
government mandated the VA and the U.S. Public dards and procedures for accrediting clinical psy-
Health System (PHS) to expand the pool of mental chology doctoral programs. The APA accredited
health professionals, largely by greatly increasing the first clinical doctoral programs in 1948, and
the number of clinical psychologists. The VA and awarded the first internships in 1956. By 2005,
PHS began collaborating with the American Psy- over 220 doctoral programs and 450 internships
chological Association (APA) in the development were accredited in the United States.
of new clinical psychology doctoral programs and
standards for these programs. Both the VA and the Doctor of Psychology (Psy.D.) Model
PHS began providing considerable funding for aca- During the two decades after the Boulder confer-
demic training programs and internships. ence, however, dissatisfaction with the scientist-
In the mid-1940s, the VA recognized clinical practitioner grew. Many practice-oriented clinical
psychology as a health care profession, and this psychologists were concerned with the control
recognition spurred the development of doctoral over clinical training by academic departments
training programs in clinical psychology. By 1947, that did not seem invested in training students for
22 universities had such programs; and by 1950, jobs in clinical practice, and that research train-
about half of all doctoral degrees in psychology ing was interfering with training students to be
were awarded to students in clinical programs. In first-rate clinical practitioners. The professional
1949, there were 4,000 psychologists of all types school movement emerged as an alternative in the
in the United States. Now, American universi- late 1960s. In 1973, a conference was held in Vail,
ties produce over 4,000 Ph.D.-level psychologists Colorado, devoted to developing a professional
every year—half of them in clinical psychology. psychology degree as an alternative to the Ph.D.,
called the doctor of psychology (Psy.D.) degree.
Scientist-Practitioner Ph.D. Model The goal of the Psy.D. was to train not scientist-
The National Institute of Mental Health (NIMH, practitioners, but scholar-practitioners (or practi-
only a few years old at the time) funded a two-week tioner-scholars). The students were taught to be
 Clinical Psychologists, Training of 119

critical consumers of research, rather than pro- Association of State and Provincial Psychology
ducers of research. By 2005, there were 57 Psy.D. Boards (formed in 1961) has worked for several
programs accredited by the APA. decades to increase the standardization of clinical
Psy.D. programs differ from Ph.D. programs, psychology credentialing—and indirectly train-
not only in the design of their programs, but also ing—throughout the United States and Canada.
in the size of their programs. Psy.D. programs Over the past 60 years, most of the accredita-
accept students at a much higher rate than Ph.D. tion standards developed by the APA and the CPA
programs (50 versus 11 percent of applicants) (e.g., required coursework and practicum experi-
and have much larger entering classes (48 ver- ences) have become written into the psychology
sus nine). Despite these differences, there is no licensing laws of the U.S. states and Canadian
research showing differences between Ph.D. and provinces. The content of the Examination for
Psy.D. students in their performance in clinical the Practice of Professional Psychology, required
practice settings. by all states and provinces, closely maps onto the
content domains required for accreditation by the
Clinical Science Model APA and the CPA.
A more recent challenge to the scientist-practi- Training of clinical psychologists in the United
tioner has come from clinical psychologists con- Kingdom closely resembles training in the United
cerned about the quality of research training in States and Canada, with similar accreditation
clinical programs. In 1995, a group of doctoral standards developed by the British Psychologi-
programs in clinical and health psychology in the cal Society and the Health Professions Council (a
United States and Canada formed the Academy government regulating agency).
of Psychological Clinical Science (APCS). The pri- In most European Union countries, a clini-
mary focus of these programs is research training. cal psychologist can practice with only a mas-
As of 2012, its membership included 54 clinical ter’s degree, although the undergraduate degree
Ph.D. programs and 11 clinical psychology intern- in psychology tends to be more concentrated on
ships. The APCS is now developing accreditation psychology courses than is the typical psychology
standards and procedures for programs that want major in the United States and Canada. The new
to pursue accreditation as a clinical science pro- EuroPsy program is an attempt to standardize
gram, instead of or in addition to accreditation clinical psychology training and certification stan-
from the APA as a scientist-practitioner program. dards across 35 member nations of the EU. Many
The primary theoretical orientations of clini- developing countries have no regulations for the
cal psychology training programs are cognitive practice of clinical psychology and therefore have
behavioral, psychodynamic, and humanistic. very little in the way of standards for the training
Most programs offer a mixture of theoretical per- of clinical psychologists.
spectives, depending on how these orientations
are defined by the program. James E. Maddux
George Mason University
Clinical Psychology Training
Outside the United States See Also: American Psychological Association;
Standards for the training and credentialing of National Institute of Mental Health; Psychiatric
clinical psychologists in Canada have developed Training.
in tandem with those in the United States. The
Canadian Psychological Association (CPA) began Further Readings
accrediting clinical doctoral programs and intern- Benjamin, Ludy. “A History of Clinical Psychology
ships in 1985, largely following the standards as a Profession in America (and a Glimpse Into Its
of the APA. The APA has also offered accredita- Future).” Annual Review of Clinical Psychology,
tion to clinical programs and internships in Can- v.1 (2005).
ada but will stop doing so in 2015. The overlap Hunsley, John and Catherine M. Lee. Introduction to
between the accreditation standards of the APA Clinical Psychology. Hoboken, NJ: John Wiley &
and the CPA is considerable. In addition, the Sons, 2010.
120 Clinical Psychology

McFall, Richard M. “Doctoral Training in Clinical Clinical psychology overlaps considerably with
Psychology.” Annual Review of Clinical counseling psychology. Counseling psychology
Psychology, v.2 (2006). has its roots in the vocational guidance move-
Riesman, John M. A History of Clinical Psychology. ment, while clinical psychology has its roots in
2nd ed. New York: Hemisphere, 1991. psychiatry, which is a field of medicine. Histori-
cally, clinical psychologists have worked with
people with mental disorders, while counseling
psychologists have worked with people with nor-
mal life problems and challenges. For this reason,
Clinical Psychology counseling psychologists were more likely to work
in educational settings, whereas clinical psycholo-
According to the Society of Clinical Psychology gists were more likely to work in medical settings
(Division 12 of the American Psychological Asso- such as general hospitals and psychiatric facilities.
ciation), clinical psychology “integrates science, Over the years, however, these distinctions have
theory, and practice to understand, predict, and considerably blurred.
alleviate maladjustment, disability, and discom- Clinical psychology also overlaps with school
fort as well as to promote human adaptation, psychology. School psychologists work primarily
adjustment, and personal development [and] in primary and secondary schools to help children
focuses on the intellectual, emotional, biological, deal with learning difficulties, as well as the emo-
psychological, social, and behavioral aspects of tional and behavioral difficulties that can inter-
human functioning across the life span, in varying fere with learning.
cultures, and at all socioeconomic levels.” Both clinical psychology and psychiatry are
This definition includes two key ideas. First, concerned with people with serious emotional
clinical psychology is based on psychological the- and behavioral problems (or mental disorders).
ories and principles that have been supported by Psychiatry, however, is a specialty of medicine.
research. Second, the goal of clinical psychology Psychiatrists earn an M.D., while clinical psy-
is to alleviate suffering and enhance well-being. chologists earn a Ph.D. or a doctor of psychol-
Clinical psychology has traditionally focused on ogy (Psy.D.). Psychiatrists also have a more medi-
mental health problems, such as those found in cal or biological approach to understanding and
the Diagnostic and Statistical Manual of Mental treating psychological problems and are more
Disorders (DSM) and the International Classifi- likely to prescribe medications than provide
cation of Diseases (ICD). However, the growth psychotherapy.
of health psychology and behavioral medicine Finally, there is some overlap between clini-
over the past 30 years has greatly expanded the cal psychology and social work. Social workers
traditional boundaries of clinical psychology to emphasize the social conditions that may inter-
include a focus on medical problems and physi- fere with psychological health and well-being.
cal health. They are more likely than clinical psychologists
The practice of clinical psychology includes the to work with community agencies and in com-
direct provision of mental health services (e.g., munity settings and are more likely to work in
psychological assessments and psychotherapy) to nonmental health settings. Most social workers
individuals, couples, families, and groups, but it are also trained in counseling or psychotherapy,
also includes indirect services such as research, as are clinical psychologists.
consultation, program development and evalua-
tion, teaching, supervision of other mental health History
professionals, and administration of mental The term clinical psychology was first used by
health services. Clinical psychologists work in Lightner Witmer, who founded the first psycho-
a variety of settings, including private practice, logical clinic in 1896 at the University of Pennsyl-
general hospitals, psychiatric hospitals, university vania and the first university training program in
counseling centers, schools, community mental clinical psychology in 1904. By 1914, there were
centers, and private industry. 20 such university clinics. Now, there are over 200
 Clinical Psychology 121

such programs in the United States and Canada. In the mid-1940s, the Veterans Administration
Witmer and the other early clinical psychologists recognized clinical psychology as a health care
worked primarily with children with learning or profession, and this recognition spurred the devel-
school problems. These early practitioners were opment of doctoral training programs in clinical
influenced by the emerging field of psychometrics, psychology. By 1947, 22 universities had such
which was largely concerned with the develop- programs, and by 1950, about half of all doctoral
ment of tests of intelligence and mental abilities. degrees in psychology were awarded to students
In fact, the early history of clinical psychology in clinical programs.
is essentially the history of psychological assess- The first doctoral programs in clinical psy-
ment, not the history of psychotherapy. chology were accredited by the American Psy-
A crucial formative event in the development of chological Association in 1948. By 2005, over
clinical psychology was Sigmund Freud’s visit to 220 doctoral programs in clinical psychology
Clark University in 1909. Soon after Freud’s visit, were accredited. The first internship programs
psychoanalysis and its derivatives came to domi- (whereby clinical psychologists receive a year of
nate not only psychiatry but also the fledgling pro- practical training) were accredited in 1956. There
fession of clinical psychology. This domination are now over 450 accredited internship training
continued until the 1950s, when behavioral, cog- programs in the United States. In 1949, there
nitive, and humanistic theories began to emerge. were 4,000 psychologists of all types in the United
Today, more than twice as many clinical psychol- States. Now, American universities produce over
ogists view their primary theoretical orientation 4,000 Ph.D.–level psychologists every year—half
as cognitive behavioral than psychodynamic. of them in clinical psychology.
Another early milestone was the creation in
1919 of the Section on Clinical Psychology in the Scientist-Practitioners
American Psychological Association, which gave In 1949, a conference on the training of clini-
official recognition to the fledgling field. cal psychologists was held at Boulder, Colorado,
The two world wars greatly hastened the devel- that included representatives from the American
opment of clinical psychology. During World War Psychological Association, Veterans Adminis-
I, psychologists developed group intelligence tests, tration, National Institute of Mental Health,
which were needed by the military services as an university psychology departments, and clinical
efficient way to determine individual differences psychology training centers. At this conference,
in mental abilities. They also developed invento- the concept of the clinical psychologist as a sci-
ries to identify soldiers with emotional problems, entist-professional or scientist-practitioner—was
mainly to determine who might be vulnerable to officially endorsed. According to the new train-
developing shell shock. ing model, a clinical psychologist was to be a
World War II forever changed the nature of the psychologist and a scientist first, and a practicing
field. Prior to World War II, the major activity of clinician second. Clinical programs were to pro-
clinical psychologists was administering psycho- vide training in both science and practice. Clini-
logical tests. They were rarely involved in psycho- cal practitioners were to devote at least some of
therapy. Because of the unprecedented demand their efforts to the development and empirical
for mental health services for military personnel evaluation of effective techniques of assessment
during and after World War II, psychologists were and intervention.
allowed to function as independent psychothera- The Ph.D. traditionally has been the degree
pists. The U.S. Veterans Administration had a earned by clinical psychologists, and the tradi-
tremendous need for providers of mental health tional model has been the scientist-practitioner
services, which could not be met by psychiatry, model. An alternative training model, developed
and hired a great many clinical psychologists. It in the late 1960s, is the Psy.D., which follows a
also provided substantial funds for the university practioner-scholar mode that focuses on training
training programs in clinical psychology. By the clinical practice skills and teaching students to be
1970s, clinical psychologists displaced psychia- consumers of research, not producers of research.
trists as the major providers of psychotherapy. A third model that was developed in the 1990s is
122 Clinical Sociology

the clinical science model, which focuses almost Clinical Sociology

exclusively on research training.
In 1945, Connecticut became the first U.S. Clinical sociology is one form of sociological
state to regulate the practice of psychology practice or service that complements the other
through licensure. In 1946, Virginia became the main form, applied sociology. Although both
first state to require a Ph.D. for licensure. Now, forms are argued by some to be less scientific
all 50 U.S. states and all 10 Canadian provinces because of their applied features, applied and
have psychology licensing laws. Most states and clinical sociology have been enjoying increasing
provinces offer only a general psychology license, recognition internationally. The resurgent popu-
but a few (e.g., Virginia) offer a separate clinical larity of public sociology, designated as a subcate-
psychologist license. Licensure requirements in gory of applied or clinical sociology, has added to
clinical psychology vary from country to coun- the international growing recognition of linking
try. A doctoral degree is required for licensure in of sociological theory and practice. Clinical soci-
all U.S states except West Virginia, which allows ologists often make use of interventions. Usually,
psychologists with master’s degrees to become clinical sociologists specialize in a particular area
licensed. (e.g., community or family counseling) and a par-
In most European countries, only a master’s ticular level or unit of analysis (e.g., organization
degree is required. Most states also require an or individual), although moving between a num-
educational program consistent with the accredi- ber of these levels is common. Many clinical soci-
tation standards of the American Psychological ologists are full- or part-time university faculty
Association and a period of supervised practice members who link intervention work with their
(typically one year) after obtaining the degree. All teaching. Certification is available and encour-
of the states and provinces require applicants to aged but is not necessary.
pass the Examination for the Practice of Profes- The formation of the discipline of sociology is
sional Psychology (EPPP). First administered in directly linked with large-scale societal concern
1961, the EPPP is a multiple-choice examination regarding inequities and deprivation. Arab his-
that assesses knowledge in a number of domains torian Ibn Khaldun (1331–1406) established a
in psychology (e.g., neuroscience, development, science of human social organization in the 14th
and social science) that are considered essential century by combining study with interventions. In
for the practice of psychology. many ways, clinical sociology predates sociology
as a discipline insofar as the pioneers of sociologi-
James E. Maddux cal thought, Auguste Comte (1798–1857), Karl
George Mason University Marx (1818–83), and Émile Durkheim (1858–
1917), predate the establishment of sociology as a
See Also: Cognitive Behavioral Therapy; Mental university discipline and offer examples of social
Illness Defined: Psychiatric Perspectives; Mental theory directed explicitly toward changing the
Illness Defined: Sociological Perspectives; Psychiatric nature of society for the better.
Social Work; Therapy, Individual. Clinical sociology is intimately linked with the
formation of the first department of sociology
Further Readings in the 1890s in the United States, where capital-
Hunsley, John and Catherine M. Lee. Introduction to ism reached a crisis and the inability of the free
Clinical Psychology. Hoboken, NJ: John Wiley & market to deliver a socially cohesive nation pro-
Sons, 2010. voked both social activism and social critique.
Korchin, Stanley J. Modern Clinical Psychology. New Established in 1892, University of Chicago soci-
York: Basic Books, 1976. ology dominated American sociology until the
McFall, Richard M. “Doctoral Training in Clinical 1930s, with scholar practitioners responding to
Psychology.” Annual Review of Clinical pressing local needs within a larger theoretically
Psychology, v.2 (2006). informed framework. This early formulation of
Riesman, John M. A History of Clinical Psychology. sociology and clinical sociology is linked not only
2nd ed. New York: Hemisphere, 1991. to practitioners actively working in either clinics
 Clinical Sociology 123

or settlement houses but also with the first lec-

ture course titled “Clinical Sociology,” which was
delivered by Ernest Burgess (1886–1966) at Chi-
cago in 1928.
W. I. Thomas (1863–1947), another semi-
nal Chicago sociologist, also believed that clini-
cal observations provided invaluable sources to
develop sociological theory, which in turn could
also be applied in a clinical setting. Included in
the Chicago clinical work is that conducted by
Jane Addams (1860–1935) and her colleagues at
Hull House, a settlement house that she based on
similar houses in urban parts of England.
Recently, the important role women played in
the early days of clinical sociology, particularly in
America, has been discussed by feminist social the-
orists. The antagonism between the practically ori-
ented work of these social scientists (whom Robert
Park, 1864–1944, derided as “do gooders”) and
the supposedly more theoretically driven, “pure”
sociological work conducted by his departmental
colleagues was to cast a shadow over applied and
clinical sociology for many years.
Although publications referring to clinical
sociology emerged with some regularity from the
1930s onward, there was a large rebirth of this
area in the latter part of the 1970s. A large num-
ber of publications were supported by the found-
ing of the Clinical Sociology Association in 1978, Jane Addams (1860–1935) conducted clinical social work in
now known as Sociological Practice Association, Chicago at Hull House, which she established to reflect similar
which continues to make publications a high homes in urban England. This practical application of social
priority. The Sociological Practice Association is work was sometimes maligned as the work of “do-gooders.”
now responsible for the entire process of Ameri-
can clinical sociological certification. Candidates
applying for certification as clinical sociologists
are required to identify an area of specialization Both qualitative and quantitative techniques
and the nature of their proposed intervention. may be applied. The highly empirical nature of
In the past, those who identified themselves the field demands that successful interventions
as clinical sociologists were very likely to have direct the researcher to choose from a variety of
gained knowledge about specific intervention approaches, rather than have interventions dic-
strategies through courses and/or workshops pro- tated by a pre-existing or consistent methodologi-
vided by other disciplines. More recently, around cal commitment. Increasingly, university syllabi
the world, clinical sociologists with training at are reflecting practical ways of applying clinical
university levels are likely to have learned specific sociology beyond the academy. Degrees in clini-
clinical sociological interventions as part of their cal sociology combine individual counseling skills
sociological programs, often in conjunction with with sociological context in order to prepare stu-
both sociological methodological and theoretical dents for a range of careers in fields such as victi-
training. mology, family therapy, and drug rehabilitation.
Theoretically and methodologically, clinical The diversity of clinical sociology as a field
sociology is marked by diversity and eclecticism. dictates a complex global labor market role.
124 Clinical Trials

Although many clinical sociologists receive Clinical Trials

funding from state- or government-linked
sources, others are funded through businesses, The randomized controlled trial (RCT) became
and some work on topics that may be consid- the gold standard for evidence of therapeutic
ered politically fueled, creating greater difficul- effectiveness in the mid-20th century. The com-
ties obtaining funds. Some set up consultancy ponents of this methodology—(1) comparative
work, whereas others specifically work through control groups, (2) randomization, and (3) blind-
marketing agencies. ing—allow for a statistically valid statement that
Perhaps because of the influences of both Comte the observed effectiveness of one drug, or other
and Durkheim, there continues to be a particu- treatment, compared to another is or is not greater
larly strong French-speaking clinical sociology than would be attributable to chance. However,
strand around the world. More recently, interest even its advocates acknowledge there are logis-
in clinical sociology has been growing in a num- tic, social, and ethical issues with the execution of
ber of other countries around the world, including many RCTs. In particular, the application of the
Greece, Brazil, Mexico, South Africa, and Uru- RCT model to treatments for mental illness is no
guay. Since 1982, clinical sociology has enjoyed simple matter.
the status of a formal research group (RC46) of
the International Sociological Association (ISA). History of Clinical Trials
The current president of the ISA Research Com- European physicians began comparing treatments
mittee on Clinical Sociology is Jan Marie Fritz, under controlled conditions and systematically
who has argued that the global growth of clinical analyzing the differences in the 18th century. In
sociology may be facilitated by policymakers and the 1720s, James Jurin and others established the
the public recognizing the value of the work con- efficacy of smallpox inoculation by comparing
ducted by clinical sociologists. the proportionate mortality of natural cases with
Clinical sociological roles should be high- those among the inoculated. Naval surgeon James
lighted in both employment and funding oppor- Lind In 1753 published his well-known report of
tunities around the world, both within academic the treatment of 12 scurvy patients, “their cases
settings and in sectors outside the ivory tower. as similar as I could have them,” and his observa-
The importance and vitality of clinical sociology tion of the most sudden and visible good effects
globally is indicated by the rapidly growingly lit- from those given oranges and lemons. The 150
erature in this area and the expanding number of years that followed included multiple instances
conferences around the world that attract clinical of controlled studies, including Pierre Louis’s
researchers from many fields. study of bloodletting for treatment of pneumonia
in Paris hospitals (1836), John Snow’s brilliant
Tanya M. Cassidy linking of cholera cases to the water companies
University of Windsor supplying London neighborhoods (1853), Ignaz
Semmelweiss’s analysis of differential morbidity
See Also: Clinical Psychology; Community in the medical and midwifery wards at the Vienna
Psychiatry; Durkheim, Émile. Lying-In Hospital (1861), and Walter Reed’s dem-
onstration in Cuba of yellow fever transmission
Further Readings through exposure to mosquito bites rather than
Fritz, Jan Marie, ed. International Clinical Sociology. to the clothes and bedding of the infected (1901).
New York: Springer Science and Business Media, Yet, these now-famous cases had little effect on
2008. clinical science and practice at the time and were
Kalekin-Fishman, Devorah and Ann Denis, eds. The often ignored; Snow’s and Reed’s findings, which
Shape of Sociology for the 21st Century: Tradition were widely accepted, offered evidence for pre-
and Renewal. London: Sage, 2012. ventive, not therapeutic, measures.
Straus, Roger A. Using Sociology: An Introduction In 1905, the American Medical Association
From the Applied and Clinical Perspectives. 3rd established its Council on Pharmacy and Chem-
ed. Lanham, MD: Rowman & Littlefield, 2002. istry to try to determine and disseminate reliable
 Clinical Trials 125

evidence on the plethora of medications for sale the new drug in Britain. He later became one of
in U.S. drugstores and through mail order, many the RCT’s major champions, seeing randomiza-
of them advertised with extravagant and unsub- tion as the key to preventing personal idiosyncra-
stantiated claims. As the council chair, Torald sies and lack of judgment from distorting the evi-
Sollmann of Western Reserve University wrote, dence. Statisticians R. A. Fisher and Richard Doll
“Clinical experimentation should follow the can- were also advocates, not because randomization
ons of other scientific experimentation.” The fol- prevented error but because the method allowed a
lowing year, the Pure Food and Drug Act created precise statement of its likelihood. But, two large-
a small office in the Department of Agriculture to scale American trials were perhaps more influen-
review false advertising claims for drugs. Great tial than expert opinion in solidifying support for
Britain’s Medical Research Council (MRC) also the RCT among researchers, physicians, and the
tackled the problem in 1931, creating a Thera- public. In a major streptomycin trial beginning
peutic Trials Committee to assist drug manufac- in 1947, the United States Public Health Service
turers in evaluating their products. (USPHS) used its financial resources to ensure that
All three projects encountered similar obstacles investigators adhered to uniform guidelines for
in finding adequate and reliable evidence of drug observations, randomization, and blinding. The
effectiveness. Although researchers were using Salk polio vaccine trial of 1954, which enrolled
controlled comparisons, there were no common some two million grade-school children, not only
standards; responsible observers often had hon- established the effectiveness and safety of the vac-
est differences of opinion in assessing outcomes; cine but received widespread public support. The
and the patients, conditions, and methods used RCT was not only statistically appealing, but it
by the most skilled and honest researcher could had become a powerful tool for standardizing
never be replicated exactly, so few findings could trial procedures across clinical settings; the find-
be generalized. Sollmann suggested in 1930 that ings thus generated were understandable, repli-
the problem of investigator bias could be elimi- cable, and translatable into practice. They were
nated and findings more strongly validated if the good evidence.
control subjects were given placebos and the out-
comes assessed by a blinded observer. Strict Guidelines
In 1937, writing for the Lancet, Austin Brad- But a major RCT, even one hailed as a gold stan-
ford Hill, the MRC statistician, proposed a study dard, was also expensive and logistically com-
design in which patients were assigned alternately plicated. During the 1950s, a decade when more
to experimental and control groups, thus ensur- than 400 new drugs, including new psychoactive
ing that the groups were comparable, the study medications, flooded into the market each year,
conditions identical, and investigator bias dis- many trials failed to meet the strict guidelines. As
counted. An earlier study in Michigan (1931) a 1970 review of the literature on the best-selling
had used a somewhat different method, tossing a drug Darvon observed, the evidence was often
coin to determine which group of patients would inconclusive or of questionable validity. The U.S.
receive the experimental treatment. William Feld- Food and Drug Administration (FDA), which had
man and Corwin Hinshaw of the Mayo Clinic evolved slowly from the Pure Food and Drug Act,
combined all these ideas in 1944 in outlining their had the power to assess advertising claims and to
proposed rules for designing a trial to generate review new drugs for safety only.
valid evidence of therapeutic effectiveness: care- This changed in 1962 when the horrific news
ful case selection, blinded observers, and some of thalidomide damage to newborns in Eng-
procedure of chance in assigning subjects to the land and Germany reached Congress just as it
experimental or control group. was considering a new set of amendments to the
The MRC reported the first published use of FDA legislation. The result, the Kefauver–Harris
this ideal design in its 1947 to 1948 trial of strep- Amendments, not only gave the FDA new pow-
tomycin in 107 tuberculosis patients. Because of ers to review and remove ineffective drugs from
ethical qualms, Hill only agreed to the use of ran- the market, as well as to approve or disallow new
domization because of the limited availability of drugs, but also the responsibility of determining
126 Clinical Trials

what would be considered valid evidence of clini- inconclusive. Various trials of one antidepressant
cal effectiveness. The agency enlisted 180 scien- between 1959 and 1963, for example, reported
tific experts and began a decades-long process results of improvement that ranged from 0 to 100
of evaluating previously approved drugs. When percent, while a 1965 review of 26 trials compar-
manufacturers went to court to challenge the ing chlorpromazine to the monoamine inhibitor
removal of some of these compounds as ineffec- reserpine found that the scales used rated chlor-
tive, the FDA in 1970 published its guidelines for promazine as more effective in about half the
acceptable evidence in the Federal Register. These studies but showed no significant difference in the
included use of a control group, exclusion of bias, other half.
defined criteria for patient selection, and statisti- Forty-five years later in 2010, an international
cal analysis of the data. With these regulations, team led by Harvard researcher Felipe Fregni
the FDA wrote the RCT into American law. systematically reviewed the methodologies of
91 studies of seven major psychoactive drugs
Clinical Trials in Mental Illness published between 1949 and 2009. They found
The early observations of mood and behavioral significant improvement over time in trial qual-
change with lithium, chlorpromazine, and imip- ity, reporting, and adherence to RCT guidelines.
ramine were so dramatic that these drugs were More recent trials used rating scales designed to
approved for marketing and adapted in clinical assess severity of symptoms based on DSM cri-
practice in the 1950s on minimal trial evidence. teria rather than to rely on personal judgments.
As manufacturers introduced newer drugs, how- But Fregni and his colleagues still saw much need
ever, particularly new classes such as atypical for improvement in rating scales, not surprisingly
antipsychotics and SSRI antidepressants, and when the DSM-IV itself allows such heterogene-
particularly after the FDA mandated RCTs as the ity of assessment. For example, DSM-IV criteria
evidence standard in 1970, researchers conducted include 39 different combinations of symptoms
extensive trials comparing individual psychoac- for depression, and one commonly used scale, the
tive drugs, drug classes, and drugs against place- Hamilton Depression Rating Scale, includes more
bos. items for anxiety and somatic symptoms than for
RCT evaluation of psychoactive drugs and major depression symptoms. Some studies have
other treatments for mental illness has consis- tried to improve assessment by using multiple rat-
tently presented special problems, including uni- ing scales, running the risk of greater subject attri-
form outcome assessment, interpretation of pla- tion. Consistent rating scales and outcome criteria
cebo effects, and subject attrition, which have for outcome assessment had yet to be developed
contributed to inadequate reduction of bias and in the early 21st century.
generalizability of results. Placebo controls are standard features of psy-
Patient selection and outcome assessment are choactive drug trials but do not always contrib-
problematic in disorders where the primary diag- ute to clear results. A mood disorder like depres-
nostic criteria are behavioral and where patients sion will often respond, if only for a short term,
with the same diagnosis may vary widely in cog- to a placebo; researchers have reported relief of
nition and functionality. What criteria should be depression from a number of “active” placebos,
used to determine, for example, whether one drug that is, drugs that have measurable subjective or
is more effective than another in schizophrenia— physiological effects. In other trials, the charac-
reduction of agitation, improved awareness and teristic therapeutic impact or side effects of par-
clarity, or dissipation of hallucinations? Psychia- ticular drugs have negated a blinded design; in
trists therefore developed numerical rating scales one 1986 study comparing phenelzine and imip-
and behavioral inventories for blinded observers ramine to placebo, 78 percent of the patients and
to use in assessing patients’ baseline status and 87 percent of the observing doctors were able to
in measuring changes following the experimental identify whether they had received a placebo or a
treatment. The scales in use in the 1960s and early real antidepressant. Interpretation of psychophar-
1970s used such varied criteria and were so sub- macology trials using placebo controls remained
ject to observer judgment that the findings proved problematic as of 2010.
 Clozapine 127

Statistical validity of RCTs depends on the Psychopharmacology.” Biological Psychiatry, v.59

recruitment and retention of a sufficient sample (2006).
to detect a therapeutic difference, yet attrition in Marks, H. M. The Progress of Experiment: Science
psychoactive trials has been high, ranging from and Therapeutic Reform in the United States,
24 percent in studies of antidepressants to 30 to 1900–1980. Cambridge: Cambridge University
35 percent of antianxiety agents to 50 percent Press, 1997.
in studies of antipsychotics for those given the Meldrum, M. L. “A Brief History of the Randomized
experimental drug; the placebo attrition rates Controlled Trial: From Oranges and Lemons to the
were higher. Patients may leave because of intol- Gold Standard.” Hematology/Oncology Clinics of
erance of side effects, lack of expected benefit, or North America, v.14/4 (2000).
life events or illness factors leading to relocation Newmark, C. S. “Techniques Used to Assess the
or hospitalization. High attrition rates contrib- Efficacy of Psychotropic Drugs: A Critical
ute to decreased validity and generalizability of Review.” Psychological Reports, v.28 (1971).
RCT findings for psychoactive drugs. The exten- Salamone, J. D. “A Critique of Recent Studies
sive RCT data generated between 1950 and 2010 of Placebo Effects of Antidepressants:
thus provided evidence of therapeutic effectiveness Importance of Research on Active Placebos.”
for the many psychoactive drugs but inconclusive Psychopharmacology, v.152 (2000).
support for the superiority of particular drugs or Smith, M. L. and G. V. Glass. “Meta-Analysis of
classes of drugs. Psychiatrists in practice made Psychotherapy Outcome Studies.” American
prescribing decisions on a patient-by-patient basis. Psychologist, v.32 (1977).
Evaluation of psychotherapy effectiveness
faced a somewhat similar set of issues into the
1970s: multiple available therapies, including
psychoanalysis, transactional analysis, behav-
ioral modification, client-centered therapy, small Clozapine
studies with no-treatment controls, and some-
what inconsistent criteria for outcome evalu- In 1958, the Swiss pharmaceutical company Wan-
ation. In 1977, however, Mary Lee Smith and der AG synthesized a series of new tricyclic com-
Gene Glass of the University of Colorado pub- pounds, one of which was isolated the following
lished their meta-analysis of 500 studies of psy- year and given the name clozapine. It is the only
chotherapy, demonstrating convincingly that all currently used antipsychotic that produces virtu-
types of psychotherapy had some positive effect ally no tardive dyskinesia and Parkinson-like side
compared to no treatment and that the differ- effects. Despite the numerous antipsychotic drugs
ences in effect between the various types were that have been subsequently developed and mar-
virtually nonexistent. The choice of methodol- keted, clozapine remains the only clearly superior
ogy remained a personal decision for therapist drug in regard to efficacy.
and patient. The early history of clozapine did little to sug-
gest its later major importance. Early animal
Marcia Meldrum testing presented mixed and anomalous results—
University of California, Los Angeles results that would eventually lead to its designa-
tion as atypical. Nevertheless, Wander began the
See Also: Antidepressants; Atypical Antipsychotics; first human tests in 1961, and like the animal
Clozapine; DSM-III; DSM-IV; Lithium; Prozac. tests, the results were mixed. One trial failed to
demonstrate that clozapine had an antipsychotic
Further Readings effect, while another trial suggested it was effec-
Brunoni, A. R., L. Tadini, and F. Fregni. “Changes tive against psychotic symptoms. Researchers
in Clinical Trials Methodology Over Time.” performed additional trials in the mid-1960s and
PLOS ONE, v.5/3 (2010). not only found that it was effective in treating
Leon, A. C., et al. “Attrition in Randomized psychotic symptoms but also observed that clo-
Clinical Trials: Methodological Issues in zapine failed to produce the motor side effects
128 Cognitive Behavioral Therapy

that invariably accompanied the then existing Further Readings

effective antipsychotic drugs. These extrapyra- Crilly, J. “The History of Clozapine and Its
midal side effects (EPS) included acute dysto- Emergence in the U.S. Market: A Review and
nias (involuntary muscle contractions that cause Analysis.” History of Psychiatry, v.18 (2007).
slow repetitive movements or abnormal postures, Hippius, H. “The History of Clozapine.”
possibly accompanied by pain), drug-induced Psychopharmacology, v.99 (1989).
Parkinson’s syndrome, and the hard-to-reverse Meltzer, H. Y. “Update on Typical and Atypical
tardive dyskinesia (late-onset involuntary move- Antipsychotic Drugs.” Annual Review of Medicine,
ment disorders that particularly affect the lower v.64 (2013).
face and tongue but may extend to the torso and
limbs). These side effects correlated closely with
the potency of the antipsychotic effect and were
believed to be a necessary concomitant of drug
efficacy. The virtual absence of the motor side Cognitive Behavioral
effects led investigators to call clozapine an atypi-
cal antipsychotic drug. Therapy
When applied in the 1960s, the “atypical”
adjective had a modest, primarily descriptive Cognitive behavioral therapy (CBT) is an effec-
meaning and, given the prevailing belief that EPS tive and popular type of therapy for a wide range
was necessary for antipsychotic effectiveness, did of mental health and other issues. Therapists use
little to promote the use of clozapine. In 1975, CBT to assist clients in managing their problems
eight patients in Finland died of agranulocytosis through changing how they think (cognitive) and
(the inability of the bone marrow to make suf- act (behavioral) toward themselves and their situ-
ficient white blood cells) while taking clozapine, ation. CBT often attempts to replace maladaptive
which led Sandoz (the pharmaceutical company emotions, thinking styles, and behaviors with nor-
that had taken over Wander AG) to halt develop- mative ways that promote health and well-being.
ment efforts in the United States. CBT can be used for a range of issues and is par-
Nevertheless, increasing concerns over tardive ticularly useful for dealing with anxiety, depres-
dyskinesia, which carries a 5 to 10 percent risk sion, drug misuse, and eating disorders.
per each year of treatment, and a belief that clo- The term cognitive behavioral therapy refers to
zapine was possibly more effective than other the development of integration in the late 1980s
antipsychotic drugs nurtured a continued inter- and early 1990s of two types of therapy, behavior
est, and beginning in 1984, Sandoz conducted a therapy and cognitive therapy. Behavior therapy
multicentered study that demonstrated the supe- was developed in the 1950s and 1960s, a behav-
rior efficacy of clozapine over chlorpromazine in ior change approach based on learning alterna-
patients previously unresponsive to antipsychotic tive behaviors through either reinforcement of
drugs. Sandoz also instituted a system of man- desirable behaviors or elimination of undesirable
datory blood monitoring in patients taking clo- behaviors. Behavior therapy was influenced by
zapine so that the medication could be stopped the behaviorist movement in academic psychol-
if white blood cells began to drop, thereby pre- ogy, such as classical conditioning and operant
venting the onset of agranulocytosis. In 1990, learning theories, and therefore is based on the
the Food and Drug Administration (FDA) gave premise that problems represent learned behav-
final approval for the exclusive marketing of ior patterns that are modifiable by reinforcement,
clozapine. management, or coping skills training. Behavioral
therapy is regarded by some therapists as the
Joel Tupper Braslow first wave of CBT because it was a major break-
University of California, Los Angeles through in the 1950s and 1960s in the psycho-
logical treatment of mental health problems, and
See Also: Atypical Antipsychotics; Pharmaceutical it was a revolutionary challenge to psychoanalytic
Industry; Tardive Dyskinesia. therapy, the dominant therapy at that time.
 Cognitive Behavioral Therapy 129

While behavior therapy continues to be an through changing client’s perceptions of illness

important component of CBT today, therapists and medical conditions.
were dissatisfied with its limitations, especially CBT is usually a one-to-one therapy but is also
the downplay of mental processes (cognitions) offered in group sessions and in self-help applica-
such as beliefs, interpretations, and thoughts that tions such as computer-based therapy (comput-
behaviorists claimed were not directly amenable erized cognitive behavioral therapy, CCBT) for
or observable in scientific studies. An intellec- delivering CBT via a personal computer. Effective
tual movement in the late 1960s—known as the CBT is partly dependent on a collaborative rela-
“cognitive revolution,” or second wave of CBT— tionship between client and therapist, who work
resulted in greater appreciation of cognition in together so that the client is actively involved in
psychology and therapy, especially their interac- therapy rather than dependent on the therapist.
tion with emotion and behavior. This led to the At the beginning of a CBT program, the cli-
development of cognitive therapy, which focuses ent and therapist meet to explore the client’s rea-
on how distorted and maladaptive thoughts sons for seeking treatment and their readiness to
underpin behavioral dysfunction. Historical change, and the therapist introduces CBT. The
accounts of cognitive therapy typically cite Albert therapist then formulates a treatment plan to
Ellis and Aaron T. Beck as its original founders address specific target behaviors and antecedents.
in the 1960s. Ellis developed rational emotive In subsequent sessions, the therapist helps the
behavior therapy (known previously as rational client to change unhelpful thoughts and behav-
therapy and rational emotive therapy), which is iors. CBT sessions tend to follow a structure and
one the first forms of CBT and is based on the begin with agenda setting to decide main topics to
ABC model. Beck’s approach to cognitive therapy work on, review of previous sessions, and review
is cognitive restructuring, which teaches clients to of homework, the tasks that the client conducts
identify and modify negative automatic thoughts, between sessions. The number of required CBT
dysfunctional assumptions, and negative self- sessions depends on the nature of the problem and
statements, thereby changing behavior. the client’s suitability for CBT, and typically range
Behavior and cognitive therapies have proven 12 to 20 weeks, with client and therapist meeting
effective across a variety of presenting concerns once per week. Sessions tend to be offered in a
and psychological conditions. In the 1980s and series of blocks, followed by review.
1990s, behavior and cognitive techniques devel- Although the combination of behavior therapy
oped together and became incorporated in an and cognitive therapy is regarded as the main-
integrated cognitive behavioral model known stream definition and theoretical foundation of
now as CBT. During the past 10 to 15 years, some CBT, there is no singular approach because CBT
new treatments have been developed that repre- refers to a family of related therapies that repre-
sent a significant departure from these assump- sent diverse theories and practices that differ in
tions, many of which incorporate acceptance and both minor and major ways, some of which are
mindfulness techniques, the third wave of CBT. quite distinct.
Not all researchers and therapists describe the
development of CBT as distinct stages, but rather Strengths and Weaknesses
as gradual advancement. CBT has strengths and weaknesses. It is a popu-
lar and effective treatment for a broad range of
Applications problems, and it has a flexible and individualized
CBT can be an effective treatment of a wide range approach that can be used for a wide range of cli-
of presenting concerns, especially mental health ents, settings, and problems. However, CBT is not
issues such as anxiety and stress, depression, eat- suitable for everyone, and its broadness means
ing disorders, drug and alcohol problems, per- that CBT treatments can widely vary.
sonality disorders, phobias, obsessive-compulsive CBT is an evidence-based therapy and has been
disorder (OCD), post-traumatic stress disorder, subjected to high-quality research and evaluation,
bipolar disorder, and psychosis. Also, CBT can be including randomized controlled trials. Though
an effective therapy for physical health problems research points to CBT as an effective treatment,
130 Cognitive Behavioral Therapy

Cognitive behavioral therapy (CBT) is usually conducted one-to-one. Initially, the client and therapist meet to explore the client’s
reasons for seeking treatment and their readiness to change and the therapist introduces CBT and formulates a treatment plan.
During sessions, which typically range over 12 to 20 weeks, the therapist helps the client to change unhelpful thoughts and behaviors.

the full extent of efficacy remains unclear and social conditions, structures, and processes. While
debatable because there is a paucity of research procedures such as randomized controlled trials
and evaluation of some types of CBT, such as are indispensible for evaluation of CBT, sociolo-
long-term treatment and third-wave therapies. gists are keen to explore a broader evidence base.
Another challenge is the meaning of evidence and A development has been a social constructivism
how it is used in the reality of everyday practice of approach in CBT, which respects the ways that
CBT; mainstream CBT is aligned with the medi- people construe life differently according to their
cal model, and treatment is viewed as analogous culture and society, and assumes that social sys-
to drug treatment, which has been criticized by tems and society underpin people’s problems.
sociologists. Therefore, social constructionist versions of CBT
This is set against a backdrop of discontent with place less emphasis on distorted and irrational
the medicalization of society, whereby conditions thinking in favor of the value of the therapeutic
and problems—even normal life events—have relationship. However, constructivism has been
come to be defined and treated as medical prob- criticized by realists who question its violation
lems with diagnoses and treatments, thereby fuel- of the basic principles of CBT and view it as an
ling the growth and professional jurisdiction of “anything goes” therapy.
CBT while overlooking the social construction of Another issue is applicability of CBT across
mental health and its determinants such as beliefs, cultures and minority groups. Traditional CBT
 Cognitive Disorder 131

and counseling theories and approaches were Cognitive Disorder

developed in the West where the profession is
established. CBT in other countries has Western Cognitive disorders are mental disorders that
characteristics, which may be less relevant to eth- develop as the result of an interruption—short
nic minorities and might even produce negative or long in duration—in a person’s basic cogni-
outcomes. However, relatively little is known tive functions. Amnesia, delirium, and dementia
about the efficacy of CBT for people from diverse represent the most commonly recognized forms
ethnic and cultural backgrounds, and culture is of cognitive disorders, and all are forms of men-
difficult to define because clients describe their tal illness. While some evidence suggests that the
ethnicity and degree of participation in ethnic occurrence of these cognitive disorders varies
communities in different ways. Therapies such somewhat depending on ethnicity and socioeco-
as CBT should be used with care, especially with nomic status, some believe that this disparity is
clients in non-Western cultures, and this is also caused by different levels of willingness to report
an important issue for counselors in developed mild levels of cognitive impairment among dif-
countries such as the United States with diverse ferent groups. Especially in those cases where the
communities. Another issue is that members of cognitive disorder does not affect the lifestyle of
minority groups may encounter barriers to treat- the individual in a negative way, members of cer-
ment such as discrimination, lack of knowledge, tain groups, such as African Americans, appear to
poor language skills, isolation, poverty, lack of be less willing in the United States to report cog-
trust in the medical system, stigma-related con- nitive disorders than Caucasians. Further study
cerns, and other social, economic, and cultural is needed to determine how these differences in
barriers, and therefore use fewer counseling ser- reporting affect how cognitive disorders are diag-
vices. There is wide variation across countries nosed, tracked, and treated.
in availability of CBT. In many low-income and Cognitive functions include such processes as
middle-income countries, access is limited, par- language, memory processing, perception, and
ticularly in rural areas. problem solving. Cognitive disorders have tradi-
These debates further justify sociological stud- tionally been explained in a variety of ways. These
ies on CBT and the interplay between society and have included attributing the abnormal behavior
mental health to shed light on CBT and its inter- to supernatural or biological reasons. When cog-
action with therapists, and the social spheres in nitive disorders were attributed to supernatural
which they are embedded. causes, it was believed that evil demons or spir-
its had possessed the afflicted individual, or that
Gareth Davey thought patterns were influenced by the moon,
Hong Kong Shue Yan University other planets, or stars. A variety of approaches
were used to dispense these causes, including
See Also: Anthropology; Clinical Sociology; exorcisms, religious rituals, punishment, and
Diagnosis; Diagnosis in Cross-National Context; confinement. Biological attributions of cognitive
Medicalization, Sociology of; Randomized disorders are often closely related to psychologi-
Controlled Trial. cal explanations. Where the biological tradition
is favored, cognitive disorders are attributed to
Further Readings medical or biological reasons. Where the psycho-
Beck, Judith. Cognitive Behavior Therapy: Basics and logical tradition is preferred, cognitive disorders
Beyond. New York: Guilford Press, 2011. are linked to flawed psychological development
Hays, Pamela and Gayle Iwamasa. Culturally and the social environment in which an individ-
Responsive Cognitive-Behavioral Therapy: ual lives.
Assessment, Practice, and Supervision. Abnormal psychology studies unusual patterns
Washington, DC: American Psychological of behavior, emotion, and thought, whether they
Association, 2006. precipitate a mental disorder or not. Abnormal
Neimeyer, Robert. Constructivist Psychotherapy: psychology incorporates behavioral, cognitive,
Distinctive Features. New York: Routledge, 2009. and medical perspectives to explain cognitive
132 Cognitive Disorder

disorders. Behavioral perspectives concentrate on traumatic brain injury, or operation. While the
observable behaviors in those with cognitive dis- loss of memory may only include that of a few
orders, such as disorientation or confusion. Cog- weeks or months, it may extend back decades,
nitive approaches focus upon how an individual’s causing the individual great difficulty.
internal thoughts, perceptions, and reasoning are Delirium constitutes a disorder manifested
factors in his or her cognitive disorder. Medical by difficulties in processing new information
explanations involve the biological causes of these and a lack of situational awareness. Delirium is
conditions, such as imbalances of neurotransmit- caused by a variety of factors, including the abuse
ters in the brain, or hormonal imbalances. of medications or narcotics, immobilization,
The Diagnostic and Statistical Manual of Men- mental illness, pre-existing medical conditions,
tal Disorders, 4th edition, text revised (DSM-IV- severe pain, sleep deprivation, and withdrawals
TR) is one of the standard reference texts used by from alcohol or drugs. Delirium has a high rate
psychiatrists and psychologists. (The DSM-5 was of onset, ranging from minutes to hours, but is
released in 2013). According to the DSM-IV-TR, almost always of relatively short duration, last-
cognitive disorders are classified as psychologi- ing for only a few hours, days, or weeks. Appear-
cal disorders in Axis I of the text, which includes ing rapidly after only a few hours, delirium has
symptom disorders and clinical disorders, includ- a fluctuating course, causing attentional deficits
ing major learning and mental disorders. Cogni- and generalized severe disorganization of an indi-
tive disorders are described by the DSM-IV-TR vidual’s behavior. Representing an organically
as those that result in a significant impairment of caused decline from previous levels of cognitive
cognition or memory that represents a consider- functioning, delirium involves a range of cogni-
able decline from an individual’s previous level tive deficits. These include an altered sleep/wake
of functioning. The DSM-IV-TR outlines three cycle, changes in arousal, perceptual deficits, and
major areas of cognitive disorders—amnesia, psychotic features that can include delusions
delirium, and dementia—although many subcat- or hallucinations or both. Delirium is a clinical
egories of these also exist. syndrome—a set of symptoms—and not a dis-
ease, meaning that treatment must focus upon an
Classifications underlying disease, instead of delirium alone.
Individuals suffering from amnesia have difficulty Dementia represents a loss of cognitive ability
retaining or accessing long-term memories. Amne- in a person who was previously unimpaired. A
sia may be caused by a variety of factors. These set of assorted symptoms and signs, rather than
include alcoholism, concussions, excessive drug a single disease, dementia is considered a nonspe-
use, post-traumatic stress, and traumatic brain cific illness syndrome. Symptoms associated with
injuries. There are two major categories of amne- dementia include impaired attention, language,
sia: anterograde amnesia and retrograde amnesia. memory, or problem solving. For a diagnosis of
When an individual has difficulty creating recent- dementia to be made, symptoms must be pres-
term memories, this is called anterograde amnesia, ent for a period of six months or longer. Demen-
and is caused by damage to the hippocampus— tia is associated with a variety of diseases such
when this occurs, difficulty with memories results as Alzheimer’s and is generally progressive and
from the impairment of a major component of incurable. Fewer than 10 percent of dementia
the brain’s memory creation process. Specifically, cases may presently be reversed with treatment.
anterograde amnesia results from the inability of
the brain to transfer new information from the Cultural Comparisons
working memory to the long-term memory store. Because cognitive screening is required to iden-
Individuals suffering from anterograde amnesia tify those with cognitive disorders, it is difficult to
cannot remember information for any significant ascertain if differences in the occurrence of these is
period of time. Retrograde amnesia manifests because of biological or other differences between
itself in the inability to access or retrieve informa- different ethnic groups or is caused by more fre-
tion acquired before a date certain. Usually, the quent screenings by members of certain groups.
date certain marks the occurrence of an accident, As a result of this, studies have been undertaken
 Colombia 133

to determine if differences exist regarding indi- Further Readings

viduals’ willingness to be screened or tested for Grant, I. and K. M. Adams, eds. Neuropsychological
cognitive impairment as a result of their member- Assessment of Neuropsychiatric and Neuromedical
ship in a certain group. Disorders. 3rd ed. New York: Oxford University
Studies suggest that fewer than 50 percent of Press, 2009.
individuals from any ethnic group in the United Potter, G. G., et al. “Cognitive Performances and
States will agree to be screened for cognitive dis- Informant Reports in the Diagnosis of Cognitive
orders. Men appear more willing than women to Impairment and Dementia in African Americans
undergo screening, as are those who re already and Whites.” Alzheimer’s and Dementia, v.5/6
taking more medications or using other assistive (2009).
devices. Over 95 percent of individuals who were Williams, C. L., R. M. Tappen, M. Rosselli, F.
willing to be screened for depression were also Keane, and K. Newlin. “Willingness to Be
willing to be tested for cognitive disorders, which Screened and Tested for Cognitive Impairment:
suggests that those who more frequently obtain Cross-Cultural Comparison.” American Journal
or have access to medical services were more will- of Alzheimer’s Disease and Other Dementias,
ing to undergo such testing. v.25/2 (2009).
Between members of different racial groups, in Wright, J. H., D. Kingdon, D. Turkington, and
the United States, Caucasians are more likely to M. R. Basco. Cognitive Behavior Therapy for
seek out and undergo screening than other groups, Severe Mental Illness. Arlington, VA: American
followed in order by those of Asian, African, and Psychological Association, 2005.
Latino ancestry. When Latinos were personally
recruited by someone they knew, however, they
were the most willing to make a purposeful visit
for cognitive screening. Members of all groups
were more likely to attend a session testing them Colombia
for cognitive impairment if invited by a personal
acquaintance. Some of these differences might be Colombia is a South American country of 41
the result of levels of comfort and familiarity with million people. A 40-year civil war had adverse
medical care, which is based in part on levels of effects, primarily on civilians, that included kid-
insurance benefits enjoyed. nappings, extortions, threats, assassinations, and
Differences have also been found in responses dislocations. Violence causes or exacerbates men-
to screening results. Caucasian Americans were tal health problems. Colombia spends one-tenth
less certain about how they would proceed than of 1 percent of its total budget on mental health
members of the other three groups. While African problems. Colombia restructured its health sys-
Americans and Latinos were more likely to seek tem in 1993, emphasizing managed competition
professional help, they were less specific about and structured pluralism but failed to include
what that treatment might be. Although Latinos mental health services. Medical outpatient service
were the least likely to seek cognitive screening, availability increased 46 percent, according to a
they were the most optimistic if testing indicated 2003 study of the restructuring. Colombians had
amnesia, delirium, or dementia. Non-Caucasians a significantly higher demand for mental health
were also more willing to undergo complemen- services because of the long-running civil war and
tary and alternative treatment if diagnosed with a the extremely high crime rate because of drug
cognitive disorder. trafficking.
In 2000, Colombia had 10 public psychiatric
Stephen T. Schroth hospitals that hospitalized 13,573 patients and
Jason A. Helfer dealt with 88,903 outpatients that year. There
Knox College were other support organizations such as the
Maral Collective Corporation, formed in 2002,
See Also: Alzheimer’s Disease; Delirium; Dementia; that facilitated access to vocational training and
Psychosomatic Illness, Cultural Comparisons of. employment in Bogotá; the Manic Depressives’
134 Colombia

Association in Bogotá that sought to increase problem was not necessarily prevalent through-
public awareness and provide support to manic out Colombia.
depressives; the Colombian Association Against The Antioquian study failed to indicate
Depression and Panic, a nongovernmental orga- whether police or other state officials targeted the
nization in half a dozen Colombian cities and mentally ill, but the March 31, 2003, CIA Coun-
involved in public awareness, research, and sup- try Report for 2002 indicated that paramilitary
port groups. groups engaged in “social cleansing” in several
The Colombian Ministry of Social Protection cities, and targets of the cleansing included those
reported in 2004 that 40.1 percent of Colombians with mental health issues.
aged between 18 and 65 years had at least one A Doctors Without Borders mental health
mental health problem in their lifetime. Only 10 effort in Tolima department in the combat region
percent of that 40.1 percent, or 4 percent of the took place between 2005 and 2008. The depart-
population, sought professional health. A 2003 ment has 47 municipalities. The program dealt
study further indicated that access to outpatient with both urban and rural psychosomatic and
mental health services, adjusted for population, psychological requirements. The observers found
declined 2.7 percent. The decline was 11.2 per- significant differences between rural and urban
cent among women, but men increased access by conditions, including type of traumatic event,
5.8 percent. The report claimed that reform not type of disorder, the way the disorder expressed,
only failed to better access but also made “insti- and the severity of the problem. For security rea-
tutional survival” of mental health facilities more sons, the treatment was shorter than desired, but
of a challenge. The Spanish chapter of Doctors most patients made at least some improvement
Without Borders concurred in 2002, noting that during their treatment. The program included
in Bogotá there were 400 documented cases of two mobile rural units and an urban site at Toli-
abandoned mentally ill people. ma’s capital, Ibague.
A pilot program by BasicNeeds ran in Usaquen, The Ibague clinic examined every internally
a province of Colombia north of Bogotá, from displaced person for health and psychological
2007 to 2009. The BasicNeeds program recorded conditions. For rural areas, those villages that
that 40 percent of Colombians, or 16.4 million had been impacted directly by the war through
people, had endured a mental illness, and in a recent or long-term violence were selected. The
given year, 10 percent endured depression (the urban treatment allowed unlimited sessions, but
world average is 4–5 percent). The country of 41 in the rural areas, only five sessions per person
million had 1,000 psychiatrists, above average were possible. Those requiring significant inter-
for developing countries. However, because half vention at the end of the sessions were referred
of the 1,000 were in Bogotá and 75 percent were to governmental institutions. There were also
in private practice, access to mental health pro- group sessions with a psychologist at which all
grams by the majority of the population was diffi- the population were present. These sessions were
cult. Colombia’s internally displaced person (IDP) intended to make people aware of symptoms and
population is the second largest in the world, sec- difficulties. In Ibague, physician referrals were the
ond only to Sudan. The 3.3 million IDPs are 7 principal avenue for accessing psychologists.
percent of the population. Over three years, the program treated 855 peo-
In 2003, a joint report by the Pan American ple in Ibague and 1,556 in the villages. The total
Health Organization and two Antioquia institu- of 2,411 was 35.5 percent urban and 64.5 percent
tions indicated that the area faced both cultural rural, with 75 percent older than 14 years, and
and social challenges in delivering mental health two-thirds women.
services to the local population. Opposition to The most common traumas in Tolima were
mental health services was based in part on soci- flight and family violence. Village children saw
etal opposition to such use, individual reluctance murders and physical abuse, had their nuclear
to acknowledge that mental health might be a families broken, and endured family violence.
problem, and a generalized stigma associated with Urban adults suffered foremost from flight, then
mental illness. The study also indicated that the from threats and lost or destroyed property. Rural
 Commitment Laws 135

adults were most frequently traumatized by seeing “The Colombian Conflict: A Description of a
murder or abuse, and having a close family mem- Mental Health Program in the Department of
ber killed. Mental diseases were most commonly Tolima.” Conflict Health, v.3/13 (2009).
distress or anxiety, followed by sadness and cry-
ing. Village rates of severe disorder (14.6 percent)
were notably higher than urban (6.4 percent).
In 2010, in Madrid, Doctors Without Borders
reported on treatment of 5,000 persons in Caqu- Commitment Laws
eta department, and found that the population
still experiences social and institutional stigma, Commitment laws exist in every U.S. state. Com-
neglect after relocation, and other problems that mitment law involves involuntary hospitaliza-
promote mental health problems in the internally tion or mandated treatment for individuals who
displaced. The report cited “violence, silence, and are, as a result of their mental illness, a danger
neglect” as the problems caused to the displaced to themselves, a danger to others, or so gravely
by armed forces: government, guerrilla, and disabled that they are unable to properly care for
paramilitary. The various forces perpetrated vio- themselves. Generally, these criteria are required
lence, and the authorities and society did nothing for an individual to be committed against their
to deal with the resulting trauma. Rather, those will, but states often have significant latitude with
who spoke of their problems were stigmatized regard to interpretation of the criteria. Variation
and unable to reintegrate themselves into society, in judgment regarding who ultimately is hospital-
rebuilding shattered lives. Natives generally view ized is largely determined on a case-by-case basis
IDPs with suspicion, making it harder for IDPs but can also be impacted by the social, political,
to find jobs, housing, education, and health ser- and economic climate of a community.
vices. IDPs and others exposed to violence tend Historically, parens patriae (parent of the coun-
to be abusive to their families, and aggressive and try) has served as the legal basis for civil com-
neglectful treatment of children by their mothers mitment. Essentially, the state had an obligation
is considered normal. to behave in a parenting capacity for individuals
who were unable to care for themselves. In the
John H. Barnhill parenting capacity, the state’s goal was to protect
Independent Scholar mentally ill individuals from harming themselves.
Another function of the state was to protect its
See Also: Post-Traumatic Stress Disorder; Shell citizens (police power) from any potential danger
Shock; Trauma, Psychology of; Violence; War. that an untreated mentally ill individual might
pose to society. Thus, the primary legal focus of
Further Readings the state was twofold: preventing harm to self and
BasicNeeds. “Colombia.” http://www.basicneeds.org/ harm to others.
colombia/index.asp (Accessed January 2013). Parens patriae served as the primary guid-
Immigration and Refugee Board of Canada. ing legal principle for civil commitment until the
“Colombia: Situation of Individuals Suffering 1960s, when there arose a great deal of concern
From a Mental Illness” (January 5, 2005). http:// about the potential for abuse with regard to civil
www.unhcr.org/refworld/docid/42df60d411.html commitment criteria. In many jurisdictions, with
(Accessed December 2012). only the recommendation of a mental health pro-
Palmer, Leo. “Report: Colombia Must Improve fessional, an individual could be involuntarily
Mental Health Services for the Displaced” (July hospitalized for an undetermined amount of time.
27, 2010). http://colombiareports.com/colombia Critics claimed that individuals were being man-
-news/news/11024-report-colombia-must-improve dated to large state hospital institutions against
-mental-health-services-for-the-displaced.html their will when in fact they were not truly men-
(Accessed December 2012). tally ill or dangerous.
Sanchez-Padilla, Elisabeth, German Casas, Rebecca By the 1970s, activists successfully changed
F. Grais, Sarah Hustache, and Marie-Rose Moro. civil commitment laws at the federal level, arguing
136 Commitment Laws

that these laws violated an individual’s constitu- individual’s likelihood to engage in violence.
tional right to liberty. Several high-profile U.S. Consideration is given to current symptoms of
Supreme Court cases placed limitations on the mental illness, a past history of violence, active
civil commitment process. Of particular impor- substance abuse, and the presence of delusions
tance was the 1975 O’Connor v. Donaldson case, or violent thoughts. Finally, individuals who are
which concluded that a mentally ill individual, deemed to be in grave danger are those who are
even one who was severely so, could not be held unable to meet their basic needs for food, cloth-
in a mental health facility against their will unless ing, and shelter.
they were also deemed dangerous. O’Connor v.
Donaldson and other reform efforts ultimately Outpatient Commitment Laws and
made involuntary hospitalization more difficult. Psychiatric Advance Directives
Most commitment law statutes also contain cri-
Criteria for Civil Commitment teria for outpatient treatment, known as outpa-
Utilizing the O’Connor v. Donaldson Supreme tient commitment (OPC), involuntary outpatient
Court ruling as a guide, many states revised their commitment (IOC), or assistant outpatient treat-
civil commitment laws. At present, all states ment (AOT). OPC is a form of mandated treat-
require that an individual be a danger to them- ment in which an individual receives treatment in
selves or a danger to others. A majority of states the community rather than in an inpatient setting.
have devised additional criteria called “grave OPC statutes are often considered extensions of
disability” or “need for treatment” standards. inpatient civil court mandates. Outpatient com-
An individual is gravely disabled if he or she is mitments are commonly considered the “least
unable to meet his or her basic personal needs restrictive alternative (LRA)” to psychiatric hos-
for food, clothing, or shelter. Need-for-treatment pitalization. OPCs are often the LRA for individ-
criteria are typically based on an individual’s uals with severe mental illnesses such as schizo-
ability, or lack thereof, to make informed medi- phrenia and other psychotic spectrum disorders.
cal decisions, to properly care for their psychiat- OPCs are designed to target individuals who are
ric needs, or to prevent further psychiatric dete- repeatedly admitted to inpatient units, with the
rioration. A variation of the need-for-treatment goal of ending chronic rehospitalization cycles.
provisions, included among some state statutes, Individuals who fail to comply with mandated
is the “protection of health, safety, and prop- community treatment risk being recommitted to
erty.” Iowa is one such example. An individual an inpatient setting.
could be subjected to involuntary commitment Forty-four states and the District of Colum-
if he or she is likely to inflict serious emotional bia have OPC laws authorizing outpatient treat-
injury on family members or others who might ment for individuals deemed appropriate to
have difficulty avoiding contact with the individ- receive treatment in the community. As of 2011,
ual in question. six states did not have OPC laws: Connecticut,
Maryland, Massachusetts, Nevada, New Mexico,
Clinical Assessment and Tennessee. While the majority of states have
Assessing the risk for danger to self or others can OPC laws in place, they are often not enforced.
be a difficult clinical task. With regard to dan- Patients may be threatened with rehospitalization
ger to self, clinicians are attempting to assess the if they fail to comply with mandated community
likelihood that an individual will attempt suicide. treatment, but this rarely occurs. One reason is
Aspects of assessing suicide include reviewing the that properly enforcing compliance with an out-
patient’s history for past suicide attempts, the patient treatment order requires the expenditure
frequency of suicidal thoughts, the existence of a of additional resources. Many communities sim-
suicide plan, the level of depression, the use of ply do not have the requisite resources to enforce
alcohol or drugs, and recent significant or trau- outpatient treatment orders.
matic loss. OPC has a long history of being controversial
With regard to assessing danger to oth- among mental health professionals and advocates.
ers, clinicians are attempting to determine an Opponents fear that OPC is a misguided exercise
 Commitment Laws 137

in social control and undermines a patient’s right The 2006 Adam Walsh Act (AWA), which was
to refuse treatment. They argue that if an effective designed to protect the public from violent sex
mental health system were in place, OPC statutes offenders, is named after a 6-year-old child who
would be unnecessary. Proponents contend that was abducted and murdered by a sex offender. The
OPC protects the most severally impaired men- AWA contains a provision that allows the attorney
tally ill (typically those who do not recognize that general or the director of the Bureau of Prisons
they are ill), is less restrictive than inpatient hospi- (BOP) to certify an individual as sexually danger-
talization, is preventive, and can assist individuals ous, which would ultimately lead to the individ-
with mental illness to stay well. OPC supporters ual’s civil commitment. To be certified as a sexu-
also contend that individuals who lack insight into ally dangerous person, an individual must be in
their illness will never make use of even the most the custody of the BOP, lack the capacity to stand
sophisticated services unless some type of leverage trial for criminal charges, or have had their crimi-
forces their treatment compliance. Thus, for sup- nal charges dismissed due to a mental condition.
porters, OPC represents a preventive measure. At The government must then establish “clear and
its core, OPC statutes purportedly exist to ensure convincing evidence” that the individual (1) has
that individuals are helped into treatment before engaged or attempted to engage in sexually violent
they become so gravely ill that they act out crimi- conduct or the molestation of a child, (2) has a
nally or try to hurt themselves or others. serious mental illness or abnormality, and (3) as a
A recent extension of the civil commitment result, would have significant difficulty refraining
process is the psychiatric advance directive (PAD). from engaging in sexually violent conduct with a
PADs are legal documents that allow competent child should he or she be released. Those being
individuals to document their psychiatric treat- civilly committed under the AWA need only to
ment preferences for their mental health care in have attempted a bad act; they are not required
the event of psychiatric incapacitation. Typically to have committed a bad act, which has led some
included in a PAD is information about an indi- critics to argue that the AWA is unconstitutional.
vidual’s treatment history, emergency contacts,
medical information, and medication preferences. The Commitment Process
Proponents of PADs suggest that they reduce coer- Though the process varies by state, there are gen-
cion and facilitate individuals to receive needed erally two ways to be involuntarily civilly com-
treatments on their own terms. mitted. The first path includes petitioning the
court for court-ordered treatment. After the court
Sexually Violent Predators has been petitioned, the court reviews the petition
Outpatient commitments have been expanded and subsequently holds a commitment hearing.
to include sexually violent predators. A 1997 At the commitment hearing, the patient is typi-
Supreme Court decision in Kansas v. Hendricks cally represented by a lawyer, witnesses are called,
indicated that with regard to civil commitment, and a jury or a judge makes the final decision. If
states could define “mental illness” however it has been determined that an individual requires
they wanted. Traditionally, individuals who were civil commitment, subsequent re-evaluations to
involuntarily hospitalized or placed in outpatient ensure that hospitalization remains necessary will
commitment typically had severe mental illnesses take place at certain legally determined time peri-
such as schizophrenia, bipolar disorder, and other ods. This is done in an attempt to ensure that the
conditions that involved a psychotic component. patient’s rights are not being violated.
Other mental health disorders such as intellectual The second type of civil commitment typically
disability, substance abuse, and personality disor- involves psychiatric emergencies. In this case, an
ders had been routinely excluded. The Hendricks individual may be brought to the hospital by law
ruling led many states to extend their civil com- enforcement, emergency medical professionals, a
mitment criteria to include individuals diagnosed mental health professional, or a relative. Individu-
with pedophilia, who are deemed dangerous to als who are civilly committed through emergency
children, to incarceration in facilities for indefi- commitment may be hospitalized for a minimum
nite periods of time. of 24 hours up to several days. At the end of the
138 Community Mental Health Centers

holding period, a patient may be released, placed (2011). http://www.treatmentadvocacycenter.org/

on voluntary status, or held on another involun- storage/documents/Standards_-_The_Text-_June
tary commitment. Depending on the length of _2011.pdf (Accessed October 2012).
stay, patients are entitled to both representative
legal counsel and a hearing to determine whether
continued commitment remains necessary. Should
an extended stay be necessary, subsequent hear-
ings will take place at legally determined time Community Mental
periods.
Another type of commitment, voluntary, typi- Health Centers
cally requires the following conditions for a
patient to be voluntarily committed to a psychi- Community mental health centers are nonprofit
atric facility: (1) a mental health condition that or for-profit organizations housed in a building
is susceptible to care, (2) an understanding of the facility located in municipalities throughout the
nature of the admission request, (3) the ability to country, designed to provide psychiatric and psy-
consent, and (4) the ability to request a release chological services to people with various types of
from the psychiatric facility. In all cases, a physi- mental health concerns. Services may include, but
cian must examine the patient and agree that he or are not limited to, behavioral and mental health
she meets the aforementioned criteria. Research evaluations, psychiatric medication, behavioral
has shown that generally, voluntary hospitaliza- therapy, case management, and emergency and
tion is preferred over involuntary commitment by crisis intervention. Related mental health services,
both patients and the legislators who devise com- such as educational and resource information,
mitment statutes. may also be provided for relatives and friends.
Individuals served include children, adolescents,
Christine M. Sarteschi and adults at different stages in life. Services are
Chatham University provided by trained mental health professionals
such as psychiatrists, physicians, nurses, coun-
See Also: Dangerousness; Deinstitutionalization; Law selors, social workers, and psychologists. Other
and Mental Illness; Voluntary Commitment. professionals include health care administrators,
educators, and behavioral health researchers.
Further Readings Community mental health centers were the
Fisher, William H. and Thomas Grisso. result of recommendations made to Congress in
“Commentary: Civil Commitment Statutes—40 1955 by the Joint Commission on Mental Health
Years of Circumvention.” Journal of The American and Health. The commission concluded that in
Academy of Psychiatry and The Law Online, comparison to other illnesses in the United States,
v.38/3 (2010). there is a lack of resources, research, knowledge,
Huss, Matthew T. Forensic Psychology: Research, and money to effectively treat mental illness in
Practice and Applications. West Sussex, UK: America. The following is a summary of their
Wiley-Blackwell, 2009. recommendations:
La Fond, John Q. “Outpatient Commitment’s Next
Frontier: Sexual Predators.” Psychology, Public • Additional types of research
Policy and Law, v.9/1/2 (2003). • Better use of mental health professionals
Swanson, Jeffrey. “What Would Mary Douglas • An affirming public image of psychiatry
Do? A Commentary on Kahan et al., Cultural • Federal aid to higher education to sup-
Cognition in Public Policy: The Case of Outpatient port student education and training in
Commitment Laws.” Law and Human Behavior, mental health
v.34 (2010). • Immediate services for people with men-
Treatment Advocacy Center. “State Standards For tal illness
Assisted Treatment: Civil Commitment Criteria • Hospitals that are not overcrowded and
for Inpatient or Outpatient Psychiatric Treatment” are appropriate to treat mental illness
 Community Mental Health Centers 139

At a disaster recovery counseling center set up by the Federal Emergency Management Agency, a counselor with Century Health,
a mental health organization, talks with a woman whose home was damaged from flooding in her community of Findlay, Ohio,
September 14, 2007. Support and advocacy services include programs that use trained volunteers and employees.

• Community resources and programs that designed to provide an alternative to admission

are designed to address the needs of the into a psychiatric hospital or emergency room for
mentally ill those individuals with psychiatric concerns.
• Rehabilitation programs in hospitals for Community mental health centers are a pro-
the chronically mentally ill vider of the following comprehensive mental
• Public education and service information health services:
available to the community
• Federal funding to provide care for per- Outpatient mental health services. These are clin-
sons with mental disabilities ical services for individuals, couples, and families.
They may include, but are not limited to, diagnos-
The Community Mental Health Act, also tic behavioral assessment; psychological testing;
known as the Mental Retardation and Commu- psychiatric evaluation; clinical laboratory tests;
nity Mental Health Centers Construction Act, psychiatric services; and individual, couple, fam-
was enacted in 1963 during the John F. Kennedy ily, and group psychotherapy.
administration. Community mental health cen-
ters throughout the country were eligible for fed- Outpatient substance abuse services. These are
eral funding, with their operations overseen by also clinical services for individuals, couples, and
the National Institute of Mental Health. families. They include diagnostic substance abuse
assessment; addiction psychiatric evaluation, clini-
Objective and Mission cal laboratory drug evaluation; and individual,
The primary objective and mission of community couple, family, and group drug counseling.
mental health centers is to serve as an interven-
tion with behavioral services to citizens; more School and community-based mental health ser-
specifically, community mental health centers vices. These are services provided to children who
140 Community Mental Health Centers

may not otherwise be engaged in traditional out- contributions, donations, and grant monies from
patient services. The services actively involve pro- government agencies and private foundations.
fessional school personnel. They facilitate special Such funding supports the organization’s opera-
programs that assist youth and families whose tions, services, and service providers. Monies are
mental health issues are having an impact on their also generated from Medicare and/or Medicaid
functioning and quality of life. insurance as well as private health insurance com-
panies. Some consumers make cash payments for
Support and advocacy services. These services the services received.
include programs such as those using trained vol- For-profit mental health centers follow a dif-
unteers and employees who monitor 24-hour cri- ferent business formation. The for-profit orga-
sis hotlines to provide information and referrals nization is obligated to pay federal taxes, is not
for mental health emergencies. Support and advo- eligible to receive grant funding, and is in the
cacy services also offer peer counseling, hospital business of selling mental health services. The for-
accompaniment, court advocacy, and referrals for profit organization may be individually owned by
victims of sexual and physical assault. one person and/or by a group of investors. Like
nonprofit organizations, for-profit organizations
Children’s support and advocacy services. These accept Medicare and/or Medicaid insurance, pri-
services include trained volunteers and employees vate health insurance, and cash payments for ser-
who provide school-based prevention and educa- vices provided.
tion to area students. These programs also work
with “at-risk” children through intervention strat- Conclusion
egies, after-school programs, and mentoring. Vol- Since their conception in the 1960s, community
unteers serve as child advocates in the legal sys- mental health centers have evolved into a criti-
tem, the school system, and hospital admissions. cal segment of society. They have provided pro-
fessional services to an infinite number of vic-
Intensive youth services. These include compre- tims of mental illness and chemical dependency.
hensive services to meet the mental health needs of Services range from outpatient services to case-
youth with serious emotional, behavioral, social, management mental health services from new-
or family concerns that may involve situations of born infants to elderly members of a community.
physical or sexual abuse. Although there are a number of for-profit com-
munity mental health centers, the vast majority
Case management mental health services. This have been classified as nonprofit organizations.
form of community mental health serves as a link Consequently, they rely largely on government
between the consumer and the resources available funds and contributions from private donors to
in their community. It is designed to assist individ- provide services for the community.
uals with disabilities attributed to chronic mental
illness and/or chemical dependency that require Dashiel Geyen
medical, psychosocial, educational, financial, Texas Southern University
vocational, legal, clothing, housing, and nutri-
tional access. These services can be offered at an See Also: Alcoholism; Case Managers; Children;
affordable cost by providers in the community. Community Psychiatry; Costs of Mental Illness;
Drug Abuse; Economics; Emergency Rooms; Health
Nonprofit and For-Profit Structures Insurance; Medicare and Medicaid; National
Nonprofit mental health centers are generally Alliance on Mental Illness; National Institute of
service based. Their activities are governed by an Mental Health; Neighborhood Quality; Policy:
established board of directors and are overseen Federal Government; Policy: State Government;
by the organization’s president and administrative Psychiatric Treatment, Pathways to; Public Education
executives. These types of organizations have a Campaigns; Service Delivery; Social Support; State
501(c) business structure (tax exempt). Moreover, Budgets; Therapy, Group; Therapy, Individual;
they are eligible to receive funding in the form of Treatment; Welfare.
 Community Psychiatry 141

Further Readings assessments of the success of community care

Cummings, Elaine. “A Review Article: The Reports of have been mixed. Ongoing tensions between care
the Joint Commission of Mental illness and Mental and control, and the claim that policy rhetoric
Health.” Social Problems, v.9/4 (1962). is not sufficiently reflected in practice, are at the
Heath, Don and Jack Downing. Handbook of heart of many such critiques.
Community Mental Health Practice. Hoboken, NJ: The central focus of community care is on pro-
Jossey-Bass, 1969. viding the most effective treatment in the least
Hess, Robert E. and John Morgan. Prevention in restrictive environment. Ideally, these environ-
Community Mental Health. New York: Haworth ments are primary care settings, especially for
Press, 1990. people with less serious disorders, such as local
Rapp, Charles A. The Strengths Model: Case community mental health centers and people’s
Management With People Suffering From Severe homes. These environments are significantly less
and Persistent Mental Illness. New York: Oxford threatening and stigmatizing than admission to a
University Press, 1998. psychiatric ward and make it easier to maintain
Ridenour, Nina. Mental Health in the United continuity and connections with family, friends,
States: A Fifty Year History. Cambridge, MA: recreational interests, the workplace, and neigh-
Commonwealth Fund, 1961. borhood groups, all of which enhance a person’s
Volkart, Edmund. “Action for Mental Health: Final recovery and social inclusion. Home and commu-
Reports of the Joint Commission on Mental nity settings also provide greater opportunities for
Health by the Joint Commission on Mental Illness clinicians to work collaboratively with patients
and Health by Kenneth E. Appel and Leo H. and their families and to provide individually
Bartemeier.” American Sociological Review, v.27/1 tailored care. Since the closure of asylums and
(1962). the associated reduction of beds, hospitalization
has been used as a last resort—only for the most
seriously ill and those considered most at risk. In
mental health practice, risk refers to an individu-
al’s vulnerability to self-harm or self-neglect and
Community Psychiatry his or her likelihood of inflicting violence on oth-
ers as a result of mental disturbance.
Following radical policy reforms from the 1970s With the shift from asylum to community care,
onward, community-based mental health ser- responsibility for the management of people with
vices were established in the United States, Can- mental illnesses was decentralized from a single
ada, the United Kingdom (UK), Australia, New service type to a range of different service types
Zealand, and western European countries. The and was accompanied by increasingly complex
development of these services marked a decisive administration. Although variations exist in the
change in the social arrangements for manag- organization of community mental health ser-
ing psychiatric disorder. Previously, large-scale vices, systems of care typically comprise commu-
stand-alone psychiatric hospitals such as mental nity mental health centers, primary health care
institutions or asylums had provided most of the settings, domiciliary services, specialist teams,
care and treatment for people with severe men- residential and day care services, informal care
tal disorders. Policies of deinstitutionalization by family and friends, and acute inpatient units.
aimed to shift psychiatric care out of the isola- The breadth of services is designed to meet the
tion of the institutions and reorganize it as part diverse needs and circumstances of different
of mainstream health services. This was to enable groups of patients, defined primarily in terms of
improvements in the quality and accessibility of their clinical needs and stage in the life course; for
care, open services to scrutiny and accountability, example, early intervention programs, acute care,
and reduce the stigma associated with mental ill- continuing care, and aged care. In theory, service
ness. Despite significant reforms in service design systems provide comprehensive and integrated
and government commitment to protecting the care. The intention is that patients be admitted,
human rights of people with mental disorders, discharged, and transferred across the relevant
142 Community Psychiatry

programs, according to their individual needs, 1970s by Mary Ann Test and Len Stein. These
without falling through the cracks. Case manag- teams provide intensive extended hours, home-
ers are charged with coordinating these processes based case management to adult patients with
in an effort to achieve seamless transitions and severe and persistent mental illnesses who would
continuity of care. otherwise require admission to a hospital. They
operate seven days per week, often for 12 hours
Specialist Community Teams per day; patients can be visited at least daily; and
The specialist teams are generally regarded as the the emphasis is on medication supervision, crisis
most innovative across the spectrum of commu- intervention, and support for family and caregiv-
nity-based services. These multidisciplinary teams ers. Service evaluations have shown that, com-
have very specific functions to cater to the needs pared with standard community care, patients
of particular groups of patients. Broadly, three managed by PACT teams are less likely to be
types of specialized teams have been developed: admitted to a hospital, are more likely to have
assertive outreach, crisis resolution and home shorter admissions, are more likely to remain
treatment, and early intervention. The assertive engaged in treatment, and achieve higher levels of
outreach teams, which were established first, clinical and social functioning.
have been researched more extensively and have Crisis resolution and home treatment teams
a stronger evidence base than the other function- have been operating in Australia and the United
alized teams. Known as PACT teams (Program States since the 1980s. These teams are known by
for Assertive Community Treatment), they were a variety of names, including crisis assessment and
originally set up in Madison, Wisconsin, in the treatment team (CATT), psychiatric emergency

Psychosocial workers (left) with the International Rescue Committee (IRC) talk with the IRC’s gender-based violence program
coordinator (right) on June 11, 2010. The IRC helps rape survivors in South Kivu, Democratic Republic of the Congo, access the services
they need to begin restoring their physical and mental health. Specialist teams, which have very specific functions to cater to the needs
of particular groups of patients, are some of the most innovative across the spectrum of community-based psychiatric services.
 Community Psychiatry 143

team (PET), and crisis resolution and home treat- delivering a youth-friendly service, working col-
ment (CR/HT) teams. They provide an alternative laboratively with other services, and providing
to hospital care for adults experiencing an acute an effective transfer of care to an adult psychiat-
mental health crisis. The emphasis is on acute men- ric service following the designated intervention
tal health problems; interventions are time limited, period, which is usually between 18 months and
often to several weeks rather than months; and three years. Although evaluations of early inter-
patients are linked into continuing care services vention services are limited in number, recent stud-
once their crises have resolved. In most service ies from the United Kingdom have shown lower
models, these teams are available 24 hours per rates of relapse and rehospitalization, higher levels
day, seven days per week, enabling out-of-hours of caregiver and patient satisfaction, and greater
and emergency responses along the lines of gen- improvements in clinical functioning and adher-
eral hospital emergency services. Depending on the ence to treatment following discharge compared
person’s level of need, home visits may be made up with standard psychiatric care.
to several times per day. These teams also have a
critical role as gatekeeper to the local mental health Assessments of Community Care
inpatient unit. If hospitalization is required, the In their sociological study of mental health and
team is often involved in discharge planning and illness, Anne Rogers and David Pilgrim explain
in providing intensive home-based care to facilitate that the old asylums had provided a “total solu-
early discharge from the hospital. tion” for the social problems caused by mentally
Service demands on crisis resolution and home disordered behavior:
treatment teams are often very high. Referrals that
do not fit neatly into the team’s inclusion criteria Whatever disadvantages the old asylum system
can generate boundary disputes with patients, had for their inmates (by creating a form of dis-
caregivers, and other service providers. Com- abling apartheid) . . . the sociopolitical benefit
plaints arising from such disputes have been well for others was that a group of nonconformist,
represented in the media and official inquiries into troublesome, worrisome and economically inef-
the quality of mental health services. Although less ficient people were . . . “warehoused” out of the
well evaluated than assertive outreach teams, there sight and mind of the majority of free citizens.
is some evidence that these teams are successful in
averting hospital admissions, reducing the length In effect, three interrelated functions of care, con-
of admissions, and retaining patients in treatment. trol, and accommodation were provided in one
Early intervention teams have been developed location. While these functions fulfilled societal
in the United States, Australia, and Scandinavia needs for social and moral order and economic
since the 1990s. These teams provide intensive productivity, the contemporary context of com-
case management of young people who are expe- munity care means that each function has to be
riencing their first episode of psychosis. The aim considered as a separate policy area. Rogers and
is to reduce the length of time between onset of Pilgrim thus surmise that ongoing debates over
symptoms and treatment, since research suggests the inadequacies of community care arise largely
that long periods of untreated psychosis are asso- because “critics . . . have complained that govern-
ciated with a poorer prognosis. Moreover, the ment has still not delivered the correct blend of
needs of this group of patients are seen as distinct, care, control and accommodation.”
given that they must negotiate the transition from In the early stages of asylum closure, the trans-
adolescence to adulthood at the same time as man- fer of resources from the hospitals to the commu-
aging and coming to terms with the early phases nity was very slow to take effect, and often was
of a psychotic illness. These services provide poorly coordinated. This created a range of seri-
home treatment, specialist inpatient units, coun- ous problems, including homelessness, the growth
seling, and partnership links with schools, youth of substandard boarding house industries, and an
services, welfare agencies, and general health ser- influx of people with mental disorders into the
vices. Many services are available for extended prison population. Homelessness was a particular
hours, seven days per week. The emphasis is on problem in the United States with the rapid closure
144 Community Psychiatry

of mental hospital beds and limited public wel- remains a key component of service provision,
fare. Surveys from the 1980s in the United States managed through community treatment orders
estimated that between 20 and 50 percent of the (CTOs) and acute inpatient units. A CTO is a
homeless population were suffering from “severe legal order made on behalf of individuals by
and persistent mental illness.” In Australia, the their psychiatrists to enforce treatment outside
prevalence of psychiatric disorders among pris- the confines of the hospital. Conditions of an
oners is more than double the rate in the general order include regular attendance at a nominated
community. In these ways, the problem of how to public mental health service and adherence to a
deal with troubled and troubling individuals has prescribed medication regime. Failure to comply
been displaced to other sectors of society. with such conditions results in involuntary admis-
New responsibilities have been devolved to sion to a psychiatric inpatient unit.
families, who are now key participants in the The function of the inpatient unit is to tem-
provision of care. Their tasks entail liaising with porarily detain and segregate high-risk individu-
and making referrals to various programs; pro- als who cannot be managed in the community.
viding physical, emotional, and financial sup- Reductions in psychiatric inpatient beds, together
port, sometimes on a daily basis; and monitoring with continuing high demand for beds, has pro-
risks and administering medication. Families have duced a revolving door of hospital admissions,
also borne the brunt of inadequate service provi- where some patients are discharged while still
sion, including poorly integrated care, and a seri- unwell to make way for others, only to be sub-
ous shortage of suitable housing for people with sequently readmitted because their discharge has
severe mental illnesses. In practice, as some critics failed. With concentrations of high-risk individu-
have suggested, the theory of care in the commu- als, acute inpatient units have become unsafe for
nity often becomes care by the community. both patients and staff, and the use of security
Concerns about public safety are prominent in guards, closed circuit television, and locked areas
the context of community care. Compared with have been interpreted by some critics as forms of
the regulated environment of the institution, reinstitutionalization.
community settings generate a range of new and With a stronger emphasis on recovery over the
intensified risks to workers, family caregivers, past decade, new forms of community care are
patients, and the public. As a consequence, the emerging. These focus explicitly on service users’
assessment and management of risk has become experiences and knowledge and include peer sup-
central to the daily work of mental health pro- port services, user-led crisis houses and commu-
fessionals. Risk assessment screens and checklists nity inpatient units, telephone counseling services,
are routinely conducted to identify and monitor and electronic self-help programs.
signs and levels of risk posed by patients, usually
classified as low, moderate, or high risk. While Anne-Maree Sawyer
diagnosis and treatment remain important, the La Trobe University
assessment of risk demands a different order of
knowledge. It concerns what must be done in See Also: Asylums; Dangerousness;
terms of formulating a management plan should Deinstitutionalization; Homelessness.
the patient be hospitalized or followed up by
the crisis team. This means increased individual Further Readings
responsibility for clinicians and a shift toward Lester, Helen and Jon Glasby. Mental Health Policy
generically oriented roles, away from the strictly and Practice. New York: Palgrave Macmillan,
defined disciplinary boundaries operating in the 2010.
institution. Social control was formerly exercised Rogers, Anne and David Pilgrim. A Sociology of
via confinement in an institution, whereas today, Mental Health and Illness. Maidenhead, UK: Open
risk management practices and procedures func- University Press, 2010.
tion as new technologies of social control. Rose, Nikolas. “Governing Risky Individuals: The
Despite the libertarian ideologies of commu- Role of Psychiatry in New Regimes of Control.”
nity care, involuntary containment and treatment Psychiatry, Psychology and Law, v.5/2 (1998).
 Competency and Credibility 145

Schutt, Russell and Stephen Goldfinger. Homelessness, competency evaluations are completed to ensure
Housing, and Mental Illness. Cambridge, MA: that an individual’s right to make decisions is
Harvard University Press, 2011. not removed unless warranted. Civil competency
White, Paul and Harvey Whiteford. “Prisons: Mental issues include competency to consent to medi-
Health Institutions of the 21st Century?” Medical cal or health interventions, consent and partici-
Journal of Australia, v.185/6 (2006). pate in research, care for self and property, and
make a contract or will. In civil cases, if an indi-
vidual is deemed incompetent, a guardian is often
appointed to make decisions for that individual.
Mental health professionals are often asked
Competency and to give opinions on an individual’s competency
to waive Miranda rights (which occur at time
Credibility of arrest) and the individual’s ability to stand
trial. Competency evaluations normally include
Individuals who come into contact with the legal assessment of intellectual functioning and psy-
system are more likely to have a mental illness chopathology. Assessments of mental status,
than those who do not. Common mental illnesses dementia, and adaptive functioning are assessed
seen in the legal system include conduct disorder, as needed. History of previous mental health
antisocial personality disorder, substance abuse treatment and past functioning is also evaluated.
and dependence, attention deficit hyperactivity Finally, specific standardized measures of legal
disorder (ADHD), mood disorders, and thought competency are administered, such as the Com-
disorders. The courts must determine whether or petency Assessment Instrument and the MacAr-
not the individual, because of impaired mental thur Competency Assessment Tool–Criminal
functioning, is able to participate in the legal pro- Adjudication. A comprehensive assessment of
cess. Mental health professionals are often called competency is necessary because severe mental
upon to determine an individual’s competency disorders or unusual behavior do not always
and credibility. equate to incompetency, and incompetency in
Competency does not have a unified defini- one area does not necessarily indicate incompe-
tion, since the term is used in mental health set- tency in other areas.
tings and legal settings with varying definitions. In the United States, competency evaluations
Generally, competency refers to a person’s ability are considered in 15 percent of cases. Between 2
to complete tasks of daily living and to function and 8 percent of cases are actually referred for
independently (e.g., maintain personal hygiene, a competency evaluation, and only 20 percent
keep a healthy diet, and manage finances). In legal of those are found to be incompetent. Individu-
settings, competency is usually defined as the per- als who are considered incompetent to stand trial
son’s ability to rationally understand the court are more often male with a previous arrest his-
process, participate appropriately in the court tory, with education just over 10 years, unem-
process, and appropriately work with defense ployed, diagnosed with a thought disorder (e.g.,
counsel. Competency is distinct from criminal schizophrenia, schizoaffective disorder, and delu-
responsibility, which is the individual’s ability to sional disorder), and have a history of psychiatric
understand that their actions were illegal. While hospitalization.
a person may not be criminally responsible, he If an individual is considered incompetent to
or she may still be competent to stand trial, and stand trial, the individual is usually involuntarily
vice versa. committed to a mental hospital with the goal
of stabilizing the individual and restoring com-
Criminal Cases petence. Competency evaluations will continue
In criminal cases, competency evaluations are at regular intervals. Once competency has been
completed to protect individuals from making restored, the individual will stand trial. If compe-
decisions that may bring harm to themselves or tency is not restored, placement in a mental facil-
others and to ensure due process. In civil cases, ity may continue indefinitely.
146 Compulsory Treatment

Credibility is the extent to which an individual’s In the United States, a person’s right to bodily
testimony is perceived as truthful and reliable by integrity and freedom of movement are among
the judge and jury. Defendants who must testify the liberty interests protected by the U.S. Consti-
in their defense must be not only competent but tution. Federal law governs the substantive and
credible. Individuals with mental disorders are procedural protections that must be in place in
often not seen as credible by the judge and jury. order to deprive a person of these rights. The
Poor personal hygiene or unusual mannerisms state’s interest in providing treatment derives
and speech patterns often decrease perceptions from its power to protect those who cannot pro-
of credibility. In addition, because of ignorance tect or care for themselves and its power to main-
or prejudice, those with mental illness are often tain safety and order in society.
perceived as less credible because of the mental Involuntary admissions to psychiatric treat-
illness. ment facilities in the United States must be justi-
fied by exceptional circumstances, such as danger
April Bradley to self or others. Admissions are time limited and
Andrew R. Gerde are subject to periodic court review. A nonmedical
University of North Dakota decision maker is critical to the required process.
People involuntarily hospitalized are not merely
See Also: Courts; Insanity Defense; Law and Mental detained; they have a right to treatment to secure
Illness. their early release. These decisions are made in
state courts, pursuant to laws that vary somewhat
Further Readings from state to state. Even when a parent, physi-
Greene, Edie, Kirk Heilbrun, William Fortune, and cian, friend, or spouse initiates a civil commit-
Michael Nietzel. Psychology and the Legal System. ment proceeding, the state takes action to detain
6th ed. Belmont, CA: Thomson Wadsworth, 2007. the person. Even emergency detentions initiated
Peled, M., G. Iarocci, and D. A. Connolly. by police or psychiatrists are subject to relatively
“Eyewitness Testimony and Perceived Credibility prompt review.
of Youth With Mild Intellectual Disability.” The potential for abuse within institutional set-
Journal of Intellectual Disability Research, v.48/7 tings is genuine. At a minimum, people detained
(2004). in psychiatric hospitals are subject to continu-
Zapf, Patricia, Gianni Pirelli, and William Gottdiener. ous observation and a range of coercive or intru-
“A Meta-Analytic Review of Competency to Stand sive practices. For example, staff may check on
Trial Research.” Psychology, Public Policy, and patients who are showering to see if they are lath-
Law, v.17/1 (2011). ered with soap. These institutional practices may
be justified. They are meant to prevent self-harm
or promote simple hygiene. The institution is lia-
ble for the safety of people who are at high risk,
and must act in a diligent fashion.
Compulsory Treatment Even within the hospital setting, a person will
ordinarily be permitted to refuse specific forms of
Compulsory treatment is one of the most con- treatment. A majority of states consider all patients,
troversial subjects connected to mental illness. even mentally ill patients hospitalized involuntarily,
Rarely are the interests of the person to receive competent to make personal decisions, including
treatment more at odds with the interests of oth- whether to take psychotropic medications, unless
ers in society. People who face being medicated, they are specifically found legally incompetent by
injected, or detained against their will see nor- a court of law. Most states provide that an invol-
mal considerations of bodily integrity, freedom of untary patient’s refusal of medications may be
movement, even freedom of thought swept away. overridden only after a court hearing. Many states
Others see value in preventing suffering, suicide, allow a legally appointed guardian to consent for
or violence, or see greater merit in restoring a the patient. A small number of states specifically
person to good health. recognize the right of voluntary patients to refuse
 Conduct, Unwanted 147

medications. However, in acute emergency situa- who were interviewed supported involuntary out-
tions, staff may administer fast-acting medication patient treatment as a way to make sure that peo-
to keep patients from harming themselves or oth- ple received needed services, but many felt that
ers, even if the patient objects. the services offered in their communities were
inadequate for making involuntary outpatient
The Americans with Disabilities Act treatment work.
In 1999, the U.S. Supreme Court held that the Court-ordered treatment can be a mere formal-
unjustified institutionalization of people with ity if treatment systems do not follow through.
disabilities is a form of unlawful discrimination For example, Seung Hui Cho never received the
under the Americans with Disabilities Act. This treatment ordered by a judge who declared him
decision, which required states to place patients dangerously mentally ill before his 2007 rampage
in the least restrictive setting, suggests that in at Virginia Tech. In the aftermath of the tragedy,
some cases, mandatory treatment may take place the Washington Post reported the following:
in community as opposed to hospital settings.
Various advocacy groups, most notably the Treat- Special justices who oversee hearings such as
ment Advocacy Center, have promoted legislation the one for Cho said they know that some
to permit courts to order mandatory administra- people they have ordered into treatment have
tion of medication on an outpatient basis. Most not gotten it. They find out when the person
states permit courts to order some form of outpa- “does something crazy again,” in the words of
tient treatment. one justice—when they are brought back into
Opponents of these laws say that there is no evi- court because they are considered in imminent
dence that outpatient commitment improves pub- danger of harming themselves or others.
lic safety. They contend that a better-organized
system of voluntary services is more effective. For Paul Komarek
example, according to the Judge David L. Bazelon Independent Scholar
Center for Mental Health Law, the evidence is
strong that building a responsive mental health See Also: Asylums; Courts; Jails and Prisons; Patient
system with services like mobile crisis teams, Rights.
assertive community treatment teams (ACT), and
supported housing is the best strategy for ensur- Further Readings
ing that people receive needed treatment. When RAND. “Does Involuntary Outpatient Treatment
people are dangerous because of mental illnesses, Work?” (2000). http://www.rand.org/pubs/research
they should be hospitalized. When safety is not an _briefs/RB4537/index1.html (Accessed November
issue, treatment should be voluntary because this 2012).
approach holds the best promise for long-term Schulte, Brigid and Chris L. Jenkins. “Cho Didn’t
engagement in treatment. Failure to engage people Get Court-Ordered Treatment.” Washington Post
with serious mental illnesses is a service problem, (May 7, 2007).
not a legal problem. Outpatient commitment is Treatment Advocacy Center. Assisted Psychiatric
not a quick-fix that can overcome the inadequacies Treatment Inpatient and Outpatient Standards by
of under-resourced and underperforming mental State. Arlington, VA: Treatment Advocacy Center,
health systems. Coercion, even with judicial sanc- 2011.
tion, is not a substitute for quality services.
In 2000, RAND Corporation researchers inter-
viewed stakeholders in eight states to gauge the
effectiveness of outpatient commitment laws.
RAND’s researchers found no evidence that a Conduct, Unwanted
court order is necessary to achieve compliance and
good outcomes. Neither did a court order have Most often in the medical context, abnormalities
any independent effect on outcomes. The attor- are categorically viewed. Diagnostic categories
neys, behavioral health officials, and psychiatrists or schemas are used to describe and define the
148 Conduct, Unwanted

clinical impressions of patient conditions held by a client-centered approach to mental health care.
physicians and other mental health practitioners. With this perspective of personal control comes
Categorical definition of mental illness occurs by likelihood of human agency for change.
grouping symptoms that are thought to be related One important distinction in this categorical
to one another across a number of factors or framework is the consideration that unwanted
functional domains. As such, many of those diag- conduct is a socially and/or culturally defined
nostic paradigms are derived by symptoms that mechanism. Unlike the many neurobiological
are believed to be related to problems with neuro- links to other disorders that arise when consid-
biological systems. ering manifestation of mood disorders, somatic
disorders, or psychotic disorders, the features
Human Agency Versus Neurobiological Links of unwanted conduct are impacted by the social
For instance, depression and anxiety are mood- and cultural lenses through which an individual’s
related disorders that have systemic links to behavior is observed and ultimately defined and
brain chemistry and activity. Many of the social, described. This makes a clear distinction between
behavioral, and even emotional difficulties that illnesses that impact the individual via personal
often arise within the context of those disorders experiences and social/behavioral expressions
are believed to be by-products of the neurobio- that impact others via engagement in socially and
logical processes common to those experiences. culturally normative settings.
In other contexts, however, those difficulties may Considering social manifestations of the prob-
not be shown to be linked to any substantiated lems associated with unwanted conduct, the
causal impact. In that context, practitioners are explorations of social norms, interpersonal rela-
likely to view those social/behavioral issues as tionships, and social institutions are relevant. Fit-
unwanted conduct that carries a denotation of ting into one’s social environment without stress
individual action, rather than a link to biologi- or hassle is of utmost importance for productiv-
cal influence. Thus, the concept of unwanted con- ity, belongingness, social harmony, and ultimately,
duct differs from other mental health labels and self-actualization. The act of fitting the social mold
concerns in that it describes the human agency in those situations, however, is related to one’s abil-
of action rather than the neurobiological links to ity to demonstrate behavioral and social choices
which other problems may be medically attrib- that are compatible with overall social desirability.
uted. These are the mental health conditions and Societies and cultures train our behaviors
symptoms that are categorically described by the through social norms. People live and operate
behaviors in which individuals engage, choices under strict assumptions of how people should
that they make, or patterns of interaction that behave, the social consequences to disrupting
they perpetuate. They are the characteristics of that norm, and how people feel about them-
mental health concerns that are directly related selves when they do and do not follow socially
to what can be understood, predicted, controlled, determined rules. People tend to quickly identify
and manipulated via behavioral means. those who do not act in accordance with those
The term unwanted conduct generally signi- implications of what society dictates is desired
fies that people who experience this concern do behavior and/or social engagement. Those who
not present themselves as having an illness or a live free from social constraint tend to stand out
disease process but rather a dysfunction. This in society as nonconformists. This is the general
viewpoint of dysfunction carries an expectation caveat about identifying and defining unwanted
that correction of this atypical behavior pattern is conduct. Via a perception-based understanding of
possible. Treatment and change are often viewed people’s behaviors in general, care must be taken
as viable, because the root issue with this concern to avoid overgeneralization of this concept, as
lies with social and behavioral characteristics that even well-intentioned behavior and socialization
are far more within the individual’s direct con- can be branded incompatible with social norms.
trol than medical or biological links, as disease When evaluating conduct as unwanted, it is
models tend to project. Therefore, this categorical important to do so through the lens of the cul-
vantage point is much more widely accepted as ture in which it is observed. Though unwanted
 Congo, Democratic Republic of the 149

conduct may create difficult obstacles for the indi- See Also: Antisocial Behavior; Deviance; “Normal:”
viduals who exhibit them, it may not, in fact, be Definitions and Controversy; Stigma.
indicative of mental illness. Religious traditions,
for example, may require a person to repeatedly Further Readings
wash themselves on a scheduled basis, a behavior Boden, J. M. “Risk Factors for Conduct Disorder
that, without observation of the religious context, and Oppositional/Defiant Disorder: Evidence
may appear symptomatic of obsessive-compulsive From a New Zealand Birth Cohort.” Journal of
disorder (OCD) or obsessive-compulsive person- the American Academy of Child and Adolescent
ality disorder (OCPD). In this distinction, culture Psychiatry, v.49/11 (2010).
is influencing behavior, rather than biology or Leary, D. E. Metaphors in the History of Psychology.
neurology. New York: Cambridge University Press, 1990.
The way in which conduct is perceived is an Sarbin, T. R. Narrative Psychology: The Storied
important aspect when attempting to understand Nature of Human Conduct. Westport, CT:
unwanted conduct from a cultural perspective. Praeger, 1986.
An early example of such unwanted conduct in Weiner, B. Judgments of Responsibility: A Foundation
early American history is exemplified in the perse- for a Theory of Social Conduct. New York:
cution of civilians during the Salem Witch Trials, Guilford Press, 1995.
during which behavior that was thought of as dif-
ferent or undesirable was branded as witchcraft
and punished by death. In these cases, unwanted
conduct was classified by behaviors that did not
fit the Puritanical social norms of 17th-century Congo, Democratic
New England, behaviors that modern-day Ameri-
cans may simply refer to as benign eccentricities. Republic of the
While some mental health concerns can be
categorized as illness based, many recognizable The Democratic Republic of the Congo (DRC) is
issues that are dealt with as treatment issues can a land-locked country in central Africa, overlap-
be easily described through the lens of unwanted ping the equator. Civilization in the DRC dates
conduct. When an individual has not yet con- back to Bantu-speaking tribes from west Africa
formed to the expectations and guidelines of a who settled in the region around 2000 b.c.e. In
particular cultural group, social situation, or 1885, as part of the Berlin Conference, King Leo-
functional behavior routine, beliefs of maladap- pold II of Belgium was proclaimed sovereign ruler
tiveness may apply. Oftentimes, not operat- over Congo, which was renamed the Congo Free
ing within the well-defined structure of a social State (later renamed the Belgian Congo). The Bel-
norm, behavior and socialization can begin to gian Congo gained independence in 1960 as the
appear odd or stereotyped to others but not yet Republic of Congo. For many years to follow, the
signal a disorder or an illness. Outside the con- Congo was embroiled in factional fighting and
text of the disease model of describing—and dif- war and power shifts, ultimately resulting in a
ferentiating between—mental illnesses, behaviors change of name to Zaire. In the 1990s, the First
that pose threat to order and predictability are Congo War spread from Rwanda to Zaire (1996–
often designated unwanted conduct. Rather than 97) and gained international notoriety for human
a diagnostic model, this mental health phenom- atrocities and violence. President Laurent Kabila
enon is one of description and comprehension. It soon changed the name of the country from Zaire
is a way of considering behavior and socializa- to the DRC. Although a peace accord was signed
tion that depart from established norms. in 2003, conflict and human rights abuses have
continued in eastern DRC, producing many phys-
Russell Vaden ical and emotional casualties of war.
University of Wisconsin, La Crosse In the DRC, a number of contextual and cul-
Steven Arenz tural influences impact the likelihood and sever-
Winona State University ity of mood and anxiety disorders. Perhaps the
150 Congo, Democratic Republic of the

most pervasive influence on mental health within and separation of family members, increased psy-
the DRC is violence and armed conflict in the chological distress and suffering is increased and
eastern part of the country, dating back to 1996. normalized.
Many individuals living in the eastern DRC have Mental health policy and funding has remained
experienced forced displacement because of the disparate for decades in the DRC. Formal care is
conflict, violence, and nonexistent health care, scarce, with an approximate 1:1,000,000 ratio
with a rise in the rate of infectious disease (most of mental health providers to patients, and very
commonly cholera). Approximately 95 percent few clinics (mostly in the capital). Formal care
of the population have exposure to some form of is costly and focuses primarily on severe mental
trauma, 25 to 41 percent meet criteria for depres- illness and neuropsychiatric conditions. Nongov-
sion, and 42 to 52 percent meet criteria for post- ernmental organizations (NGOs) provide some
traumatic stress disorder (PTSD). In this psycho- basic mental health care, and when combined
logical context, illicit substance use and abuse are with the function of the family and the impor-
common. tant role of religion, serve as a buffer to remedi-
Sexual violence against women continues as a ate the impact of ongoing social distress on the
tool of war and produces many negative psychi- individual. Westernized approaches to the con-
atric consequences. Because perpetrators often ceptualization of symptoms (stomach pains, lack
include militia members but also peacekeepers, of inner peace) and treatment of mental disorders
family members, and close acquaintances, fre- in the DRC by NGOs has been questioned by
quent symptoms of victims exposed to sexual some social scientists, though a limited amount
assault and rape include diminished trust, mood of research is under way to evaluate efficacy of
disturbance including depression, memory and Westernized techniques in the management of
cognitive difficulties, avoidance, anger, anxiety, psychopathology in the DRC.
social and interpersonal problems, sexual and
intimate partner difficulties, suicidal tendencies, Christopher Edwards
and alcohol and substance abuse. Up to 20 per- Sarah M. Wilson
cent of men also report being victimized by rape. Eve S. Puffer
Intimate partner violence (IPV) is the most com- Duke University
mon source of gender-based aggression, affecting
nearly a quarter of women both within and out- See Also: Violence; War; Women.
side conflict regions.
Compounding violence, chronic environmen- Further Readings
tal and psychosocial stressors like poverty, poor Bass, J., S. Murray, J. Annan, D. Kaysen, S.
nutrition, historical gender inequalities, burden Griffiths, J. Jinor, L. Murray, and P. Bolton.
from human immunodeficiency virus (HIV) and “Using Cognitive Processing Therapy (CPT) to
other infectious diseases, and dislocated and Heal the Mind: Results From a Randomized
altered family dynamics increase potential for Controlled Trial for Sexual Violence in South Kivu,
negative psychiatric outcomes. The family sys- Democratic Republic of Congo.” Paper presented
tem is central to life in the DRC, with empha- at the International Society for Traumatic Stress
sis placed on the immediate and extended family Studies, Los Angeles, November 2, 2012.
for social and economic support. Family support Peterman, A., T. Palermo, and C. Bredenkamp.
is integral to the mental health and stress cop- “Estimates and Determinants of Sexual Violence
ing system and serves to insulate the individual Against Women in the Democratic Republic of
from many of the comorbidities of trauma. The Congo.” American Journal of Public Health,
important role of the family in coping may par- v.101/6 (2011).
tially explain the significant psychological impact World Health Organization. “Mental Health Atlas
of physical displacement because of war and the 2011—Democratic Republic of the Congo.”
escalated rates of psychopathology among those Project Atlas: Resources for Mental Health. http://
who are disenfranchised from family. With war www.who.int/mental_health/evidence/atlas/en
and disease leading to many orphaned children (Accessed April 2013).
 Consumer-Survivor Movement 151

Consumer-Survivor animating ideas. The first is that individuals who

receive mental health care should have a meaning-
Movement ful role in defining the services that they receive; the
second is that the stigma associated with mental
A vibrant social movement, variously labeled the illness should be reduced or eliminated. There are
mental health consumer movement, the mental a variety of movement organizations active at the
health ex-patient movement, the mental health national, state, and local level in the United States.
survivor movement, and the antipsychiatry move- These organizations differ in the mix of former or
ment, has emerged over the past 40 years. The current patients, family members, and profession-
contemporary consumer-survivor movement has als in their staff and membership. Some organiza-
much earlier precursors—dating back to a 19th- tions focus more on advocacy in the policy arena,
century campaign against involuntary commit- whereas others focus more on self-help and mutual
ment by Elizabeth Packard, who had been the support. The movement has had a significant
victim of involuntary commitment to a mental impact in influencing policy changes and in gain-
asylum. The contemporary consumer-survivor ing an ongoing “place at the table” with respect to
movement has shared ideas, adherents, and other the planning and delivery of mental health services.
resources with a number of related movements, Ongoing challenges for the movement include
including the broader consumers’ movement, the internal cleavages, potential co-optation by gov-
women’s health movement, the disability rights ernment and by the pharmaceutical industry, and
movement, and the patients’ rights/health con- health care reform.
sumer movement. Part of having a role in one’s treatment is the
While there is considerable intellectual heteroge- right to refuse drugs or therapies. Thus, much of
neity within the movement, there are two central, the early focus of the movement was on eliminating

First Lady Rosalynn Carter (center) chairs a mental health hearing on January 17, 1978. Her interest in the stigma of mental health
was sparked during the 1966 presidential campaign, and since that time, she has been one of the nation’s most visible social
promoters of the rights of people with mental illnesses. The Carter Center Mental Health Program works to promote awareness about
mental health, inform public policy, achieve equity for mental health care, and reduce stigma and discrimination.
152 Consumer-Survivor Movement

or at least providing the right to refuse treatments strategies. Movement organizations have focused
that were seen as adverse, or that were associated on a number of policy changes at the federal and
with serious side effects—such as involuntary com- state level, including the Protection and Advo-
mitment, electroconvulsive treatment, and some cacy for Mentally Ill Individuals Act (1986), the
psychotropic medications. Over time, movement Americans with Disabilities Act (ADA; 1990,
organizations have come to focus more on advanc- amended in 2008), and the Paul Wellstone and
ing positive conceptions of treatment, often involv- Pete Domenici Mental Health Parity and Addic-
ing the development of an individualized treatment tion Equity Act (2008). A number of organiza-
plan that is tailored to the individual, integration of tions have pursued litigation strategies.
community support, and active consumer involve- For example, a 1999 decision by the U.S.
ment in shaping the plan. Supreme Court (Olmstead v. L.C.) found that
Efforts to reduce the stigma of mental illness state institutionalization of individuals with men-
have taken a number of forms. For example, many tal illness or intellectual disabilities, absent justifi-
in the movement have advanced the idea that cation, constitutes discrimination under the ADA.
symptoms of illness can be temporary and short- This decision has served as a basis for consumer
lived, with a strong expectation of full recovery, organizations to apply litigation strategies against
if appropriate treatment is provided. Others have state mental health authorities that continue to
disputed the reality of the concept of mental ill- rely on institutionalization of mental patients in
ness generally and specific psychiatric diagnoses lieu of other, less restrictive options.
in particular. This view, which is advanced by the Support groups and self-help organizations run
antipsychiatry or “mad liberation” movement, is by consumers or family members are a common
an argument that those whom society has defined organizational form, especially at the local level.
as mentally ill are in fact simply different and that The provision of services by and for consumers can
these differences should not serve as a basis for be seen as an advocacy strategy in that services can
discrimination. be delivered independently of conventional mental
health authorities in a manner that is consistent
Organization, Strategy, and Tactics with the ideology of movement adherents. Beyond
The movement includes a number of organiza- that, these organizations may serve an important
tions at the national level in the United States, political socialization function, potentially leading
including the National Alliance on Mental Illness, to involvement in activism.
National Mental Health Association, National
Association of Mental Patients, National Asso- Impact of the Movement
ciation of Mental Health Consumers, Mental Mobilization of the consumer-survivor move-
Health America, National Association for Rights ment has had an important impact on struc-
Protection and Advocacy, National Mental tural changes in mental health care in the United
Health Consumers Association, National Coali- States, including major federal policies. However,
tion for Mental Health Recovery, Antipsychia- some major structural changes in mental health
try Coalition, and MindFreedom International. care, such as deinstitutionalization, predated the
Some of these organizations also have state and/ contemporary movement and contributed to its
or local affiliates. In addition to these advocacy emergence and growth.
organizations, disability rights organizations at Consumers’ “place at the table” has increased.
the national and state level often focus in part on Consumer representation in planning and deci-
mental health issues and services. Some organi- sion making is now required of states in order to
zations largely consist of ex-patients and current qualify for the federal government’s major fund-
patients, others include family members of past ing initiatives in disability and mental illness.
or current patients, and others include profes- Many state mental health agencies now designate
sionals such as psychiatrists, social workers, and professional staff positions that must be filled by
mental health administrators. consumers. Consumers and their families have
A second key distinction is the extent to which played a growing role in writing official policy
organizations focus on advocacy or self-help documents, such as the 1999 surgeon general’s
 Costs of Mental Illness 153

report on mental health. Finally, there have been See Also: Human Rights; Mental Health America;
efforts to systematically include consumers in National Alliance on Mental Illness; Patient Activism;
research efforts, not just as subjects as in the past, Patient Rights.
but in helping define the important research ques-
tions, providing input on design and measures, Further Readings
and interpreting and disseminating results. Crossley, Nick. Contesting Psychiatry: Social
Cleavages within the movement create poten- Movements in Mental Health. New York:
tial barriers to unified political action. There are Routledge, 2006.
many such splits, but the most salient revolve Emerick, Robert. “Mad Liberation: The Sociology
around ideology; for example, organizations that of Knowledge and the Ultimate Civil Rights
advance a radical critique of the concept of men- Movement.” Journal of Mind and Behavior, v.17/2
tal illness and of psychiatry versus groups that (1996).
simply favor greater sensitivity to consumer needs Goldstrom, Ingrid, et al. “National Estimates for
and openness to consumer involvement in deliv- Mental Health Mutual Support Groups, Self-Help
ery of services. Organizations, and Consumer-Operated Services.”
A second challenge results from increased Administration and Policy in Mental Health
movement involvement in planning and decision Services Research, v.33/1 (2006).
making around the delivery of services. Some Tomes, Nancy. “The Patient as a Policy Factor: A
question whether this involvement—for example, Historical Case Study of the Consumer-Survivor
involvement of consumer organizations as direct Movement in Mental Health.” Health Affairs,
service providers—compromises the ability of v.25/3 (2006).
these organizations to serve as vigorous advocates
for their constituencies, which may require them
to take stands in conflict with those of govern-
mental mental health authorities that now pro-
vide a portion of their funding. Costs of Mental Illness
A third challenge stems from the relationship
between some of the consumer organizations and Like all health conditions, mental illness imposes
the pharmaceutical industry. For example, some costs on individuals and society. These costs
consumer organizations have accepted significant include the financial expenses of treating mental
grants from pharmaceutical companies—a prac- illness symptoms and restoring social functioning
tice that has been criticized, both inside and out- as well as the economic value lost when mental
side the movement, on the grounds that accept- disorders prevent full participation in the labor
ing such funds could co-opt organizations’ ability force or result in early death. Additional eco-
to take critical positions in relation to industry nomic and social burdens such as alienation from
practices. the community, increased levels of crime and dis-
Finally, trends in the organization and delivery order, and diminished quality of life for individu-
of mental health services, and health care more als, family members, and others are covered in
generally, may present important challenges for other articles in this volume.
the movement. One example is the increasing The cost implications of mental illness differ
emphasis on evidence-based practices in the deliv- from those of somatic conditions in a number
ery of mental health services. It is unclear whether of ways, the most important of which may be
this emphasis creates new opportunities for con- that diagnosis of many mental disorders depends
sumer involvement in the definition of what con- partly on an individual’s inconsistent ability to
stitutes an evidence-based practice or reinforces perform certain cognitive tasks, develop social
the decision-making power of traditional mental skills, or exhibit behaviors that facilitate partici-
health authorities. pation in the labor force. Moreover, while identi-
fying causal directions between health status and
Mark Wolfson socioeconomic outcomes is inherently compli-
Wake Forest School of Medicine cated, it is especially difficult with mental health
154 Costs of Mental Illness

because financial hardships and macro-level eco- costs in six European countries are estimated to
nomic downturns may precipitate conditions such range from 0.4 percent (Germany) to 2.3 percent
as mood and anxiety disorders. (France).
Finally, mental illnesses are more likely than
many somatic illnesses to be underdiagnosed and Labor force opportunity costs. In addition to
undertreated. This implies greater “savings” in direct treatment expenses, mentally ill individu-
treatment expenses but also greater trade-offs in als also face opportunity costs in the labor mar-
productivity costs to the extent that higher utili- ket. Although there are differences in outcomes
zation of effective treatments could increase eco- by sex, age, and diagnosis, persons with mental
nomic activity. Given these complexities, much of disorders generally have lower employment rates
this review discusses the different approaches and and, in some cases, lower earnings than their
underlying concepts used to assess the costs of healthier peers. Diminished educational attain-
mental illness in commonly measured units—the ment, the inability to conform to behavioral
individual, the workplace, and society at-large. norms on the job or in job interviews, and the
stigma associated with a history of institutional-
Individual-Level Costs ization can all contribute to labor market diffi-
Mental illness imposes costs on individuals in the culties. Employed mentally ill persons may also
form of treatment expenses, labor force opportu- be more vulnerable to unemployment and work-
nities, and socioeconomic status. place pressures during economic downturns. To
the extent that psychological distress impairs
Treatment expenses. From the perspective of an job performance during an economic downturn,
individual with a mental illness, the most basic they may be among the first to be dismissed or,
costs are money spent out of their own pockets if retained, may not possess adequate psychologi-
for mental health treatments. These include pay- cal and emotional resources to deal with added
ments for psychiatric and psychological therapies, stress and heavier workloads during a downsiz-
psychopharmacological treatments, medical pro- ing. Observations that the utilization of mental
cedures (such as electroshock therapy), and stays health services goes up as national unemployment
in a hospital or a mental health facility. While the rates increase reveals the tenuous labor force posi-
overall expense of a mental health condition is a tion of the mentally ill, who may experience fewer
function of multiple factors, including the likeli- opportunity costs under better economic condi-
hood of diagnosis and subsequent treatment as tions. Assessing the costs of mental illness to indi-
well as the type and quantity of treatments uti- viduals, then, requires consideration of both their
lized under the dominant treatment model, cost- disorders and the larger socioeconomic context.
sharing arrangements between patients and insti- Moreover, there is a strong and consistent link
tutional payers (such as insurers and government between poor mental health and socioeconomic
health systems) mediate how much of the costs an status. Overall, the prevalence of mental disor-
individual bears. ders is highest among lower economic strata (with
For example, in the United States, individu- some variation by diagnosis). Yet debate remains
als with mental disorders incurred an average of over whether the emotional and material hard-
$2,039 in treatment expenses in 2009. Almost ships of poverty contribute to mental disorder or
$2 out of every $5 spent (nearly 40 percent) was whether social mobility processes favor concentra-
for medications, with the remaining expense split tions of the mentally ill in the lower strata and
in roughly equal shares among outpatient, inpa- the mentally healthy in the higher strata. This cre-
tient, and home care expenses. About 16 percent ates conceptual difficulties for the understanding
of overall mental disorder treatment expenses of costs; it makes little sense to attribute labor
were paid by patients themselves; the remainder force costs to mental disorders that are “caused”
were paid by private or government insurance. by poverty, low social mobility, and inequality in
In contrast, pharmaceuticals represented only the first place. Without a better understanding of
about 13 percent of European mental health care the inequality–mental health nexus—which likely
expenses in 2003, and total patient out-of-pocket varies by different types of disorders—correlations
 Costs of Mental Illness 155

between socioeconomic outcomes and mental ill- range from a low of 5 percent (China) to a high
ness must be viewed as necessary, but not suffi- of 31 percent (United States). A nationally repre-
cient, to identify labor force opportunity costs. sentative sample of U.S. workers in a 2007 study
However, several conceptual definitions of indicated that about 1 percent met the criteria for
mental disorders—including versions of the Diag- bipolar disorder, while 6 percent met the crite-
nostic and Statistical Manual of Mental Disorders ria for major depressive disorder. Other studies
(DSM)—require not only that individual thought of specific workplaces estimate the prevalence of
and behavioral patterns deviate from an ideal depression or anxiety disorders in the range of 7
standard in undesirable ways but also that these to 13 percent.
deviations result in impaired social functioning.
For working-age adults, an inability to find and Absence from work. Studies of mood and anxi-
hold a job due to chronic or periodic episodes ety disorders generally concur that compared to
of psychological distress (including early-onset workers with better mental health, mentally ill
disorders that contribute to lower educational workers are more likely to be absent from work or
attainment) or to difficulties with basic activi- to work fewer hours overall. For example, relative
ties of daily living (such as self-care, hygiene, or to people without depression, depressed work-
money management) would almost certainly be ers are about 1.5 times more likely to miss work
considered an impairment in social functioning. and are absent between 0.3 and 3.8 more days
In many cases, diminished labor force attach- per month (between 2 and 18 percent of expected
ments represent both signifiers and consequences work time). Moreover, absences increase with
of mental disorders. the severity of depressive symptoms. Depressed
employees may also be more likely to experience
Workplace Costs a work-related illness or accident and tend to have
Regardless of their mental health, most people par- longer-term spells of absence (such as two weeks
ticipate in the labor force at some point in their or more) when they are temporarily disabled
adult lives, if not earlier. Mental illness imposes from work because of a physical health condition.
costs on employers to the extent that (1) disorders This increases the expense of benefits payments to
are widespread among the employed population disabled workers as well as claims administration
and (2) workers with mental disorders have more and disability management expenses.
absences and worse job performance than oth- In principle, mentally ill workers’ absence costs
ers. In essence, employers are paying wages for a can be estimated as the product of a condition’s
certain amount of work (or “labor inputs”) at an prevalence in a workforce, its marginal impact on
expected level of quality but are receiving less of units of work time (such as days or hours), and
both. Given that mental illness diagnoses are often the average pay for that time unit. At the same
based partly on one’s ability to function in a work time, there is an important distinction between
environment, much of the research on mental dis- financial expenses and economic costs. Employ-
orders among the working population focuses on ers incur financial expenses when they pay wages
mood and anxiety disorders rather than highly dis- to workers who miss work due to a mental illness;
abling conditions such as schizophrenia. Depres- they are also assumed to suffer economic losses
sion is an extensively researched disorder. Com- equivalent to the absent employee’s daily output
pared to workers without depression, depressed (the value of which, according to the marginal
employees in the United States lost the equivalent product theory of labor, is assumed to be equal
of $31 billion in productive work time (in absences to their wages). Thus, an employer who pays no
and reduced job performance) in 2002. sick day wages and replaces absent workers with
temporary substitutes of equivalent quality would
Workforce mental illness prevalence. While not suffer neither financial nor economic losses, while
focusing specifically on employed persons, the an employer who pays sick day wages (even at a
World Health Organization (WHO) in 2004 esti- fractional rate, as is typical for temporary disabil-
mated that across 17 different countries, the life- ity absences) but does not utilize substitute work-
time prevalence of anxiety and mood disorders ers is penalized both financially and economically.
156 Costs of Mental Illness

Some economists argue that the cost of an absence monetizing absences; costs are equivalent to aver-
can exceed the unit price of wages to the extent age wages for the population-level duration of lost
that the absent employee works as part of team, productivity. Using this method, cost estimates of
performs time-sensitive tasks, and cannot be eas- presenteeism attributable to mental illness exceed
ily substituted by a worker with similar quali- the costs of mental illness–related absences by a
ties. In practice, then, employers’ cost burden of factor of about 1.9 to 5.1.
mental illness–related absences varies according Again, monetizing presenteeism may under- or
to how their work is structured, their pay scale, overstate the magnitude of mental illness–related
and their policies for handling situations where presenteeism. On one hand, employers typically
employees miss work due to illnesses. would not utilize a temporary substitute for a
worker who is at work but not performing, in
Presenteeism. In addition to absenteeism, esti- which case both expenses and opportunity costs
mates of the workplace costs of mental disorders are incurred. In this case, monetizing might under-
also tend to focus on the extent to which psycho- state costs, particularly if an organization’s levels of
logical symptoms (or side effects from treatments) overtime use and overstaffing of personnel partly
reduce a worker’s ability to perform well or be reflect the productivity losses associated with men-
productive while on the job. This phenomenon is tal disorders, which may be largely hidden from
referred to as “presenteeism.” Direct comparisons organizational leaders and supervisors. On the
of presenteeism among healthy and mentally ill other hand, assuming that mental illness–related
workers using quantifiable measures of employee- performance decrements occur uniformly on each
level output (such as telephone call volume or worked day—rather than only on those days on
items produced) are appropriate to a minority of which psychological distress would legitimately
occupations and are not widely available. In light warrant an absence—would likely overstate costs.
of this, most presenteeism research utilizes survey
instruments that ask workers retrospective ques- The work environment. Similar to the relation-
tions about their general job performance (usually ship between mental health and socioeconomic
during the prior week, month, or year) or about outcomes, the complex relationship between the
specific difficulties accomplishing work tasks and workplace context and mental disorders poses
correlates these responses to their history of men- additional challenges to understanding costs.
tal illness or to measures of psychological distress. High-tempo or hostile work environments, long
Regardless of the approach used, studies typi- hours, work overload, a poor work–life balance,
cally concur that workers with mental illnesses lack of control over one’s work pace and func-
have worse on-the-job performance and produc- tions, poorly defined work roles, or simply bad
tivity than other workers and that performance management can all contribute to high levels of
declines as the severity of symptoms increases. stress and symptoms of psychological distress.
Estimates of mental illness–related presenteeism This may increase the likelihood that a worker
are expressed in terms such as 10 to 20 percent of will present with a mental disorder or contribute
the productive time loss; seven to 10 annual days to absences and lower job performance. In either
of equivalent time loss; or 40 percent impairment case, it complicates efforts to attribute workplace
in the ability to perform mental-interpersonal costs to mental illnesses that are properly under-
tasks. Performance decrements associated with stood as a function of the workplace context.
depression are frequently found to be greater
than for those associated with physical health Societal Costs
conditions. A WHO report for 2004 estimated that world-
Nonetheless, interpreting these results as costs wide more than 151 million people suffered from
to employers remains a challenge. Cost estimates depression, 30 million suffered from bipolar dis-
are generally not executed when the focus is on order, and 26 million suffered from schizophrenia.
performance impairment for work-related tasks. Along with cardiovascular conditions, mental ill-
Studies that measure productive time loss typi- ness is a dominant contributor to the global eco-
cally take an approach similar to that used for nomic burden of disease, with worldwide costs of
 Costs of Mental Illness 157

over $2.5 trillion. Estimating the costs of mental of mental illness DALY was about $1.7 trillion
illness to society at-large brings together elements in 2010, more than twice the costs of treatments
of both individual and workplace perspectives. for mental disorders. Depression, bipolar disor-
Accordingly, it is important again to distinguish ders, and schizophrenia accounted for almost half
financial expenses for treatments from economic of all mental illness DALYs. Suicides (the most
costs such as foregone productivity. salient form of mental illness–related mortality)
accounted for almost 20 million DALYs, about
Treatment costs. Worldwide, mental health treat- 1 percent of all DALYs. Relative to other causes
ment expenses were over $800 billion in 2010. of DALYs, the productivity cost burden of men-
These estimates do not include the expenses tal illness is greater in high- and middle-income
associated with mental illnesses’ comorbid influ- countries than in the low-income countries.
ence on other chronic illnesses; about one-third
of medical conditions that present with somatic Conclusion
symptoms remain medically unexplained and are In addition to the most prominent contemporary
strongly associated with comorbid mood and perspectives on the costs of mental illness, there
anxiety disorders. Moreover, relative to popula- are smaller but nonetheless important factors,
tion size, mental health treatment expenses vary such as the economic burdens imposed on fami-
across countries according to the prevalence of lies of the mentally ill, the communities within
disorders and access to diagnosis and subsequent which they reside, and the institutions charged
care. Generally speaking, treatment-seeking after with educating, caring for, and, in some cases,
the onset of a mental disorder occurs sooner for segregating them from the rest of society. It
persons in wealthier countries than in poorer raises conceptual challenges to separating costs
countries. By itself, this would affect treatment from causes, yet one of the major limitations to
expenses, even if the prevalence of disorders and cost analysis is that values are always relative to
types of care were identical. Taxpayers bear treat- a hypothetical alternative based on the current
ment expenses to the extent that mental health paradigm for defining and identifying the prob-
care is publicly provided or paid for. However, lem. Costs themselves will change if currently
even when the payers are patients, providers, observed values remain constant but the feasible
employers, and insurers, these expenses represent alternative baseline changes. For example, high
costs to society in terms of foregone investment levels of underdiagnosis and under- or inade-
opportunities in other productive activities. quate treatment are partly what defines the cost
of mental disorders because the avoidable por-
Lost economic output. Societies bear economic tion of losses could change if better diagnostic
costs of mental disorders in much the same way and treatment practices emerge.
as employers; that is, mental illness lowers the The history of the psychological and psychiat-
collective capacity to engage in activities that ric professions demonstrates that mental illness
produce economic value, albeit value that is dis- is a fluid, socially defined concept. The defini-
tributed with differing degrees of equality. This tion of certain behavioral and thought patterns
reduced level of economic output is captured by as deviant and undesirable greatly determines the
the concept of “disability-adjusted life years” prevalence of mental illness. Because prevalence is
(DALY). A DALY is the equivalent of one year of arguably one of the most important factors affect-
life lost due to a health condition that limits a per- ing cost estimates, behavioral norms that narrow
son’s economic capacity or results in premature the scope of mental illness will necessarily lower
mortality, relative to how much they could do and cost estimates, while broader definitions will raise
how long they would be expected to live if they costs. Like mental illness itself, costs are therefore
were disease free. context specific.
The WHO estimates that mental illness accounts
for almost 200 million DALYs worldwide— Brian Gifford
about 6 percent of all DALYs for all communi- Kimberly Jinnett
cable and noncommunicable diseases. The costs Integrated Benefits Institute
158 Courts

See Also: Business and Workplace Issues; Depression; an exception to normal judicial processes through
Diagnosis in Cross-National Context; Economics; insanity defenses, competency hearings, or the
Employment; Health Insurance; International assessment of mitigating circumstances in sentenc-
Comparisons; Measuring Mental Health; Social ing. Over the past 20 years, the justice system has
Causation; Social Class; Stress; Unemployment; also seen the rise of problem-solving courts spe-
Work–Family Balance. cializing in mental health. Nevertheless, obstacles
remain in the equitable use of these options. Legal
Further Readings and medical understandings of mental problems
Aronsson, Gunnar, Klas Gustafsson, and Margareta have not been reconciled, and the general public
Dallner. “Sick But Yet at Work: An Empirical Study continues to believe that exceptions for mentally
of Sickness Presenteeism.” Journal of Epidemiology ill offenders fail to address its demand for retribu-
and Community Health, v.54 (2000). tion and incapacitation.
Bloom, D. E., E.T. Cafiero, and E. Jané-Lopis, Criminal law and the trial process assume that
et al. “The Global Economic Burden of Non- the offender is a rational actor, that is, the per-
Communicable Diseases.” Geneva: World son makes choices about behavior using free will.
Economic Forum, 2011. Thus, a crime is not simply a criminal act (actus
Ettner, Susan L., Richard G. Frank, and Ronald C. rea); the offender must intend (mens rea) for the
Kessler. “The Impact of Psychiatric Disorders on act to occur, either purposively or knowingly
Labor Market Outcomes.” Working Paper 5989. committing the act or allowing the act to happen
Cambridge, MA: National Bureau of Economic through negligence or recklessness. During the
Research, 1997. trial, the accused must be clearheaded enough to
Kessler, Ronald C., Hagop S. Akiskal, and Philip understand the charges and assist legal counsel
S. Wang. “The Prevalence and Effects of Mood in developing a defense. For the sentence to have
Disorders on Work Performance in a Nationally a deterrent effect on future offenses, the punish-
Representative Sample of U.S. Workers.” ment must fit the crime. The presence of a mental
American Journal of Psychiatry (July 18, 2007). illness can undermine the court’s ability to estab-
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC19 lish criminal intent, the defendant’s ability to par-
24724 (Accessed June 2013). ticipate fully in the trial, and the appropriateness
Kessler, Ronald C., Catherine Barber, and Howard of severe sentences. The adjustments that courts
G. Birnbaum, et al. “Depression in the Workplace: make in this situation are one of the most compli-
Effects on Short-Term Disability.” Health Affairs cated parts of criminal law, not simply because of
(September/October 1999). the patchwork of procedures resulting from the
Stewart, Walter F., Judith A. Ricci, and Elsbeth decentralized nature of the criminal justice sys-
Chee, et al. “Cost of Lost Productive Work Time tem, but also because of deep-seated philosophi-
Among U.S. Workers With Depression.” Journal of cal disagreements about if and how these excep-
American Medical Association, v.289/33 (2003). tions should be applied.
World Health Organization (WHO). “2008: The
Global Burden of Disease: 2004 Update.” Geneva: Insanity Defenses
WHO, 2008. Not guilty by reason of insanity (NGBI) remains
one of the most controversial verdicts that a
court can render. While the history of legal
exceptions for “madness” can be traced to the
ancient world, the antecedents for modern-day
Courts discussions emerged during the late medieval and
early modern period, with three justifications for
In the criminal justice system, mentally ill defen- the acquittal of the mentally ill: (1) the mentally
dants introduce complications, undermining the ill are like children, and thus do not have the
court’s ability to establish guilt and deliver pun- same culpability for their actions as sane adults;
ishment. Within the traditional courtroom, the (2) the mentally ill are like wild beasts, lacking
presence of these individuals is often handled as understanding or memory; and (3) the mentally
 Courts 159

ill cannot distinguish the difference between Durham’s replacement was the substantial
right and wrong. capacity test, proposed in 1962 by the Ameri-
The contemporary debate about the defini- can Law Institute in its Model Penal Code. This
tion of criminal insanity has its origins with the standard permitted the insanity defense if “men-
M’Naghten rule. The standard bears the name of tal disease or defect” damaged the ability of the
Daniel M’Naghten, whose assassination attempt offender to “appreciate the criminality [wrongful-
on Prime Minister Robert Peel in 1843 resulted ness] of his conduct or to conform his conduct
in the death of Edward Drummond, Peel’s secre- to the requirements of the law.” This rule kept
tary. M’Naghten defended himself with the claim Durham’s emphasis on the psychiatric definition
that Tory politics had driven him crazy, an argu- of mental health, but the language of apprecia-
ment that the jury accepted because of the lack tion and conformity placed behavioral limits on
of legal guidelines on what constituted insanity the insanity defense not specified in Durham.
and how to deal with it. While many experts were initially satisfied with
In response to an outraged Queen Victoria, the substantial capacity test, public perception
the House of Lords ordered the Supreme Court was that the revisions let offenders off too easily.
of Judicature to clarify the insanity defense. The In 1975, the Michigan Supreme Court ruled that
Lord Justices incorporated the early modern test a person acquitted by insanity could not be sub-
of the ability to distinguish between right and sequently detained for mental health treatment.
wrong, defining insanity as a state in which “the Criticism escalated in 1982, when the jury ren-
party accused was laboring under such a defect of dered a “not guilty by reason of insanity” verdict
reason, from disease of the mind, as not to know after John Hinckley, Jr.’s lawyer claimed that his
the nature and quality of the act he was doing; or attempted assassination of Ronald Reagan was
if he did know it, that he did not know he was the product of his client’s schizophrenia. Public
doing what was wrong.” demands elicited three major responses.
The M’Naghten rule gained many critics, A new verdict, guilty but mentally ill (GBMI),
though it remains highly influential, even into was developed. This decision was a compromise.
the present. One criticism regarded M’Naghten It satisfied the public demand for retribution but
as too narrowly focused on cognition (knowing allowed the judge to include mandatory treat-
right from wrong) to the exclusion of the possibil- ment in the sentence. Today, 12 states use a ver-
ity that emotions could override knowledge. This sion of GBMI.
concern was subsequently addressed through the Many states returned to the M’Naghten rule. In
irresistible impulse test—a simple modification of the United States, 21 states now incorporate the
M’Naghten recognizing the influence of uncon- M’Naghten rule, four more combine M’Naghten
trollable urges. with irresistible impulse, the substantial capacity
Later modifications of the insanity defense test is used by 21 states, and only one uses the
incorporated, as psychiatrists saw it, a more sci- Durham rule.
entific understanding of mental illness. Durham Congress passed the Insanity Defense Reform
v. United States (1954) focused exclusively on Act in 1984. The act invoked the substantial
“mental disease or mental defect.” The decision capacity defense as the standard in federal cases. It
avoided both the partitioning of the mind and also made the insanity plea an affirmative defense,
the moralistic tone of M’Naghten. The emphasis a position subsequently adopted by several states.
on “mental disease or mental defect” made the
expert testimony of mental health professionals Competency Hearings
essential in determining whether someone was One of the first problems with mentally ill defen-
not guilty by reason of insanity. Although the new dants is whether they are competent to stand
rule was well intentioned, critics complained that trial in the first place. English courts pondered
the Durham test conceded too much to psychia- the problem of competency as early as the 17th
trists and handcuffed a jury’s ability to rule on the century. The original concern stemmed from
facts of the case. Consequently, the rule has been defendants who refused to enter a plea—the ques-
rejected in at least 22 states. tion was whether this “standing mute” was a
160 Courts

malicious attempt to avoid trial or a “visitation emerged through later rulings. A court is free to
from God,” that is, a natural condition prevent- look at a broad range of behaviors in assessing
ing a person from participating. The latter were competency, though neither the presence of men-
deemed unfit for trial, though no consensus about tal illnesses such as schizophrenia and bipolar dis-
what constituted incompetency emerged. order nor a history of psychiatric hospitalization
The Burger court, noted for its efforts to clarify and treatment are in themselves proof of incom-
the civil rights of defendants, introduced standards petence. Mental health professionals now have
concerning competence to stand trial in Dusky v. a variety of standardized tests and unstructured
United States (1960). The decision is regarded methodologies that can be used to assist in their
as the first step toward establishing a constitu- determination. Furthermore, since Sell v. United
tional minimum with regard to competence, and States (2003), many courts permit the forced
although directed only at federal courts, influ- medication of defendants in order to make them
enced subsequent rulings of state courts as well. competent to stand trial, though this practice is
The Dusky test was tied to two questions: Does limited by medical appropriateness and is not
the defendant have the capacity to understand the without controversy. Sell theoretically limits situ-
criminal process as applied to the case at hand. ations in which medication can be forced, but the
And does the defendant have the ability to func- inadvertent effect of the ruling was to clarify those
tion during that process? situations in which medication could be forced.
Though the court did not designate how these Finally, mental illness or diminished capacity
criteria must be fulfilled, certain approaches have may be used as a mitigating factor in sentencing
whenever the judge has discretion over the pen-
alty. In states where determinate sentencing limits
options, the judge often opts to issue the minimum
sentence as specified by statute. Health conditions,
including any mental health issues, are routinely
collected as part of the Presentence Investiga-
tion Report. Many states accept the testimony of
mental health professionals and social workers as
sources of information, but they are not required
to do so constitutionally. Since Atkins v. Virginia
(2002), the use of the death penalty against men-
tally ill offenders has been banned as a “cruel and
unusual punishment” per the Eighth Amendment.

Mental Health Courts

An alternative means of handling mentally ill
defendants is the mental health court, which is
patterned after the success of drug courts. Early
efforts to create separate courts for mentally ill
defenders were random. In the early 1960s, the
Municipal Court of Chicago had an affiliation
with the Psychiatric Institute, and New York
City created a diversion program sending males
to Bellevue Hospital and females to Elmhurst.
In this court sketch printed in the Baltimore Sun, John Hinckley, Indianapolis had a mental health court during the
Jr.’s, mother responds to questions posed by her son’s lawyer, 1980s at Wishard Hospital. Interest in the mental
P. Vincent Fuller, during Hinckley’s 1982 trial for attempting to health alternative accelerated in the 1990s, with
assassinate President Ronald Reagan in 1981. A “not guilty by courts appearing in Broward County (Ft. Lau-
reason of insanity” verdict resulted after Fuller argued that his derdale), Florida; King County (Seattle), Wash-
client was schizophrenic. Public criticism ensued. ington; Anchorage, Alaska; and San Bernardino,
 Courts 161

California. Today, approximately 300 mental This problem is partially addressed by the rise
health courts operate in the United States. of mental health courts. By specializing in this
The evaluation of these courts is still in an early type of case, the judge and other members of the
stage, but the evidence to date suggests that these courtroom work group develop a familiarity with
courts reduce recidivism and increase treatment mental health issues greater than the typical legal
among their participants. Because of the decen- professional. Similarly, mental health profession-
tralization of the American judicial system, men- als become accustomed to court processes and
tal health courts cannot be reduced to a single set expectations through recurring encounters with
of processes and procedures, though some com- mental health courts in their communities.
monalities are present across courts, and some The second issue pertains to the public per-
differences emerge over time. The first generation ception of mental health exceptions. The efforts
of mental health courts tended to identify partici- of legal and medical professionals to deal with
pants within 48 hours of an arrest, was likely to mentally ill offenders in a manner consistent
focus on misdemeanors, and preferred commu- with the philosophies of law and rehabilitation
nity corrections at the time of sentencing. A sec- are inconsistent with public demands for retri-
ond generation of courts is more inclined to treat bution and incapacitation. The public perceives
mental illness as a mitigating circumstance, often that insanity is invoked more often than it is, and
not intervening until after a guilty plea is entered its knowledge of how the system works is built
or issued, is more willing to accept felony cases, around high-profile celebrity cases, which have
and is more likely to include jail as a penalty if the symbolic value but little to do with the every-
circumstances warrant. day operations of the court system. These prej-
udices carry over into the trial process, where
Obstacles to Implementation jurors often find it difficult to accept an insanity
Two problems undermine the creation of excep- defense.
tions in the court process for mentally ill offend-
ers. The first issue pertains to the collision of legal Richard Lee Rogers
and medical spheres—neither side is expertly Youngstown State University
trained in the affairs of the other. Mental health
professionals struggle with court proceedings. See Also: Competency and Credibility; Forensic
While mental illness is conceptualized as a dis- Psychiatry; Insanity Defense; Law and Mental Illness;
ease, the science behind mental health rests on Right to Refuse Treatment.
probabilities and is difficult to apply to individual
cases. In dealing with specific individuals, courts Further Readings
often allow experts only a few hours of assess- Council of State Governments Justice Center,
ment to form an opinion, but in reality, much lon- Criminal Justice/Mental Health Consensus Project.
ger timeframes are needed by mental health pro- Mental Health Courts: A Primer for Policymakers
fessionals for diagnosis. Disagreements among and Practitioners. New York: Council of State
professionals are easy to find under such circum- Governments Justice Center, 2008.
stances, and this lack of consensus only serves Melton, Gary B., John Petrila, Norman G. Poythress,
to undermine the authority of expert testimony and Christopher Slobogin. Psychological
in the eyes of juries. Furthermore, mental health Evaluations for the Courts: A Handbook for
professionals sometimes exceed their boundar- Mental Health Professionals and Lawyers. 3rd ed.
ies and make judgments on the legal aspects of New York: Guilford Press, 2007.
the case, which is expressly prohibited. For its Perlin, Michael L., Pamela R. Champine, Henry A.
part, the court struggles with the science: Courts Dlugacz, and Mary A. Connell. Competence in the
swing between extremes, either challenging men- Law: From Legal Theory to Clinical Application.
tal health professionals over minuscule points Hoboken, NJ: John Wiley & Sons, 2008.
or accepting mental health statements without Redlich, Allison D., Henry J. Steadman, John
question, even when the expert testimony enters Monahan, John Petrila, and Patricia A. Griffin.
prohibited areas. “The Second Generation of Mental Health
162 Creativity

Courts.” Psychology, Public Policy, and Law, v.11 that is different, novel, or innovative. Second,
(2005). something that is creative must be appropriate,
Schneider, Richard D., Hy Bloom, and Mark relevant, or useful for the task at hand.
Heerema. Mental Health Courts: Decriminalizing Theorists and researchers typically share a
the Mentally Ill. Toronto: Irwin Law, 2007. sociocultural perspective of creativity. Accord-
ing to this perspective, definitions of novelty and
appropriateness are imbedded in specific social,
cultural, and historical periods and therefore
change over time.
Creativity This perspective also distinguishes among the
creative product (the end result such as a work
Speculations about the link between creativity of art or literature), the creative process (how the
and mental illness are almost as old as civiliza- person goes about creating something novel and
tion itself, going back at least as far as the ancient useful), the creative person (the intellectual and
Greeks. The possibility of such a relationship has personality characteristics of people who produce
been raised repeatedly, at least in Western civili- works considered creative), and the creative press
zation, by such thinkers as William Shakespeare, (the environments that encourage or facilitate cre-
William Dryden, Lord Byron, Virginia Woolf, ativity). Much of the work on the creative press
and, more recently, by author William Styron has been concerned with understanding work
and psychiatrist Kaye Redfield Jamison. Among environments that encourage creativity.
recent creative people who are said to have suf- The sociocultural perspective is also concerned
fered from significant mental illness are authors with how creativity emerges. It suggests that cre-
Sylvia Plath, Ernest Hemingway, and William ativity is the result not just of the efforts of a sin-
Styron; artist Mark Kothko; and entertainers gle individual but emerges from the juxtaposition
Judy Garland, Brian Wilson, and Lenny Bruce. of many conditions of societies, cultures, and his-
Creativity requires a certain ability to view the torical periods, such as Florence, Italy, during the
world in ways that are unconventional, as defined Renaissance.
by one’s culture. Finally, the sociocultural perspective distin-
In addition, highly creative people often behave guishes among the person, the domain, and the
in unconventional ways and violate cultural and field. The person is the source of innovation
social norms. Mental illness is also almost always who develops an idea or product in a particular
characterized by unconventional or “non-nor- domain or topic area, such as painting, sculpture,
mal” thoughts, feelings, and behavior—again, as literature, or science. The domain consists of all
defined by one’s culture. of the shared products, ideas, and conventions of
the area. The field consists of the acknowledged
Defining Creativity and the experts of that domain who determine the novelty
Sociological Perspective and appropriateness of the idea or product and
Creativity has been discussed and analyzed for at decide whether it will enter the domain and be
least 2,500 years, but it has been studied scien- disseminated or rejected.
tifically for only the past 100 years or so, and in Most theorists and researchers also distin-
particular the past 60 years. The modern period guish between “Small-c” creativity and “Big-C”
of the study of creativity began in 1950 with creativity. Small-c creativity consists of all of the
an address at the meeting of the American Psy- little ways in which people improvise and make
chological Association by J. P. Guilford, who is useful changes in their everyday lives, such as dis-
known mainly for his theories and research on covering a new, faster route to work or tweaking
intelligence. a recipe and thereby improving it. Big-C creativity
The scientific study of a topic requires a con- refers to those creative products that make signifi-
sensus of definition among those studying it. The cant and enduring contributions to a domain, such
consensus definition of creativity includes two as Picasso’s innovations in art, Einstein’s innova-
components. First, creativity involves something tions in science, and Henry Ford’s innovations in
 Creativity 163

automobile manufacturing. The majority of the managing their psychopathologies. These notions
research on creativity has been concerned with have been largely debunked by scientific research
Big-C creativity, although the differences between demonstrating that truly creative contributions to
the two types are a matter of degree. a domain come only after many years of mastering
the knowledge and techniques of the domain and
Measuring Creativity engaging in intense, deliberate practice.
Measuring creativity depends on whether one
wants to measure the product, process, person, Intelligence and Personality
or press (environment). Many early attempts at Some models of intelligence view creativity (or
measuring creativity were concerned with mea- originality) as a component of intelligence. Most
suring creativity as a personality trait. Because tests of intelligence, however, do not measure cre-
personality traits are viewed as fixed properties of ativity directly. The relationship between intel-
people, these studies were not particularly useful ligence and creativity depends on the measures
in understanding the creative process and in sug- being employed, but most studies have shown
gesting ways to enhance creativity. Most recent a positive but not very strong relationship. The
research, however, has focused on measuring the threshold theory suggests that there is a strong
creativity of products and attempting to under- association between intelligence and creativity
stand the cognitive processes that lead to creative but that there is a certain level of intelligence (a
products. These studies have been much more threshold) beyond which greater intelligence does
useful in understanding the conditions under not enhance creativity.
which creativity is facilitated or stifled. Measures Research has also shown that the personality
of creativity as a personality trait, a process, and a trait known as openness to experience (curiosity,
product tend to correlate with one another. interest in, and receptiveness to new ideas and
experiences) is positively related to a wide variety
Theories of Creativity of measures of creativity. In addition, people who
In ancient times, creativity was viewed as the are highly creative will be more productive if they
result of divine inspiration from a supernatural are also highly open to experience. Conscien-
being such as a god or a muse (from which the tiousness and creativity in the arts are inversely
words museum and music are derived). In fact, the related—creative artists tend not to be conscien-
words inspire and inspiration are derived from the tious. Scientists appear to be more conscientious
Latin word that means “to breathe into,” reflect- that nonscientists, but conscientiousness does
ing the notion that the gods literally breathed cre- not seem to be related to creativity among scien-
ativity into humans. Mental illness has also been tists. In addition, creative people are more likely
attributed to the influence of supernatural powers to be independent, nonconformist, and uncon-
since ancient times (and before), which may help ventional; have a wide range of interests; have
explain why creativity and mental illness have for greater cognitive flexibility; and are more willing
so long been linked. to take risks.
This idea changed somewhat over the centuries
and was overtaken by 19th-century Romanticism, Motivation
which viewed creativity as the spontaneous expres- Research suggests that intrinsic motivation (doing
sion of an irrational unconscious or an “inner something for the love of doing it) is positively
muse.” In the Romantic view, rational thinking associated with creativity, while extrinsic motiva-
and deliberation disrupted the creative process. tion (doing something to attain a concrete reward
The early Freudian explanation for creativity such as money) is negatively associated with cre-
was that of a compensatory phenomena—that ativity. People are usually more creative when they
is, an unconscious activity masking unexpressed, engage in creative behavior for the love of it rather
instinctual wishes and unfulfilled sexual desires. than in an attempt to reap a more tangible reward
In this view, highly creative people were suffer- such as money or fame. People are also more cre-
ing from unconscious psychological disturbances ative when they are not concerned about how
and engaged in creative behavior as a way of their creative products will be evaluated by others.
164 Critical Theory

Creativity and Mental Illness Sawyer, R. Keith. Explaining Creativity: The Science
Most of the research on emotions and creativity of Human Innovation. New York: Oxford
has shown that positive emotions (happiness, joy) University Press, 2006.
lead to greater creativity, possibly because posi- Simonton, Dean Keith. “Are Genius and Madness
tive emotions enhance intrinsic motivation and Related? Contemporary Answers to an Ancient
cognitive flexibility (such as “thinking outside the Question.” Psychiatric Times, v.22 (2005).
box”). This link between positive emotions and Simonton, Dean Keith. “Creativity.” Oxford
creativity argues against the notion that, except in Handbook of Positive Psychology. 2nd ed.
relatively rare circumstances, creative people typi- New York: Oxford University Press, 2009.
cally suffer from mental illnesses. Simonton, Dean Keith. “Creativity: Cognitive,
Research also suggests, however, that creative Personal, Developmental, and Social Aspects.”
people and people at risk for developing psycho- American Psychologist, v.55/1 (2000).
pathology share a tendency toward divergent
thinking—thinking “outside the box” and a will-
ingness to have and explore novel and unconven-
tional thoughts. Several measures of mental health
are negatively related to creativity, although rela- Critical Theory
tively few creative people can be considered truly
mentally ill. In fact, mental illness usually inhib- Critical theory can refer to any theory that pro-
its rather than helps creative expression because vides a critique of its subject. More specifically, it
mental illness involves painful emotions and, in generally refers to a body of neo-Marxist social
most cases, concerns about the negative evalua- theory emerging from the Frankfurt Institute
tion of others, both of which interfere with the for Social Research (the Frankfurt school) in the
attention, problem solving, and perseverance 1930s and 1940s. The Frankfurt school combined
essential in the creative process. A society’s or Freudian psychology and economic, sociological,
culture’s perception of the link between creativity philosophical, and political science approaches
and mental illness will depend on the society’s or with the critical study of contemporary society.
culture’s definitions of both of these constructs, In this specific sense, critical theory sought to dis-
which are likely to be continually in flux. tinguish itself from “traditional” social theory
through the development of theory that pursues
James E. Maddux human emancipation and transformation. It is
George Mason University not simply a theory of social conditions and forces
but is a form of social inquiry that claims to aim
See Also: Art and Artists; Freud, Sigmund; for progress in human freedom and the reduction
Intelligence; Mental Illness Defined: Sociological of domination.
Perspectives; “Normal”: Definitions and The critical theory of the Frankfurt school
Controversies; Rationality; Unquiet Mind, An; is associated with Max Horkheimer, Theodor
Visual Arts. Adorno, Herbert Marcuse, Erich Fromm, the
young Jürgen Habermas (the later Habermas
Further Readings departs markedly from this standpoint), and oth-
Hennesey, Beth A. and Teresa M. Amabilie. ers. It is a dissenting form of Marxism closely
“Creativity.” Annual Review of Psychology, v.61 associated with Hegelian or Western Marxism,
(2010). critical of the “orthodox” Marxism of Engels,
Kaufman, James C. Creativity 101. New York: Plekhanov, and Lenin.
Springer, 2009. Max Horkheimer’s 1937 essay “Traditional
Kottler, J. A. Divine Madness: Ten Stories of Creative and Critical Theory” can be taken as a program-
Struggle. San Francisco: Jossey-Bass, 2006. matic statement of critical theory. He addresses
Nettle, Daniel. Strong Imagination: Madness, two key themes: first, what the Frankfurt school
Creativity, and Human Nature. New York: Oxford considers to be genuine or “scientific” knowl-
University Press, 2001. edge, and how such knowledge is achieved or
 Critical Theory 165

produced; and second, with the essential nature alternative, critical reading where the possibilities
of the “reality” with which Marxism concerns, or for human emancipation can be identified and
ought to concern, itself. pursued from existing circumstances; critical the-
Many members of the Frankfurt Institute fled ory is thus explanatory, practical, and normative
Nazi Germany in the 1930s, mostly to New York all at the same time.
and California. After World War II, the institute Critical theory suggests that emotional and
was reformed in Germany in 1951, before it even- behavioral “problems” are the result of underly-
tually dissolved in 1969. ing social conditions, particularly those associated
with capitalist production and objectification.
Critical Theory Versus Traditional Theory While this theme is present in all critical theory,
Critical theory distances itself from “traditional the works of Erich Fromm most clearly articulate
theory,” particularly positivism and orthodox critical theory’s relevance to mental health/illness
Marxism, which is taken to be indistinguishable concerns.
from each other, particularly as regards episte-
mology and ontology. Both positivism and ortho- Erich Fromm and Social Character
dox Marxism are taken to display an “undialecti- In providing a synthesis of the work of Marx and
cal” separation of the “subject” and “object” of Freud, Erich Fromm offers a basis upon which
knowledge. the possibility of radical social change might
Society is seen not as a natural object (to assume develop. This demanded the supplementing of
that it is to reify it) but as produced by human historical materialist theory with an understand-
beings through their social arrangements, actions, ing of the psychological situation of individuals
ideas, and ethics. As such it can—and ought to and social classes. Fromm sought to describe
be—changed, particularly where it can be seen as the mechanisms by which structural social con-
oppressive or systematically preventing fully real- ditions were transmitted to, or found expres-
ized, healthy human beings. sion in, individual subjectivity. Central to this
In the production of knowledge of the social was his concept of the social character, and his
world, there is a dialectical or reciprocal interac- own innovation—adding to Freudian categories
tion between the subject and the object of knowl- of character—of the marketing character, pecu-
edge: human beings are both subject and object liar to 20th-century capitalist society. In effect,
in the production of knowledge. In this, critical Fromm took Marx’s claim that the economic and
theorists disagree with traditional theory regard- social structure of society are the most power-
ing the possibility of separating knowledge from ful forces shaping human consciousness, mental
human interests; in their view, all beliefs are influ- health, and well-being and integrated it into psy-
enced by the interests and the values of the person choanalytic theory.
who holds them. Thus, all claims to knowledge The marketing character perceives the self as a
are associated with that person’s or group’s socio- commodity whose value and meaning are exter-
historical position or perspective. Facts are never nally determined. While some degree of confor-
objective but are the product of the social world mity makes social life possible—so we can rely on
from which they emerge. For the first generation others to behave in certain ways, for instance—
of critical theorists there was no way out of capi- conformity can also block the creative expres-
talist modernity. Modern capitalist society was sion of a sense of individuality. Thus, Western
a self-reproducing, self-stabilizing system where consumer society needs, and creates, individuals
only individual resistance, rather than significant with a pervasive need for possessions, an endless
political opposition, was possible. desire to consume, no deep feelings or convic-
Other Frankfurt school thinkers, however, tions, standardized tastes, and an uncritical sug-
saw reason for hope in their mixing of normative gestibility. By identifying the processes that block
ethical thought with descriptive analysis. Later or absent human flourishing, Fromm’s critical
versions of critical theory, however, held that it theory is able to indicate alternative processes
is critical theory’s purpose to reveal this relation- that would serve to foster such flourishing and
ship between subject and object and provide an well-being.
166 Cross-National Prevalence Estimates

Habermas and Second-Generation in order to compare the incidence of various men-

Critical Theory tal illnesses from country to country. In order for
Habermas gradually rejected much of first-gen- such estimates to be useful, specific criteria have
eration Frankfurt school critical theory. Through to be set for thresholds of severity. Surveys of self-
his later work, he has sought to develop a more reported symptoms are the most common source
modest, empirically grounded account of theo- of data for national estimates. Cross-national
retical claims to universality and rationality. His estimates may rely on national estimates, or
particular focus has been on democratic theory larger-scale projects may conduct surveys interna-
and the theory of communicative action, in which tionally.
systematically distorted forms of communication Prevalence is also defined in terms of a time
will systematically distort human relations. In a period of occurrence. Surveys will usually ask
culture dedicated to and driven by commercial about occurrences within a specific timeframe,
or self-interested concerns, communicative action such as the week or year leading up to the survey
serves to distort human relations rather than form assessment. If the time period is left indefinite, in
the basis of healthy, rational relations. Habermas other words, asking those surveyed to report any
claims that an “ideal speech situation” will pro- symptoms experienced during their lifetime, the
vide ample opportunity for free expression to all, resulting data is called the lifetime prevalence.
will provide the opportunity for challenges to
topics and rules of communication, and will be World Mental Health Survey Initiative
free of coercive distortions. Though surveys of mental illness go back more
than a century, and serious epidemiological stud-
Jeffrey I. Goatcher ies of mental illness have been conducted since
Nottingham Trent University World War II, it is principally since the 1980s that
large-scale population surveys have been con-
See Also: Freud, Sigmund; Psychoanalysis, History ducted. The World Health Organization (WHO)
and Sociology of; Psychosocial Adaptation; Social began encouraging mental illness prevalence stud-
Causation. ies in the 1980s and developed a structured diag-
nostic interview in conjunction with the U.S. Pub-
Further Readings lic Health Service, the Composite International
Crossley, Nick. Key Concepts in Critical Social Diagnostic Interview (CIDI). The standard prac-
Theory. London: Sage, 2005. tice is to conduct the CIDI by phone or in person.
Fromm, Erich. The Sane Society. 2nd ed. London: The flagship organization of such surveys is the
Routledge, 2001. WHO, which has an ongoing survey of 26 coun-
Held, David. Introduction To Critical Theory: tries (regionally dispersed), with data released one
Horkheimer to Habermas. Cambridge, MA: Polity, country at a time.
1990. The study is known as the World Mental Health
Horkheimer, Max. “Traditional and Critical (WMH) Survey Initiative, a project of the Assess-
Theory.” In Critical Theory: Selected Essays, Max ment, Classification, and Epidemiology Group.
Horkheimer, ed. New York: Continuum, 1999. WHO announced in 2001 that 450 million people
suffered from a mental illness or brain disorder out
of a population of about 6 billion, or about one in
13 people. Further, the estimated lifetime preva-
lence was one in four people. However, WHO’s
Cross-National findings are already greeted with challenges, some
methodological (not everyone trusts self-reported
Prevalence Estimates symptoms as reliable data), and some because of
the lack of mental health awareness in the devel-
Cross-national studies look at similar categories oping world, where respondents may not have
of data in many different countries, and in the case the vocabulary to correctly respond to interview-
of prevalence estimates, they do so quantitatively ers’ questions. The lifetime prevalence figure, in
 Cross-National Prevalence Estimates 167

particular, is much lower than the suspected life- instead based its projections on literature review
time prevalence of as much as three times as high. and isolated studies. The WMH survey will pro-
Not all mental illnesses are equally prevalent. vide more robust data. The eventual sample size
One of the questions that cross-national preva- will be more than 150,000 respondents. Unlike
lence estimates often seek to answer is whether most surveys, the WMH surveys are carried out
there is an uneven international distribution of face-to-face. Interviews are divided into two
specific conditions, an inequality that could be halves; the first half consists of a core diagnostic
anticipated based on either biological factors assessment and is answered by all respondents.
(if there is a gene predisposing the patient to Those who respond affirmatively to mental illness
develop a specific mental illness, that gene could symptoms, and 25 percent of those who do not,
logically be more prevalent in some populations answer the second half, which consists of ques-
than others) or environmental factors (do certain tions about correlates and secondary disorders.
cultures predispose their citizens toward certain The interview is a structured diagnostic interview,
mental illnesses, or inoculate them against oth- WMH-CIDI, developed specifically for the survey.
ers? do certain geographical or climatic condi- The disorders considered by the WMH survey
tions do so?). are anxiety disorders such as agoraphobia, gen-
The WHO studies found that the highest preva- eralized anxiety disorder, obsessive-compulsive
lence estimates were in the United States, Colom- disorder, panic disorder, post-traumatic stress dis-
bia, the Netherlands, and Ukraine. Asian coun- order, social phobia, and specific phobias; mood
tries in general have lower prevalence estimates disorders such as bipolar, dysthymia, and major
than the rest of the world; and Shanghai, Italy, depressive disorder; impulse control disorders
and Nigeria had the lowest prevalence overall. such as bulimia, intermittent explosive disorder,
In 13 of the 14 countries for which WHO and adult persistence of childhood disorders like
released studies, anxiety disorders were the most attention deficit hyperactivity disorder, conduct
common forms of mental illness (with 12-month disorder, and oppositional-defiant disorder; and
prevalence ranging from 2.4 to 18.2 percent). In substance abuse. The Diagnostic and Statistical
12 countries, mood disorders were the second- Manual of Mental Disorders (DSM) is used for
most common. The WHO study has called the diagnostic criteria.
usefulness of institutionalization into question, Until WHO’s study, cross-national prevalence
finding that cross-nationally, patients experience estimates usually relied on the National Comorbid-
not only stigma but also a loss of social and prac- ity Survey (NCS) for U.S. data. The NCS was con-
tical skills, a growing dependency on caregivers ducted from 1990 to 1992, with a follow-up study
and care facilities, human rights violations, and from 2001 to 2003. Though it relied on now-out-
difficulty with rehabilitation. The stigma of men- dated DSM-III-R diagnostic criteria, the NCS con-
tal illness, even apart from the stigma of inpatient tinues to be valuable as the first serious large-scale
care for mental illness, is so great that as many survey of American mental health. Its emphasis on
as two-thirds of those who are aware of experi- comorbidity is especially valuable, and in the NCS
encing mental illness symptoms will forgo care. data, of the 48 percent of the American population
Unlike physical ailments, those who suffer from a with a lifetime prevalence of at least one mental
mental illness are liable to be labeled for life. illness, 27 percent experienced more than one. The
disordered population as a whole experienced an
Global Burden of Disease Study average of 2.1 disorders. Further, only 40 percent
One of the aims of the WMH survey is to provide of disordered respondents received treatment.
more data for the WHO Global Burden of Dis-
ease (GBD) study, which has estimated that men- Bill Kte’pi
tal and addictive disorders are among the most Independent Scholar
burdensome worldwide and that their burden is
projected to increase in at least the first half of the See Also: Cultural Prevalence; Diagnosis in Cross-
21st century. The GBD study, though, had little National Context; Epidemiology; International
cross-national prevalence data to rely upon and Comparisons; Measuring Mental Health.
168 Cultural Prevalence

Further Readings address the real needs of a population, and this is

Bromet, Evelyn et al. “Cross-National Epidemiology also the case for the WHO.
of DSM-IV Major Depressive Episode.” BMC Unlike incidence, which gives the rate of the
Medicine, v.9/90 (2011). number of new cases and therefore measures
Fayyad, J. et al. “Cross National Prevalence and changes (such as in the evolution of a pandemic:
Correlates of Adult Attention Deficit Hyperactivity 5.3 new cases per 1,000 person-years), prevalence
Disorder.” British Journal of Psychiatry, v.190 is the proportion of a pathology, calculated in
(2007). the form of a percentage, between the total pop-
Ferri, Cleusa P., et al. “Global Prevalence of ulation and the number of cases diagnosed at a
Dementia.” Lancet, v.366/9503 (2005). given time (point prevalence), over a given period
Kessler, Ronald C., et al. “Lifetime Prevalence and Age- (period prevalence), or over a lifetime (lifetime
of-Onset Distributions of Mental Disorders in the prevalence). For example, the percentage of the
World Health Organization’s World Mental Health world population suffering from schizophrenic
Survey Initiative.” World Psychiatry, v.6/3 (2007). disorders is estimated at 1 percent.
Nock, Matthew K., et al. “Cross-National Prevalence Epidemiological measures of the prevalence of
and Risk Factors for Suicidal Ideation, Plans, and mental illnesses rely on the quality of diagnosis.
Attempts.” British Journal of Psychology, v.192 Given the fact that psychiatric diagnosis relies
(2008). on how the illness is expressed in the context of
a structured clinical interview or how it is self-
reported in the case of questionnaires being filled
out, it is necessary to interpret the results of such
studies with caution.
Cultural Prevalence
Diagnostic Universality
Since the 1980s, the World Health Organiza- When the prevalence of a mental illness varies
tion (WHO) and the International Consortium between different cultures, whether or not it is
in Psychiatric Epidemiology (ICPE) have increas- within the same society, it is necessary to check
ingly measured the state of populations’ mental the validity (how well the study measures what it
health using large-sample surveys with standard- is intended to measure) and the reliability (how
ized measures and methods. However, psychi- consistently the same result can be achieved)
atric epidemiology and cultural psychiatry are of the epidemiological studies conducted. Four
constantly faced with a problem: Why is mental potential reasons can be identified to explain this
illness, or why are some mental illnesses, more need for methodological caution.
prevalent in certain societies than in others? The first reason, which is now very rare, con-
How can we explain, for example, the cultural sists of confusing the rate of admission into
differences in the prevalence of depression, such psychiatric hospitals with the real prevalence
as 1.5 percent in Taiwan and 19 percent in Leba- measured within the local population. There are
non? Do certain cultures protect mental health many undiagnosed cases, particularly among
more than others? migrant populations and the racial and ethnic
minorities within multicultural societies (for
The Importance of Prevalence example, 30 percent of the U.S. population
In public health, epidemiology is tasked with in 2000). However, it is also important not to
studying the distribution of diseases in a popu- confuse cultural differences with differences in
lation as well as the course and determinants of social status within society because of the strong
these disorders. In this context, the prevalence of link that exists between mental illness and pov-
a disease is an important epidemiological mea- erty or between racism and misdiagnosis. More
sure in order to evaluate a population’s state of generally, patients from one culture may mani-
health. Public health policies, preventive action, fest and communicate symptoms in a way that is
and the organization of a country’s health system poorly understood in the culture of the diagnos-
all depend directly on such measures in order to ing clinician.
 Cultural Prevalence 169

The second reason that can contribute to is a lack of epidemiological information in many
explaining this underestimation is the predomi- countries, such as France, for example.
nant use of self-reporting data rather than semi- The fourth potential reason, valid until 1994,
structured instruments such as the Structured relates to the fact that cross-cultural research in
Clinical Interview for DSM-IV (SCID) or the psychiatry focused on similarities rather than dif-
20-item Self Reporting Questionnaire (SRQ). ferences. Arthur Kleinman suggests that there is a
Because of possible stigma, all symptoms may very strong bias toward discovering universals in
not be declared, either because of self-censorship mental disorders. In this way, the lack of attention
or because these symptoms are not recognized as paid to culture-specific symptoms limits the abil-
being of a psychiatric nature. ity to detect cultural differences.
The third potential reason lies in the combina-
tion of results measuring different types of preva- Cultural Factors
lence using different diagnostic classifications. The influence of social and cultural factors extends
Different countries use different diagnostic tools, to the frequency, form, and distribution of a dis-
for example, the 10th revision of the Interna- order. In this way, social problems/pressures and
tional Statistical Classification of Diseases (ICD- cultural differences may lead to a higher preva-
10), the Chinese Classification of Mental Disor- lence of disorders in some cultures. From this per-
ders (CCMD), or the fourth edition, text revision spective, which can lead to the formulation of an
of the Diagnostic and Statistical Manual of Men- etiology in the thinking of social psychiatry, envi-
tal Disorders (DSM-IV-TR). More broadly, there ronmental factors are unevenly distributed, for

A distressed resident in Ponce, Puerto Rico, seeks disaster assistance after being affected by flooding in 2008. In Caribbean cultures
such as Puerto Rico, an explanation for mental distress is commonly described as ataques de nervios, which is a cultural idiom. Clinicians
must take into account cultural explanations for illness such as this, as well as other important cultural dimensions: cultural identity, the
psychosocial environment, cultural elements in the patient-clinician relationship, and an overall cultural assessment for diagnosis and care.
170 Cultural Prevalence

example, those that induce the modernization of de Girolamo, G. and M. Bassi. “Community Surveys
societies through urbanization, industrialization, of Mental Disorders: Recent Achievements
and individualization. According to this hypoth- and Works in Progress.” Current Opinion in
esis, culture—as a system of norms and values— Psychiatry, v.16 (2003).
preserves mental health when it retains its coher- Desjarlais, Robert, Leon Eisenberg, Byron Good, and
ency and traditional form. Arthur Kleinman. World Mental Health: Problems
Social and cultural factors also affect symptom and Priorities in Low-Income Countries. New
recognition, public attitudes, help seeking, and York: Oxford University Press, 1995.
treatment. Different cultures have different con- Dinesh, Bhugra. “The Global Prevalence of
cepts of what constitutes abnormal behavior. The Schizophrenia.” PLoS Medicine, v.2/5 (2005).
issue is nothing more than the reformulation, in Grinker, Roy Richard, Marshalyn Yeargin-Allsopp,
a different field, of the central problem of psy- and Coleen Boyle. “Culture and Autism Spectrum
chiatry: how can mental illnesses be reliably diag- Disorders: The Impact on Prevalence and
nosed and measured? All of these aspects have Recognition.” In Autism Spectrum Disorders,
an impact on large-scale epidemiological studies David Amaral, Daniel Geschwind, and Geraldine
involving different ethnic groups. Dawson, eds. Oxford: Oxford University Press,
It was only in 1994 that the DSM-IV included 2011.
the role of culture in shaping the symptom pre- Guarnaccia, P. J., G. Canino, M. Rubio-Stipec, and
sentation, expression, and course of mental dis- M. Bravo. “The Prevalence of Ataques De Nervios
orders. The “Outline for Cultural Formulation” in the Puerto Rico Disaster Study: The Role of
calls attention to five distinct aspects of the cul- Culture in Psychiatric Epidemiology.” Journal of
tural context of illness and their relevance to Nervous and Mental Disease, v.197/12 (1993).
diagnosis and care. Henceforth, clinicians must Kessler, R. C. and T. B. Ustun. “The World Health
be careful to take into consideration five impor- Organization World Mental Health 2000
tant cultural dimensions regarding their patients: Initiative.” Hospital Management International,
their cultural identity; their cultural explana- v.2 (2000).
tions of the illness, including their idioms of Kirmayer, Lawrence. J. “The Fate of Culture in DSM-
distress (such as ataques de nervios); cultural IV.” Transcultural Psychiatry (1998).
factors related to the psychosocial environment, Kleinman, Arthur and Byron Good, eds. Culture
cultural elements in the patient-clinician rela- and Depression: Studies in the Anthropology and
tionship; and an overall cultural assessment for Cross-Cultural Psychology of Affect and Disorder.
diagnosis and care. Berkeley: University of California Press, 1985.
Krieger, N. “Shades of Difference: Theoretical
Samuel Lézé Underpinnings of the Medical Controversy on
Ecole Normale Superieure de Lyon Black/White Differences in the United States,
1830–1870.” International Journal of Health
See Also: Anthropology; Cross-National Prevalence Services, v.17/2 (1987).
Estimates; Diagnosis in Cross-National Context; Leff, Julian. Psychiatry Around the Globe: A
Epidemiology; Ethnopsychiatry; International Transcultural View. London: Gaskel, 1988.
Comparisons; Mental Illness Defined: Psychiatric Lewis-Fernandez, R. and A. Kleinman. “Cultural
Perspectives. Psychiatry: Theoretical, Clinical, and Research
Issues.” Cultural Psychiatry, v.18/3 (1995).
Further Readings Littlewood, Roland. Pathologies of the West: An
Angel, Ronald and Peggy Thoits. “The Impact of Anthropology of Mental Illness in Europe and
Culture on the Cognitive Structure of Illness.” America. Ithaca, NY: Cornell University Press,
Culture, Medicine, and Psychiatry, v.11/4 (1987). 2001.
Cooper, C. R. and J. Denner. “Theories Linking Lopez, S. R. and P. J. Guarnaccia. “Cultural
Culture and Psychopathology: Universal and Psychopathology: Uncovering the Social World of
Community-Specific Processes.” Annual Review of Mental Illness.” Annual Review of Psychology,
Psychology, v.49 (1998). v.51 (2000).
 Cultural Prevalence 171

Manson, Spero. “Culture and Depression: Saha, S., D. Chant, J. Welham, and J. McGrath.
Discovering Variations in the Experience of “A Systematic Review of the Prevalence of
Illness.” In Psychology and Culture, Walter Lonner Schizophrenia.” PLoS Medicine, v.2/5 (2005).
and Roy Malpass, eds. London: Pearson, 1994. Vega, William A. and Rubén G. Rumbaut. “Ethnic
Neighbors, Harold W., James S. Jackson, Linn Minorities and Mental Health.” Annual Review of
Campbell, and Donald Williams. “The Influence of Sociology, v.17 (1991).
Racial Factors on Psychiatric Diagnosis: A Review Waxler, Nancy. “Culture and Mental Illness: A Social
and Suggestions for Research.” Community Mental Labeling Perspective.” Journal of Nervous &
Health Journal, v.25/4 (1989). Mental Disease, v.159/6 (1974).
Patel, Vikram. “Cultural Factors and International Weich S. and R. Araya. “International and Regional
Epidemiology: Depression and Public Health.” Variation in the Prevalence of Common Mental
British Medical Bulletin, v.57/1 (2001). Disorders: Do We Need More Surveys?” British
Robins, Lee and Darrell Regier. Psychiatric Disorders Journal of Psychiatry, v.184 (2004).
in America: The Epidemiologic Catchment Area World Health Organization International Consortium
Study. New York: Free Press, 1991. in Psychiatric Epidemiology. “Cross-National
Rogler, Lloyd. “The Meaning of Culturally Sensitive Comparisons of the Prevalences and Correlates of
Research in Mental Health.” American Journal of Mental Disorders.” Bulletin of the World Health
Psychiatry, v.146/3 (1989). Organization, v.78/4 (2000).
 D
Dangerousness dangerousness refers to an individual’s risk for
danger to self or others. Legal standards are often
Prior to the 1990s, the term dangerousness was used less specific than those used by mental health pro-
to describe violence risk, and more specifically, vio- fessionals in violence risk assessment. Legally,
lent crime and offending behavior. Mental health dangerousness may include any type of criminal
professionals, typically psychiatrists and psycholo- offending, not simply violence toward others.
gists, were charged by the legal system with making Legal standards for dangerousness vary by con-
predictions about future dangerousness; however, text and may be ascertained by review of relevant
the methods by which such predictions were made statutes and case law. Contexts in which legal
relied largely on clinical judgments and rarely on standards may differ include correctional trans-
scientific findings. In 1983, the American Psychi- fers, hospitalization and release, capital sentenc-
atric Association filed an amicus brief in the U.S. ing, civil commitment, and commitment of sexu-
Supreme Court case Estelle v. Barefoot, arguing ally violent predators. Although legal standards
that mental health professionals held no particular may vary, there are five considerations in regard
expertise in the prediction of dangerousness. This to these standards: nature of risk factors, level of
was further supported by the work of psychologist risk, harm severity, length of outcome period, and
John Monahan, who concluded that prediction of context of harm.
dangerousness could not be done. Following the Mental health definitions are more nuanced than
wide criticisms of dangerous predictions by mental legal definitions of dangerousness. Mental health
health professionals in the 1980s, a great deal of has shifted from assessment of dangerousness
research was conducted to better understand the to violence risk assessment. Within this context,
factors that make an individual dangerous and to dangerousness includes several concepts. Risk is
assist mental health professionals in their predic- the likelihood that the individual will offend, and
tions and decision making. the idea that those most likely to reoffend should
receive the highest level of intervention. Risk state
Legal Versus Mental Health Perspectives refers to dynamic and changing aspects of risk
While the legal system still uses the term dan- that are present or absent at the time when a deci-
gerousness, research and scholarship in this sion about risk is made. Risk factors are variables
area defines dangerousness as multifaceted vio- that have been empirically related to the increased
lence risk assessment. Within the legal system, probability of offending. Protective factors are

173
174 Dangerousness

variables that have been empirically related to the prediction beyond that of official records. Other
decreased probability of offending. important factors identified by the MacArthur
Mental health professionals consider all of the Risk Assessment Study included substance abuse
above concepts when determining an individual’s and economic characteristics of the individual’s
probability of reoffending. Assessment of risk may community (i.e., poverty, single-parent families,
occur via unstructured clinical judgment, actuarial and few economic opportunities).
assessment, or structured professional judgment.
Unstructured clinical judgment does not include Violence Risk Assessment
reliance on specialized risk assessment tools and and Special Populations
relies solely on the professional’s judgment. This The empirically supported static and dynamic
type of risk assessment is unfavorable because risk factors for violence vary by specific popula-
it has shown poorer prediction when compared tions. Empirically supported static risk factors for
empirically with other approaches. Actuarial offenders with a mental disorder include age, his-
assessment uses an algorithm to determine the tory of nonviolent and violent criminal behavior,
probability of offending. This approach relies on poor education and employment history, interper-
a combination of empirically derived tools and sonal or familial problems, and substance abuse.
empirically supported risk factors to draw conclu- Dynamic risk factors for this population include
sions. Structured professional judgment uses risk antisocial attitudes, noncompliance with supervi-
and protective factors from the literature to draw sion and medication, mood disturbance, and sub-
conclusions. This approach is more flexible than stance abuse.
actuarial assessment because it allows the profes- Static risk factors for sex offenders (i.e., sexually
sional to use his or her judgment regarding the dangerous individuals and sexually violent preda-
specific individual’s needs and characteristics. tors) include having male or stranger victims, a
history of both sexual and nonsexual offenses,
Contemporary Approaches to Violence Risk young age, sexual deviance, and personality dis-
Assessment by Mental Health Professionals orders. Dynamic risk factors for this population
Violence risk assessment is based on empiri- include a preoccupation with sex, being single or
cally derived risk factors that are either static or lonely, behavioral impulsivity, emotion dysregula-
dynamic. Static risk factors are related to likeli- tion, antisocial attitudes, relationship or intimacy
hood of violent offending but are not changeable deficits, access to victims, and noncompliance.
through intervention. Dynamic risk factors are For juveniles, static risk factors include a his-
related to likelihood of violent offending and may tory of violence, early delinquency (i.e., prior to
change over time and through intervention. age 14), history of self-harm or suicide attempts,
Several meta-analyses have yielded risk fac- educational problems including low achievement
tors for offending and violent offending. Some and truancy, parental criminal activity, and famil-
of these predictors are criminal history, juvenile ial conflict and violence. A history of abuse or
delinquency, antisocial personality disorder, insti- neglect is a modest predictor of future violence
tutional adjustment, hospital admissions, sub- for juveniles; however, evidence has indicated that
stance abuse, family problems, violent history, this effect may be stronger for girls than boys, espe-
single marital status, mental disorder, age, psy- cially considering the long-term effects of sexual
chosis, and not guilty by reason of insanity status. abuse. Characteristics of the juvenile’s commu-
Specific risk assessment tools are often used to nity are also important risk factors such as pov-
predict violence risk. erty, urban versus rural, and crime rate. Dynamic
The MacArthur Risk Assessment Study, a predictors of juvenile violence risk include sub-
large-scale multisite study, assessed serious violent stance abuse, antisocial and narcissistic attitudes,
acts and other aggressive acts by individuals dis- social-cognitive deficits in responding to inter-
charged from inpatient mental health treatment personal problems and misinterpreting other’s
facilities into the community. Findings indicated intentions as aggressive, chronic peer rejection,
that self-report and collateral report of static association with other delinquent juveniles, poor
and dynamic risk factors increased sensitivity of child-rearing practices and parental socialization
 Deinstitutionalization 175

of children, and access to social support. Atten- asylums (large custodial institutions) to their
tion deficit hyperactivity disorder (ADHD) is also home communities. The transition was prompted
an important dynamic risk factor because it may by changes in federal policy initiated in the early
lead to increased risk of violence in juveniles via 1960s by the John F. Kennedy administration, but
various paths such as poor academic functioning, was largely carried out after U.S. community men-
co-occurrence with oppositional behaviors, and tal health center funding was eliminated by the
impulsivity leading to aggression. Ronald Reagan administration. As a result, people
Current risk assessment tools have been devel- with significant levels of disability were discharged
oped for use with male offenders, and were later to communities that were not prepared to deliver
used with female offenders. This is problematic adequate levels of support. In the half century
because relevant risk factors assessed by these tools since the beginning of deinstitutionalization, the
vary by gender. While the majority of violence risk former asylum system has been replaced by net-
assessment research has focused on male samples, works of community-based service systems funded
some evidence exists for gender-specific risk fac- by a mix of Medicaid, private insurance, and state
tors that vary by nature and strength. Empiri- funding. Problems related to treatment of people
cally supported risk factors for women include with mental illness persist, notably chronic home-
financial problems, substance use, problems with lessness, violence connected to mental illness, and
self-efficacy, poverty, mental health issues, and confinement of people with mental illness in jails
victimization. A history of sexual abuse may be a and prisons. As difficult as the process has been,
particularly strong predictor for female offenders deinstitutionalization has achieved several of its
because rates of childhood sexual abuse are typi- major goals. It eliminated the abuses of the asylum
cally lower in male than female offender samples. system, supported the right of people with disabil-
ities to live within communities, and created the
Darci Van Dyke mental health recovery movement.
Troy Ertelt
University of North Dakota Institutionalization
Throughout history, people with mental illness,
See Also: Attention Deficit Hyperactivity Disorder particularly those with very difficult symptoms,
(ADHD); Children; Compulsory Treatment; Courts; have been subjected to cruel treatment, neglected,
Hospitals for the Criminally Insane; Jails and Prisons; isolated, outcast, coerced, or confined. In the
Mechanical Restraint; Prison Psychiatry; Self-Injury; mid-19th-century United States, supportive insti-
Suicide; Violence. tutions for difficult populations were largely non-
existent. Reformer Dorothea Dix encountered
Further Readings people with mental illness chained in jails, con-
Borum, R. and D. Verhaagen. Assessing and fined in barns, and existing in other settings with
Managing Violence Risk in Juveniles. New York: inadequate care, and lobbied state legislatures to
Guilford Press, 2006. create institutions where people with mental ill-
Heilbrun, K. Evaluation for Risk of Violence in ness could be maintained with dignity.
Adults. New York: Oxford University Press, 2009. The large-scale institutions developed in
Mills, J. F., D. G. Kroner, and R. D. Morgan. response to 19th-century calls for reform mir-
Clinician’s Guide to Violence Risk Assessment. rored the large farm enterprises of surrounding
New York: Guilford Press, 2011. communities. People confined to the institutions
benefited from a supported, semiagricultural
institutional economy that allowed many resi-
dents to become productive through employ-
ment within the institution’s gardens, laundries,
Deinstitutionalization and other facilities. However, conditions in these
morality-driven reform institutions, including
Deinstitutionalization refers to the period of tran- asylums and madhouses, tended to deteriorate
sition of people with mental illness from state over time. While some residents improved and
176 Deinstitutionalization

A hallway of the Old Bryce Hospital (also known as the Jemison Center) remains abandoned in 2010 in Tuscaloosa, Alabama. It
was closed in the 1970s. “Old Bryce” was the African American segment of Bryce Hospital, Alabama’s oldest and largest inpatient
psychiatric facility, which opened in 1861. Deinstitutionalization of mental facilities in the United States was prompted by changes in
federal policy in the early 1960s by the Kennedy administration as well as in the 1980s during the Reagan administration.

rejoined their families, the numbers of residents were warehoused in state hospitals were subjected
with more severe levels of impairment increased to indiscriminate seclusion and physical restraint
over time. It became more difficult and expensive and harmful treatments, including lobotomies
to maintain the planned institutional activities. (brain surgery), electric shock therapy, and medi-
When institutions lost resources, daily life dete- cations with horrible side effects. For the “crime”
riorated, and people suffered. of having a disability, these people were also sub-
Clifford W. Beers wrote his book A Mind That jected to the devastating effects of being deprived
Found Itself after experiencing coercive treatment their freedom and other basic rights. Their social
in several mental institutions, public and private. identities became little more than case num-
Beers founded the organization that became Men- bers in massive public systems. And when they
tal Health America to promote better treatment died, thousands of these people were buried in
of people with mental illness. The organization’s unmarked graves on the grounds of the hospital.”
symbol is the 300-pound Mental Health Bell, The patient mix in state asylums included peo-
which was cast from iron chains and shackles that ple with medical conditions that would not be
had been used to restrain people with mental ill- classified as mental illness today. For example,
ness in asylums across the country. Robert Bern- about 20 percent of residents had tertiary syphi-
stein, president of the Bazelon Center for Mental lis. This population exhibited an array of dis-
Health Law notes: “Over the decades, those who abling neurological and psychiatric symptoms,
 Deinstitutionalization 177

and their disease led to horrific deaths in many manageable person to their family. Still, the new
cases. Asylums also cared for people with tuber- drugs seemed to have positive effects on people.
culosis affecting the brain, and people with other Experience with medication in institutional set-
dementias. People with schizophrenia and other tings eventually changed the prevailing notion of
modern-day “mental illnesses” had compara- the life course of people with mental illness. Peo-
tively better outcomes, but only if they were sup- ple could do better, and even survive in the world,
ported in their daily institutional lives. Some with some support.
institutions were also used to isolate people with
tuberculosis. Over time, the institutional popu- Reversing the Trend
lation also became older. People admitted with Deinstitutionalization began at the national
psychosis or cognitive difficulties increasingly level in 1955, when the mental hospital census
required expensive medical care. By the mid-20th declined for the first time in a century and a half.
century, the asylums, funded exclusively through It acquired more momentum and ideological sup-
state funds, not only provided care that ranged port in 1963, when John F. Kennedy signed into
from fair to poor, but did so very expensively. law the Mental Retardation Facilities and Com-
Institutional care was one of the most costly munity Mental Health Centers Construction Act
items within state budgets. of 1963 (CMHCA). The legislation, signed one
Asylums for much of the 19th century offered month before Kennedy’s death, created new plan-
what would be characterized today as custodial ning entities within states, charged with devel-
care. As time passed, the asylum system provided oping a network of federally funded community
opportunities to experiment with treatment for mental health centers. These planning entities
mental health conditions. Modern considerations were required to include “consumers” of the
of informed consent to participation in research planned service system. The former institutional
were not in place before the 1960s. Many treat- patients who participated in these planning efforts
ment approaches rejected today as inhumane or or participated in community health center gov-
ineffective were developed and put into wide- erning boards formed the core of the consumer/
spread use in psychiatric institutions. Examples survivor movement. They developed the literature
of these include insulin shock therapy and tran- and practices that form the core of today’s recov-
scranial lobotomy. ery movement.
After World War II, medications that were use- The intended transition from institutions to
ful in the treatment of mental illness emerged. Not communities encountered difficulties from the
only penicillin for patients with syphilis (which start. Communities had never experienced large
quickly reduced asylum populations), but also numbers of people who required medication to
true psychiatric drugs like lithium, antidepres- manage difficult behaviors. The promised federal
sants, and antipsychotics. These medications were mental health center funding never materialized
less designed than improvised, as modern testing at the level that Kennedy envisioned. It was sub-
protocols were not in widespread use. The insti- sequently reduced by the Nixon and Ford admin-
tutional context for this research was important. istrations and eliminated by the Reagan adminis-
Asylums were established to keep people with tration. From the outset, the community mental
challenging conduct safe and removed from a health centers sought out less disturbed patients
community unwilling to tolerate them, and those and were reluctant to treat the severely mentally
running them aimed to reduce disorder within the ill who had been discharged from state mental
walls of the facilities. This meant that treatments hospitals, or their successors who in an earlier era
that reduced agitation, oppositional behavior, would have been hospitalized. State funding for-
and hyperactivity—treatments that tranquilized merly allocated to psychiatric institutions did not
the population—were regarded as positive. The follow the persons who were released. Treatment
effect of medication on capacity to lead a normal systems did not receive resources to implement
life was not as important because people with the plans that they had developed. In fact, states
severe symptoms were not regarded as capable of continued to fund their hospital systems, even as
rehabilitation. It was success enough to return a institutionalized populations decreased. Not until
178 Deinstitutionalization

1993 were more state-controlled mental health receiving mental health services today have never
dollars allocated to community care than to state experienced the debilitating effects of long-term
institutions. institutionalization. Institutionalization proved
The state-funded institutions were designed to unsustainable. Community-based approaches
house people and maintain order. They mainly have emerged with varied degrees of effective-
provided care. The population released from insti- ness, in a political and social environment that
tutions needed more expensive treatment, medical struggles with the economic challenges of health
services paid for by Medicaid, or private health care funding, the agendas of treatment organi-
insurance. Because Medicare and Medicaid poli- zations and pharmaceutical manufacturers, and
cies were specifically designed to prevent states the struggles of people with mental illness to live
from transferring the costs of institutionalization effective and safe lives.
to the federal government, the developing dein-
stitutionalized system became somewhat better Contemporary Struggles
at delivering treatment (which was funded) than On a day-to-day basis, life for people with men-
it was at providing care (which was not funded). tal illness remains challenging. The 2003 New
Communities developed local psychiatric treat- Freedom Commission on Mental Health reported
ment systems that, even when well-managed, had that systems of care for people with mental illness
difficulty serving people who had trouble living remained fragmented, and noted great disparities
orderly lives or maintaining stable housing. The in quality and availability of services throughout
deinstitutionalized population had experienced the United States. A 2007 Kaiser Family Foun-
years of separation from their families and home dation white paper noted that “while promising
communities, and most were extremely poor. models of community care were tried, they were
Two of the most difficult social problems rarely fully evaluated and even more rarely incor-
commonly attributed to deinstitutionalization, porated into standard practice. As new technolo-
chronic homelessness and the criminalization gies came online they were often provided only
of people with mental illness, relate directly to through temporary pilot programs or in insuffi-
poverty. People with severe mental illness typi- cient capacity; old approaches were not replaced
cally rely on Supplemental Security Income (SSI) but continued to eat up resources. The history of
benefits, with a federal payment rate of $698 per deinstitutionalization began with high hopes and
month in 2012, a payment that does not support by 2000, our understanding of how to do it had
market rent anywhere in the United States. The solidified. But it was too late for many.”
criminalization of people with mental illness is On the other hand, deinstitutionalization has
connected with the war on drugs and other crimi- transformed the experience of mental illness in
nal justice initiatives of the 1980s. many positive ways. People with mental illness
As U.S. law enforcement ramped up the war on are now legally regarded as members of commu-
drugs, state legislatures imposed zero-tolerance nities, not outcasts. Law enforcement is devel-
sentencing policies and passed three-strikes legis- oping more appropriate responses to disordered
lation. These changes disproportionately affected conduct attributable to mental illness. Mental
the urban poor and swept tens of thousands of health is being addressed within the context of
Americans into jails and prisons, including many primary health care. The recovery model designed
people with mental illness. Throughout this by members of the first generation of persons
period, the census in state psychiatric facilities treated in community settings is becoming the
remained relatively flat, while the prison popula- “gold standard” within treatment systems. Mod-
tion shot up. There are many more people with els of care founded on patient self-determination
mental illness in prisons and jails today, simply are emerging. A developing literature of recovery
because people with mental illness entered prison and wellness is changing how treatment is deliv-
with other impoverished citizens. ered in every setting. Care within communities
Assessing the success or failure of deinstitu- may not yet be optimized, but it has become the
tionalization benefits from a long-term perspec- social norm. This alone may have set the stage for
tive on social change. The bulk of individuals eliminating mental illness stigma. Research shows
 Delirium 179

that stigma relating to mental illness is reduced or for others the symptoms persist. It is accompa-
eliminated when people simply get to know each nied by rapid changes in brain function, including
other. Even the Detroit Free Press, which labeled imbalances involving acetylcholine, dopamine,
deinstitutionalization “an underfunded disas- and gamma aminobutyric acid, and occurs with
ter,” has offered a reform agenda that focuses on physical or mental illnesses. The term delirium
improvements and better funding of community- comes from the Latin deliro, which means to
based services, but no return to the large psychi- move out of the proper path. Descriptions of
atric institutions of the past. cases of what appear to be delirium have been
identified in characters from many early works
Paul Komarek of literature; these characters include Euripides’s
Independent Scholar Heracles, Sophocles’s Ajax, the Arthurian Ivain,
and Shakespeare’s King Lear.
See Also: Architecture; Board and Care Homes; There are many circumstances that can cause
Hospitals for the Criminally Insane; Mental Health delirium, such as electrolyte imbalances or other
America; Mental Institutions, History of. body chemical disturbances, withdrawal from
alcohol or other depressant drugs, drug abuse,
Further Readings assorted infections such as pneumonia or urinary
Bernstein, R. Criminal Justice Reform: Lessons From tract infections, exposure to toxins, or surgery.
the Deinstitutionalization Movement. Washington, Many other disorders can contribute to confusion
DC: Bazelon Center for Mental Health Law, 2011. and need to be treated medically; these include
Human Rights Watch. “‘Once You Enter, You Never anemia, heart failure, hypercapnia (high carbon
Leave:’ Deinstitutionalization of Persons With dioxide blood levels), hypoxia (low oxygen blood
Intellectual or Mental Disabilities in Croatia. New levels), infections, kidney failure, liver failure,
York: Human Rights Watch, 2010. nutritional conditions, thyroid disorders, and
Kliewer, Stephen, et al. “Deinstitutionalization: Its assorted psychiatric conditions, such as depres-
Impact on Community Mental Health Centers and sion. Differential diagnosis between delirium and
the Seriously Mentally Ill.” Alabama Counseling dementia can be very difficult because many signs
Association Journal, v.35/1 (2010) are common to both conditions. Furthermore,
Nasrallah, H. “Bring Back the Asylums? The Tragic delirium increases the subsequent risk of devel-
Consequences of Deinstitutionalization.” Current oping dementia eight times. Epilepsy, or seizure
Psychiatry, v.7/3 (2008). disorder, can also present as delirium.
Torrey, E. F., et al. “The Shortage of Public Hospital
Beds for Mentally Ill Persons: A Report of the Symptoms
Treatment Advocacy Center.” Arlington, VA: Delirium involves a sudden shift in mental states,
Treatment Advocacy Center, 2008. such as from lethargy to agitation, and then back
to lethargy. Patients with delirium typically pres-
ent with an array of symptoms, but no one pres-
ents with all of them. These presenting symp-
toms include a rapid change in consciousness
Delirium or in levels of awareness, as well as in changes
of alertness, sensation, and perception. Visual
Delirium is a condition characterized by disori- hallucinations can occur in individuals expe-
entation of time and place, along with a state of riencing delirium; these hallucinations may be
mental confusion and/or excitement. The mind formed, such as representing people or animals,
tends to wander in a person with delirium, speech or they may be unformed, such as appearances
is likely to be incoherent, and the individual may of flashes of light or spots. Drowsiness is com-
be in a condition of continuous, aimless physical mon with delirium, as are changes in sleep pat-
activity. terns. Changes in movement are not uncommon,
Delirium is an acute state of severe confusion, such as being either hyperactive or very slow
which is generally temporary and reversible, but moving. Disorientation about time or place is
180 Delirium

characteristic, and there may also be a decrease There are many specific varieties of delirium.
in short-term memory and recall. This consists Delirium constantium, for instance, is exhibited
of either anterograde amnesia, not being able by patients expressing the reiteration of fixed
to remember things since the delirium began, or ideas. Delirium cordis is represented by a violent
retrograde amnesia, not being able to remember heartbeat, such as in atrial fibrillation. Delirium
things from before the onset of delirium. epilepticum follows an epileptic attack, or it can
A state of disrupted or wandering attention and appear instead of the attack. Delirium febrile
a lack of concentration may also be exhibited; occurs with high fevers. The delirium of a state
sometimes this is observed as having the inability of hysteria is known as delirium hystericum.
to behave or to think with purpose. Disorganized Delirium mussitans is a state of excitement caus-
thinking may also be evident through incoherent ing lingual delirium. Delirium of negation is the
speech or being unable to stop speech patterns variety where the individual thinks that a part of
or behaviors. Personality changes or rapid emo- their body is missing. Delirium of persecution is
tional changes may be expressed by shifts in states a condition in which the patient feels that they
of agitation, anger, anxiety, apathy, depression, are being persecuted by those around them. Toxic
euphoria, irritability, or psychosis. Other physical delirium is a condition caused by the presence of
presentations include psychomotor restlessness toxins in the body. Traumatic delirium is a condi-
and incontinence. Sleep problems are common in tion following injury or shock. Delirium tremens
individuals experiencing a state of delirium. They is a disorder occurring in chronic, heavy alcoholic
may fall asleep periodically during the day, but drinkers undergoing withdrawal; they may expe-
then be awake for considerable periods of time at rience auditory and visual hallucinations.
night. This condition, combined with the overall
state of confusion, can be extra dangerous, partic- Tests and Treatment
ularly with the lack of environmental cues avail- A physician or other health professional might
able at night; consequently, patients with delirium administer an array of tests to help in the diag-
are at a greater risk of falls, and they tend to pull nosis of delirium. These tests, any of which might
out IV lines, Foley catheters, and nasogastric tub- have abnormal results indicative of delirium,
ing; mechanical and/or physical restraints may be include blood ammonia levels, blood gas analy-
necessary. sis, cerebrospinal fluid analysis, comprehensive
metabolic panel, chest X-ray, creatine kinase lev-
Types of Delirium els, electroencephalogram (EEG), head CT scan,
There are three major variants of delirium: hyper- head MRI, liver function tests, mental status test,
active, hypoactive, and mixed types. Those with serum magnesium, thyroid function test, toxicol-
the hyperactive variant tend to be delusional, agi- ogy screens, urinalysis, and vitamin B1 and vita-
tated, and disoriented; they may even experience min B12 levels. For example, the EEG in a patient
hallucinations. This subtype may be misdiagnosed with delirium may show as diffuse slow waves or
as having either agitated dementia, schizophrenia, as epileptiform discharges.
or a psychotic condition. Those with the hypoac- Several instruments have been developed for
tive variant of delirium tend to be subdued, apa- screening individuals for delirium. These screen-
thetic, disoriented, and quietly confused; these ing tools include the Folstein Mini-Mental State
individuals are often overlooked or may be misdi- Examination (MMSE), the Confusion Assess-
agnosed with dementia or depression. The mixed ment Method (CAM), the NEECHAM Confu-
variant is characterized by shifting between the sion Scale, the Delirium Rating Scale, and the
hyperactive and hypoactive variants. The fourth Memorial Delirium Assessment Scale (MDAS).
edition, text revision of the Diagnostic and Statis- Acceptable levels of reliability and validity have
tical Manual of Mental Disorders (DSM-IV-TR) been established for these screening instruments.
identifies four subtypes of delirium: delirium due Many medications may worsen confusion, and
to a general medical condition, substance-induced thus may need to be stopped or at least have the
delirium, delirium due to multiple etiologies, and dosages changed. The medications that should
delirium not otherwise specified. be particularly considered in cases of delirium
 Delusions 181

include analgesics (particularly narcotics like call delirium is a condition associated with several
codeine, hydrocodone, morphine, or oxycodone), culturally bound conditions including amok or
anticholinergics, Cimetidine, Lidocaine, and cen- mata elap among Malaysians, pibloktoq among
tral nervous system depressants. Alcohol and Arctic or subarctic peoples like the Eskimos,
illicit drugs can also worsen confusion, and ces- iich’aa among the Navaho, cafard among Poly-
sation is typically indicated. Estimates on the inci- nesians, and mal de pelea among Puerto Ricans.
dence and prevalence of delirium range from 0.4
percent in the general adult population and 1.1 Victor B. Stolberg
percent in adults aged 55 years and older, while it Essex County College
affects about 10 to 30 percent of patients hospital-
ized with a medical illness and 30 to 40 percent of See Also: Anthropology; Assessment Issues in Mental
those hospitalized with human immunodeficiency Health; Dementia; Depression; Ethnopsychiatry;
virus and acquired immune deficiency syndrome Thorazine and First-Generation Antipsychotics.
(HIV/AIDS). In addition, delirium among inpa-
tients has been estimated from 13.3 percent in Further Readings
young patients, 53.2 percent in older inpatients, Cole, Martin G., Nandini Dendukuri, Jane McCusker,
and up to 88 percent in patients suffering from and Ling Han. “An Empirical Study of Different
terminal cancer and similar terminal illnesses. Diagnostic Criteria for Delirium Among Elderly
The goal of treating delirium is to control or Medical Inpatients.” Journal of Neuropsychiatry
reverse the cause of the symptoms presented, and and Clinical Neurosciences, v.15/2 (2003).
the specific treatment selected depends on the par- Dasgupta, M. and L. M. Hillier. “Factors Associated
ticular condition or conditions causing the delir- With Prolonged Delirium: A Systematic Review.”
ium. Medications may be prescribed to help control International Psychogeriatrics, v.22/3 (2010).
agitated or aggressive behaviors. If the individual Fann, J. R. “The Epidemiology of Delirium: A Review
suffering from delirium is depressed, then antide- of Studies and Methodological Issues.” Seminars in
pressants such as citalopram or fluoxetine may be Neuropsychiatry, v.5/2 (2000).
prescribed. Dopamine blockers, such as haloperi- Foreman, Marquais D. and Koen Milisen. “Improving
dol, quetiapine, or risperidone, are commonly used Recognition of Delirium in the Elderly.” Primary
in the treatment of those experiencing delirium. For Psychiatry, v.11 (2004).
cases of delirium caused by withdrawal from alco- Gleason, Ondria C. “Delirium.” American Family
hol or other depressants, sedatives such as clon- Physician, v.67/5 (2003).
azepam or diazepam are typically used. Thiamine
supplementation is also routinely implemented.
In Great Britain, the National Institute for
Health and Clinical Guidance (NICE) released
guidelines for preventing and treating delirium. Delusions
The British Geriatric Society also issued guidelines
for the diagnosis and management of delirium in A delusion is a false belief. Delusional beliefs are
the elderly. strongly held (convictions), and the holder does
Cultural background must be considered in not change his or her beliefs when presented with
assessing for delirium. For instance, individuals contrary evidence (incorrigibility). Within the
from different backgrounds may be unfamiliar basic definition of delusions, there is some defer-
with items used to assess memory, such as the ence to cultural beliefs—the tenet of idiosyncrasy.
names of former U.S. presidents, while Jehovah’s Delusional beliefs are not held by other members
Witnesses do not celebrate birthdays, and thus of the holder’s cultural systems.
might have greater difficulty in providing their Delusions are theorized to result from either
date of birth than others would. Delirium was inaccurate perceptions or defective cognitive pro-
long thought of as a form of insanity, a concep- cessing of accurately perceived information. Delu-
tion that was shattered with the discovery in 1952 sions have a typical age of onset in the 20s. Cul-
of chlorpromazine (Thorazine). What Westerners ture plays a significant role in delusional content.
182 Delusions

The American Psychiatric Association recognizes First, delusions are a universal symptom, appear-
the following five types of delusions: ing in every culture studied. Second, persecutory
delusions are the most common type (over 50
• Erotomanic delusions involve the false percent), followed by grandiose delusions (15–
belief that someone else is in love with 25 percent). The specific rate may vary in each
them, or is their lover. Often, this false culture and timeframe. Some accept this pattern
lover is of higher social status. Sexual- as a universal factor of delusions. Critics of this
ity is typically not the most important position have argued that persecutory delusions
aspect, with an idealized romance or spir- are especially disruptive, and therefore patients’
itual connection prominent. This delu- families bring them to treatment, thus skewing
sion may coexist with stalking behavior. the percentage of those seeking treatment with
• Grandiose delusions involve the false this delusion as compared to other types. This
belief that one has incredible power, dynamic is consistent across cultures, and the
self-worth, special knowledge or impor- specific content of the persecutory or grandiose
tance, or a special relationship with an delusion is informed by many cultural variables:
important person or entity such as a culture of origin, gender, religion/spirituality, cur-
celebrity or a god. rent environment, and socioeconomic status.
• Jealous delusions involve one’s sexual What is considered delusional in one culture
partner, with the belief that the partner may not be delusional in another. A belief in a
is romantically or sexually involved with deity that is held by others in their cultural envi-
another. This delusion may coexist with ronment, for instance, would not be considered
controlling behavior toward the partner. delusional in that culture, whereas a belief in a
• Persecutory delusions can involve the false special relationship with that deity that no oth-
belief that one is being harmed. The harm ers in the cultural group have could be considered
can be physical (e.g., being poisoned or delusional. Delusions are culturally subjective. In
drugged) or social (e.g. a conspiracy against persecutory delusions, the main aspect of content
them, or someone spreading rumors about that varies by culture appears to be the persecu-
them). This may coexist with violent tor. In Pakistan, the persecutor is often believed
behavior against imagined persecutors. to be friends and neighbors. This is consistent
• Somatic delusions involve the physical with the cultural experience of Pakistan and other
body, with the false belief in a medical Islamic societies, where social support/social con-
condition or physical defect. trol is common. In Austria, the persecutors are
often unknown or supernatural beings. This can
Delusions form one component of psychotic be understood as a reaction to the relative ano-
disorders. The American Psychiatric Association’s nymity of life in Western societies. Perhaps the
Diagnostic and Statistical Manual of Mental increased prevalence of certain delusional content
Disorders and the World Health Organization’s (i.e., “everybody knows something about me”)
International Classification of Diseases recognize in cities versus rural areas occurs because there is
delusional disorder. Other psychotic disorders more reactivity to anonymity in cities.
with delusions include schizophrenia, schizoaf- Delusion of descent, a subcategory of delusions
fective disorder, schizophreniform disorder, brief of grandeur, is more common in Eastern societies.
psychotic disorder, and shared psychotic disorder In Japan, it is diagnosed as lineage denial. In West-
(folie à deux). Drugs and alcohol can also cause ern society, the notion of guilt is found in 15–20
delusional psychosis. Delusions are present in percent of delusional content, while it is rare in
around 90 percent of those diagnosed with a psy- Eastern societies. Some researchers identify a dif-
chotic disorder. ference between guilt and shame cultures and use
this dynamic to explain the impact on delusional
Cross-Cultural Universals content. In guilt cultures, the locus of control is
In studies looking at the presence of delusions in deemed internal, whereas in shame cultures, con-
various cultures, two major themes have emerged. trol exists in the external society and misdeeds
 Delusions 183

way for them to make sense of their natural sexual

desires and the cultural perception that sexuality
or enjoyment of sexuality is denied to women.
The impact of gender is mediated by other
aspects of culture, including the status of women
and men in a given culture, and the holder’s
socioeconomic status (SES). All relevant identi-
ties affect the specific content of delusions. For
instance, in Pakistan, delusions involving special
powers or stardom were found in a subsample of
wealthy Pakistani men, and delusions of persecu-
tion and black magic were held by a subsample of
poor Pakistani women. These can be understood
through the lens of cultural impact. In Pakistani
society, lower SES women have very little power,
and their lives are more at the mercy of others.
Delusions that provide the holder an explanation
of this circumstance, that they are the target of
black magic, allows the holder to make meaning
Ben Hana, the “Blanket Man” of Wellington, New Zealand, of their lived experience of the world. Conversely,
November 2008. After a drunk driving accident that killed a in Pakistani society, high SES men hold significant
friend, Hana began to live under the delusion that he should live power. Delusions that they have special powers
on the streets as penance, worship a Maori sun god, and wear and status are more consistent with their lived
as little clothing as possible. He died in January 2012. experience within their cultural framework.
Some cultures also show that women’s delu-
sions of persecution differ in content from men’s
delusions of persecution. In Pakistan, for instance,
lead to interpersonal shame. When people move women’s persecutory beliefs typically center on
to a different culture from their culture of origin, the family (i.e., their culturally sanctioned social
their delusional content is more similar to others environment), whereas men’s persecutory beliefs
in the new culture. This may mean that the imme- typically center on the outside world (i.e., the pre-
diate environment is more important in the devel- scribed social sphere).
opment of delusion than cultural background.
Religious Delusions
Impact of Gender Despite the existence of delusions with religious
There is no significant gender difference in the content, religion is not a risk factor for experienc-
prevalence of delusions overall however, certain ing delusions. Religious affiliation of people with
types of delusions may be more common among delusions parallels the overall distribution of reli-
a specific gender. Jealous delusions appear more gious affiliations in a given society. Additionally,
commonly in men, whereas erotomanic delusions religious delusions have a great degree of variabil-
are more common in women. Despite this imbal- ity across time and region; this is hypothesized
ance, in forensic samples, there are more men to be a reflection of changing cultural mores in a
than women with erotomanic delusions. given society.
This increased prevalence of erotomanic delu- Though religion is neither a risk nor a pro-
sions in females can be understood by a commonly tective factor in the development of delusions,
experienced suppression of women’s sexual iden- a society’s majority religion has an impact on
tities and desires. This aspect of sexism is experi- the prevalence of religious delusions specifi-
enced across a wide variety of cultures and may cally. Catholic societies have the highest levels of
underlie the cross-cultural finding that women religious delusions, with Protestant and Islamic
more often have these fantasy love-objects. It is a societies following. Buddhist cultures have the
184 Dementia

lowest rates of religious delusion. Researchers Alzheimer’s disease is the most common type
have theorized this as a consequence of the par- of dementia, accounting for 60 to 80 percent of
ticular religious experience for each faith, with all dementia cases, and is the sixth-leading cause
some more amenable to delusional content (e.g., of death in the United States. There are no cur-
the existence of a god allows for delusions that rent diagnostic tests for Alzheimer’s dementia,
one is god or has a special relationship with a thus it is often identified through process of elimi-
god). Others note that this finding may be a nation and postmortem identification of beta-
result of some societies treating religious delu- amyloid plaques and tangles in the brain. Vascu-
sions as a spiritual rather than a mental health lar dementia, the second most common form of
problem, therefore affecting the ability to sample dementia, results from cerebrovascular disease
them in clinical settings. and is detected by the presence of focal neuro-
logical signs and symptoms like central nervous
Laura Johnson system lesions, gait abnormalities, and extremity
Chicago School of Professional Psychology weakness. Other types of dementia include Lewy
body dementia, fronto-temporal dementia, cor-
See Also: Grandiosity; Pakistan; Paranoia; Religion; tico-basal degeneration, and progressive supranu-
Schizoaffective Disorder; Schizophrenia. clear palsy. In addition, many dementia subtypes
are related to diseases like Huntington’s disease,
Further Readings Pick’s disease, Parkinson’s disease, HIV infection,
Georaca, Eugenie. “Reality and Discourse: A Critical and Creutzfeldt-Jakob disease. Newer immuno-
Analysis of the Category of ‘Delusions.’” British chemical assays and genetic analyses allow for
Journal of Medical Psychology, v.73 (2000). differentiation of these dementias.
Oltmanns, Thomas F. and Brendan A. Maher, eds. Rates of dementia are comparable across coun-
Delusional Beliefs. Oxford: John Wiley & Sons, tries. The largest difference in prevalence rates of
1988. 60 to 64 year olds is between northern Africans
Suhail, Kausar and Raymond Cochrane. “Effect of (1.2 percent) and sub-Saharan Africans (0.3 per-
Culture and Environment on the Phenomenology cent); and above age 85, the largest prevalence rate
of Delusions and Hallucinations.” International discrepancy is between South Americans (33.2
Journal of Social Psychiatry, v.48 (2002). percent) and sub-Saharan Africans (9.7 percent),
World Health Organization (WHO). International according to Alzheimer’s Disease International
Statistical Classification of Diseases and Health- in 2008. In the United States, African Ameri-
Related Problems. 10th ed. Geneva: WHO, 2008. cans and Hispanics have almost twice the rate
of dementia found among Caucasians, according
to the Alzheimer’s Association in 2012. Demen-
tia is most common among individuals aged 65
or older, with the highest prevalence above age
Dementia 85; however, children and adolescents can also
develop dementia from complications like head
Approximately 6 million Americans and 30 mil- injury, brain tumors, HIV infection, and stroke.
lion people worldwide are currently living with The condition has long been viewed as a disease
dementia. A variety of conditions fall under the of aging. The process of aging varies among cul-
category of dementia, but the most common tural groups and subsequently influences the eti-
manifestation is a decline in mental capacity, ology and progression of dementia.
primarily memory impairment that affects func-
tional capacity. Associated complications often Aging Across Cultures
include deficits in language, motor activity, object With improvements in health care and technol-
recognition, and executive function, in addition ogy, all regions of the world are experiencing an
to related changes in behavior (e.g., aggression) increase in life expectancy and dramatically rising
and mood (e.g., depression) that contribute to the numbers of adults over the age of 65. This effect is
morbidity and mortality of the disease. referred to by the United Nations as “population
 Dementia 185

aging.” In their global review of aging across cul- and Koreans view caretaking as “serving” their
tures, N. Hooyman and H. A. Kiyak explain how elders, rather than caring for them, to maintain
global economic development has decreased inter- the tradition of reverence, according to Hooyman
generational contact, leaving the elderly in many and Kiyak. African cultures often place men of
regions of the world to care for their demented a certain age in political positions, Indian cul-
relations while younger family members migrate ture relegates older Hindu men at a higher stage
to cities or more developed countries for work. In of enlightenment, and Native American cultures
addition, fertility rates have dropped, shifting the denote their older men as tribe mentors.
global age distribution from a pyramid to a cylin- Western cultures hold very different perspec-
der shape, with comparable proportions of peo- tives from these Eastern traditions. Americans in
ple at all age groups. Japan in particular is facing particular have promoted the ideal of indepen-
an aging crisis, with projections that 40 percent dence and individualism, which is contrary to liv-
of the Japanese population will be 65 or older ing in multigenerational households. Studies of
by 2050. Just a few generations ago, couples had acculturation have shown that American immi-
three or four children to help care for them as grants from Eastern cultures lose their filial piety
they aged; now, fertility rates are close to dipping and sense of obligation to the elderly in only one
below replacement levels. generation. A survey of over 3,000 college stu-
These factors, along with sociocultural vari- dents across six countries revealed that countries
ables, influence the aging process and decrease with greater population aging viewed aging to be
traditional family support for elders. Resources associated with worse outcomes and had lower
like money, property, political power, and knowl- rates of intergenerational contact. Personality and
edge influence how the elderly are viewed in cultural factors ultimately influence aging and
society. In traditional cultures, older adults hold aging-related cognitions.
many of these resources and are placed in a higher
social status than younger generations. However, Caregiving and Dementia
aging populations lose these resources in modern Changes in filial piety, population aging, and eco-
societies that value efficiency and progress. Youth nomics influence how caregivers manage their
has increasingly become the symbol of success aging cohorts across cultures. In Western culture,
and achievement in Western cultures, creating urbanization and ideals of independence decrease
a divide among generations. Older adults strug- intergenerational contact and have left many
gle to maintain their jobs as technology rapidly older adults to reside in residential facilities for
changes, requiring them to learn new skills before care, or to care for themselves, despite worsening
they become outdated. In turn, increasing rates health and cognition. Dementia is exacerbated by
of urbanization and economic decline have left chronic illness and lack of cognitive stimulation.
young adults with limited financial resources to Older adults with early symptoms of memory loss
care for their aging family, which requires young and motor deficits often struggle to maintain ade-
men and women to leave their elders behind in quate nutrition or access to health care and have
rural areas. These changes have led young adults little intellectual and social stimulation.
to feel less able and less obligated to care for their Similarly, nursing home and residential care
aging family members. facilities are becoming increasingly overpopu-
All of these changes have led to reduced filial lated and often provide residents with little cog-
piety, an ideal encompassing respect and deference nitive stimulation. Controlled studies show that
for elders. Asian countries like China, Taiwan, stimulating adults with dementia through social
and Japan have continued practicing filial piety activities and group discussions leads to improved
to uphold Confucian teachings; however, even cognition, well-being, and quality of life. Eastern
these countries have seen declines in this practice, cultures that continue to incorporate elders into
especially in areas of China feeling the reduced their family structure through social engagement
population effects after the one-child-per-family and involvement in family decisions likely benefit
policy of 1979. In Japan, it is considered publicly with similar improvements seen in these interven-
shaming to not care for parents in their old age, tion studies.
186 Dementia

In addition to cultural variations in aging, there and diabetes, which are all associated with more
are also learned, social differences in cognition. risk for dementia. It has long been known that
There appear to be variations in information pro- African Americans have higher rates of hyperten-
cessing between Easterners and Westerners that sion than most other ethnic groups, and the CDC
might influence the aging process and the devel- shows that African Americans have the highest
opment of dementia. Easterners tend to perceive prevalence of hypertension (40.4 percent), above
the environment holistically and look to the inter- both Caucasians (27.4 percent) and Hispanics
actions between objects and the environmental (26.1 percent). There are a number of reasons for
space to explain events. In contrast, Westerners these differences, and many relate to cultural life-
focus on and attribute causality to the objects style factors like diet and exercise. Among older
rather than the field space. adults, African American women aged 65 and
For Easterners, this translates into a reliance older have the highest rates of obesity.
on contextual, environmental cues to remember In a cross-ethnic focus group, older men and
information. In addition, Easterners often group women identified barriers to physical exercise.
objects into relational categories while perform- African Americans, Latinos, American Indians,
ing memory tasks (i.e., fruit goes in a basket), and Filipinos were found to have lower rates of
rather than characteristic categories (i.e., fruits physical activity. Physical energy has tradition-
versus containers). Thus, when assessing for ally been viewed in many minority cultures as a
symptoms of dementia like deficits in processing resource that should not be spent on “purpose-
speed and working memory, there are culture-sat- less” activities like exercise. This perspective has
urated tasks that vary depending on the popula- kept older African Americans and Latinos from
tion assessed, rather than the level of impairment, integrating exercise into their lifestyle. In addi-
and these are opposed to culture-invariant tasks. tion, older adults report that high crime rates
These variations in cognition should be taken into and dangerous neighborhoods, common to areas
account when considering group differences in with high minority populations, are deterrents
dementia across cultures and point to the impor- from engaging in preferred exercises like walking.
tance of within-group rather than between-group African Americans and American Indians have
comparisons. a history of oppression and poverty, resulting in
low self-esteem and little attention to self-care.
Cultural Variations in Dementia Risk Factors Native Americans reports less physical activity
There are considerable cultural differences in and higher rates of diabetes than the general pop-
these risk and protective factors that contribute ulation. Low socioeconomic status has also been
to the development of dementia. In their review associated with higher rates of dementia-related
of Alzheimer’s disease, vascular dementia, and all risk factors.
cause dementia, M. Patterson and colleagues iden- Dementia varies globally and within subcultures
tified a number of culturally variable factors that of countries like the United States, and a number
likely contribute to the development of dementia. of factors influence the etiology and manifesta-
Chronic illnesses, like hypertension and diabetes, tion of this disease. The dramatically increasing
almost double the risk of developing dementia, number of adults over the age of 65 has created
and health behaviors like eating a high-fat diet devaluing perspectives while decreasing resources
and smoking are identified risk factors, while to care for them. Risk factors for dementia include
exercise, education, moderate wine consumption, chronic illnesses like hypertension, diabetes, and
and high omega-3 fatty acid diets are protective obesity; therefore, eating a low-fat diet and physi-
factors. Vegetable, and less so, fruit, consump- cal exercise help decrease rates of dementia. In
tion has been identified as a protective factor for addition, continued cognitive stimulation and
cognitive decline. The Centers for Disease Con- social interaction have been shown to improve
trol (CDC) also recognizes social engagement and cognition and well-being in those already show-
cognitive stimulation as a protective factor. ing signs of dementia. In cultures that do not pro-
Obesity is one health variable that contributes to vide adequate care for elderly populations, these
the development of hypertension, vascular disease, factors contribute to higher rates of dementia
 Dementia 187

and worse morbidity and mortality. These factors presentation of dementia. These within-group
vary considerably across cultures and hold room summaries are best constructed within the frame-
for further research and understanding into how work of a cultural variant model of understand-
to prevent dementia from developing. ing differences, in which variation in dementias
is viewed as a process of adaptation to environ-
Other Comparisons mental influences, emphasizing the resiliency of
The revised National Institute of Health guide- each cultural group’s response to factors contrib-
lines for human subject treatment now require uting to its development. A higher level of under-
the inclusion of minorities in federally funded standing is, hence, achieved by exploring the het-
research. This comes after decades of research erogeneity, psychosocial influences, and unique
conducted primarily with Caucasians and samples developmental processes of dementia within each
of convenience. Effective recruitment of diverse cultural group.
populations has become an essential element of
responding to these guidelines. Christopher Edwards
Although these guidelines have produced con- Duke University
siderably more research with minority popula- Andrea Hobkirk
tions, the intended results have been marred by LaBarron K. Hill
the recruitment of small minority samples that Duke University Medical Center
allow for only Caucasians versus “other” com- Rose Brown
parisons or analyses that control for the between- University of North Carolina at Chapel Hill
group differences of race, rather than exploring Goldie Byrd
their qualitative meaning within the data. The North Carolina A&T State University
standard in most research exploring between- Keith Whitfield
group differences among racial or cultural groups Duke University
has been to utilize Caucasians, or the majority
sample, as a control group, to which all other See Also: Age; Ageism; Alzheimer’s Disease;
groups are compared. Dementia Praecox.
Subsequently, the importance of findings
among ethnic minorities is contingent upon the Further Readings
relative difference from Caucasians. Although Aguirre, E., R. T. Woods, A. Spector, and M. Orrell.
this method is important in identifying inequities “Cognitive Stimulation for Dementia: A Systematic
among cultural groups, several problems arise Review of the Evidence of Effectiveness From
from this practice of comparison: the within- Randomised Controlled Trials.” Ageing Research
group variability of combined categories is often Reviews, v.2 (2012).
lost, it facilitates the belief that Caucasians must Aiken-Morgan, A., J. Bichsel, J. C. Allaire, J. Savla,
be included as a comparison for results to be C. L. Edwards, and K. E. Whitfield. “Personality
valid, and it assumes similar underlying processes as a Source of Individual Differences in Cognitive
among all groups. In addition, there are analytic Aging Among African American Older Adults.”
challenges that typically arise with these types of Journal of Research in Personality, v.46 (2012).
comparisons that include unequal sample sizes Hooyman, N. and H. A. Kiyak. Social Gerontology:
with larger Caucasian groups; measurement error A Multidisciplinary Perspective. Upper Saddle
because of dissimilarities in language, history, River, NJ: Pearson, 2010.
socialization, and psychosocial factors; and vio- Lockenhoff, C. E., et al. “Perceptions of Aging Across
lations of homogeneity of variance assumptions 26 Cultures and Their Culture-Level Associates.”
between the groups, which predicate most stan- Psychology and Aging, v.24 (2009).
dard analytic methods like analysis of variance. Whitfield, K. E., J. C. Allaire, R. Belue, and C.
For this reason, cultural variations in dementia L. Edwards. “Are Comparisons the Answer to
are less important when compared to a major- Understanding Behavioral Aspects of Aging
ity population than a brief, qualitative expla- in Racial and Ethnic Groups?” Journal of
nation of the role of culture in the etiology and Gerontology, v.63 (2008).
188 Dementia Praecox

Dementia Praecox “deteriorating processes” such as problems with

attention, memory, thinking, and language. Krae-
Dementia praecox is a chronic psychiatric disor- pelin believed that the remission of symptoms in
der originally characterized by adolescent age of dementia praecox was rare and that the prognosis
onset, significant thought distortions, and psy- was poor. It was generally regarded as an incur-
chotic symptoms. Dementia praecox is the Lati- able disorder with little hope of recovery.
nized phrase of the French démence précoce, a There were no effective treatments known for
term first used in 1852 by the French physician dementia praecox. Standard treatments included
Bénédict Augustin Morel to describe a group of prolonged baths in heated tubs, structured activi-
adolescent psychiatric patients who demonstrated ties, healthy diets, and, when necessary, sedative
difficulty “expressing their will” and engag- drugs or physical restraint. A lack of effective
ing in voluntary movements. The term praecox treatments led to dangerous experimentation that
means “precocious,” or “maturing earlier than included surgery. Bayard Taylor Holmes, a sur-
expected.” The word dementia, translated from geon, and his colleagues operated on 22 patients
its German origins, means “deterioration pro- with dementia praecox, two of whom died. Hol-
cess,” “mental weakness,” or “defect.” mes and his colleagues were influenced by theories
of autointoxication. They believed that demen-
Emil Kraepelin‘s Psychiatrie tia praecox was biochemical in nature and that
Dementia praecox was broadly introduced into patients were poisoned by toxins that originated
the psychiatric lexicon by Emil Kraepelin, a Ger- in the organs of the abdomen. Surgery proved an
man physician who is known for Psychiatrie, a ineffective treatment for dementia praecox.
classification system that arranged insanity into Dementia praecox was quite well known among
a variety of disorders. There were nine versions European physicians but less so among American
of the textbook Psychiatrie, each one encapsulat- physicians. A broader understanding of the dis-
ing Kraepelin’s evolution of understanding with order was brought to America by two European
regard to dementia praecox. The first edition of his physicians, Adolf Meyer and August Hoch. Both
book was just 385 pages. The ninth (and final) edi- Meyer and Hoch are regarded as responsible for
tion was over 2,400 pages. Kraepelin was the first transforming American psychiatry’s understand-
to systematically document and produce quantifi- ing of dementia praecox. They convinced Ameri-
able longitudinal data about patients with demen- can psychiatrists to follow Kraepelin’s systematic
tia praecox. Some believe that Kraepelin’s psychi- documentation methods and to utilize the classi-
atric classification system served as the structural fication system outlined in his Psychiatrie. Soon
basis for the Diagnostic and Statistical Manual of thereafter, psychiatric hospitals in the United
Mental Health Disorders, used by American cli- States adopted Kraepelin’s case recording meth-
nicians to diagnose contemporary mental health ods and new classification system.
disorders. Kraepelin is regarded by many as one of Dementia praecox was first introduced to the
the most important figures in psychiatry. American public in 1907 in a New York Times
Kraepelin studied dementia praecox extensively article about the murder trial of Henry Thaw.
and believed that it may be a central nervous sys- Thaw was the son of Pittsburgh socialites. He had
tem disorder, involving permanent lesions in the been living in New York when he killed Stanford
part of the brain known as the cerebral cortex, White, a chorus girl. Thaw was diagnosed with
though these etiological claims were speculative. dementia praecox, paranoid type. At the trial,
Like other physicians of his time, he believed that Thaw was found not guilty by reason of insanity.
dementia praecox was biological in origin and The New York Times article marked the first time
that certain metabolic syndromes may influence that the term dementia praecox was printed in an
the development of the disorder. Symptoms of American newspaper. By the early 20th century,
dementia praecox included disorganized speech thousands of Americans had received the diagno-
and behavior (occurring typically after puberty sis of dementia praecox.
and between the ages of 18 and 22), hallucina- Dementia praecox was a recognized diagnosis
tions, and delusions. It also included cognitive for nearly three and a half decades (approximately
 Denmark 189

1896–1930s). In the early 1900s, Swiss psychia- Psychiatry and Clinical Neurosciences, v.53
trist Eugene Bleuler began criticism of “demen- (1999).
tia praecox” and presented his new theory of Durand, V. M., and D. H. Barlow. Essentials of
“schizophrenia” (splitting of the mind). In his Abnormal Psychology. 5th ed. Belmont, CA:
theory, symptoms of schizophrenia included dis- Wadsworth, 2010.
turbance of thoughts, feelings, attention, intelli- Noll, Richard. American Madness: The Rise and Fall
gence, memory, sense of self, activity (volition), of Dementia Praecox. Cambridge, MA: Harvard
behavior and the presence of hallucinations and University Press, 2011.
delusions. Autism was a prominent feature of
schizophrenia. Patients with schizophrenia, from
Bleulers’s perspective, could respond favorably to
treatment. There was no cure, but Bleuler believed
that patients could improve with psychotherapy. Denmark
In the past, psychiatrists often used the terms
schizophrenia and dementia praecox interchange- Denmark is a high-income northern European
ably. Though many once considered dementia country, and its residents enjoy a high standard
praecox and schizophrenia to be the same disorder, of living and excellent health care, including men-
they are not. In 1899, Emil Kraepelin explained tal health care. The history of mental health care
that dementia praecox was a disorder that devel- in Denmark largely follows the pattern of other
oped after puberty, was progressive, and was an European countries, with early stigmatization of
irreversible and permanent “mental weakness.” patients and misunderstanding of the causes of
Schizophrenia, alternatively, had no such singu- mental illness gradually giving way to scientific
lar identifiable symptom or clusters of symptoms; understanding and humane treatment. Today,
no symptoms were more or less important than access to mental health care, including a wide
others. Schizophrenia, according to Bleuler, did array of community-based services, is guaranteed
not always appear after adolescence, and patients by law, and Denmark has active programs in place
with schizophrenia could recover. to combat the stigmatization of the mentally ill.
In the first edition and publication of the Diag- Denmark also has specialized treatment centers
nostic and Statistical Manual: Mental Disorders to treat refugees suffering from post-traumatic
in 1952, “dementia praecox” was replaced with stress syndrome, and patients have the legal right
the phrase “schizophrenia reaction.” It is now to translation services if required.
termed schizophrenia. Schizophrenia is currently
understood as a debilitating, severe brain disease, History
characterized by delusions, hallucinations, and The Sc. Hans Hospital, established on the island
problems with emotions, memory, and overall of Roskilde, Zealand, in 1816, was the first
executive functioning. Though there is still no Danish institution specifically created to treat
cure for schizophrenia, contemporary treatment patients with mental disorders. In earlier centu-
can reduce symptoms and produce remission. ries, the mentally ill were cared for at home or
were housed in institutions where they were kept
Christine M. Sarteschi apart from the general population, but received
Chatham University little to no effective care; the most famous of these
“madhouses” was the Plague House established
See Also: Asylums; Mental Illness Defined: Historical in 1527 outside Copenhagen. However, inter-
Perspectives; Mental Institutions, History of; est grew in providing humane care and effective
Schizophrenia. treatment for the mentally ill by the late 18th and
19th centuries, influenced in part by reformers
Further Readings such as French physician Philippe Pinel and Brit-
Adityanjee, Yakeen Aberibigbe, Dimitrios ish reformer William Tuke.
Theodoridis, and R. Victor Vieweg. “Dementia In the 1840s, two Danish physicians, Jens
Praecox to Schizophrenia: The First 100 Years.” Rasmussen Hübertz and Harald Selmer, became
190 Denmark

strong proponents of the theory that mental ill- 2011, the country had about 3,000, with much
ness had physical causes, and that specialized psychiatric care provided in community centers.
hospitals should be created to find effective ways Psychoanalysis has never been a major force
to treat the mentally ill. This emphasis on the in Danish psychiatry, probably because of the
somatic causes, as well as the moral responsibility somatic emphasis of the Danish approach to men-
to treat mental patients with kindness, became a tal illness. In the 1920s and 1930s, several groups
dominant theme in Danish attitudes toward pro- formed to discuss psychoanalytic ideas, including
viding care for the mentally ill. The asylum Jydske one formed by pupils of Wilhelm Reich, who was
Asyl was established in the port city of Aarhus in granted temporary asylum in Denmark in 1933.
1852, and in 1875, a major hospital department After World War II, two Danish analysts with for-
devoted to treating mental illness was established mal training in New York and Vienna, Thorkil
in Copenhagen. As scientific knowledge about Vanggaard and Erik Bjerg Hanson, founded the
mental illness increased in the late 19th and early Danish Psychoanalytic Society, which gained
20th centuries, it became easier to differentiate full membership in the International Psychoana-
among different types of patients. This led to the lytical Society in 1957. Interest in psychoanaly-
creation in 1918 in Nykobing Sjaelland of the sis remains relatively minor in Denmark: In the
first secure unit, which was used to house insane 1990s, the Danish Psychoanalytic Society only
persons with criminal records or who seemed to had about 30 full members, and one-third of
pose a danger to others. those were Swedish.
In 1886, Alfred Lehman, who had studied at
the Wundt Institute for Experimental Psychology Current Mental Health Services
in Germany, established the first psychophysical and Epidemiology
lab in Denmark, thus pioneering the scientific In 2011, Denmark had a total of 2,955 beds in
study of psychology in the country. The Danish mental health facilities, for a rate of 53.91 beds
Psychiatric Association, founded in 1908, is the per 100,000 population. Outpatient mental health
country’s chief professional association for psy- care was more common, with a rate of 1,684 per-
chiatry; it maintains close ties with other Scan- sons per 100,000 population receiving care in this
dinavian psychiatric associations and participates way; whereas for inpatient psychiatric care, the
in editing the Nordic Journal of Psychiatry. Inter- rate of admissions was 836 per 100,000. Females
est in finding somatic treatments for mental ill- were slightly more likely to seek both types of care
nesses increased during the first half of the 20th (54 percent of those receiving outpatient care and
century, as did construction of state hospitals to 51 percent inpatient care); persons aged 17 and
house the mentally ill. Academic psychiatry also younger constituted 17 percent of those receiving
grew during this period, with chairs of psychiatry outpatient care and 3 percent of those receiving
established at universities in Copenhagen (1934), inpatient care. The median length of stay in a com-
Aarhus (1945), and Odense (1970). munity-based psychiatric unit was 30 days, and
The availability of more effective pharmaceu- long-term stays in mental hospitals are relatively
tical treatments led to shorter stays for many rare: 90 percent of patients are discharged in less
patients by the 1950s, and an early experiment than one year, and only 0.3 percent remain in the
in community psychiatry in 1957, the Samsø hospital longer than three years. The suicide rate
Project led by Erik Strömgren, suggested that for males in 2011 was 17.5 per 100,000 popula-
most patients in psychiatric care did not need to tion, and for females was 6.4 per 100,000.
be housed in hospitals but could be effectively In 2011, Denmark had 11 psychiatrists per
treated on an outpatient basis. The concept of 100,000 population, 10 psychologists working in
mental illness as a social construction became mental health care per 100,000, and nine mental
popular in the 1970s, and this, coupled with the health care nurses per 100,000. Specialized train-
availability of effective drugs to treat many ill- ing programs for psychologists are available in
nesses, led to widespread deinstitutionalization the fields of child and adolescent mental health,
of mental patients. In 1972, Denmark had about geriatric mental health, forensic psychiatry, drug
12,000 psychiatric beds in hospitals, whereas in addition, and alcohol treatment. In 2008, 7.5
 Department of Health and Human Services, U.S. 191

percent of Denmark’s total health budget was public health interventions. While the federal gov-
dedicated to mental health care, and neuropsychi- ernment has taken a leadership role to improve
atric disorders were estimated to account for 38.8 access to mental health services, there remain the
percent of the country’s total burden of disease. issues of rising costs, decreasing budgets, gaps in
Psychotherapy is provided free of charge from services, and other significant challenges.
psychiatrists and general practitioners. The cost
of psychotherapeutic medicines in 2011 was esti- Organizational Structure
mated at $5.5 million, with $3.4 million of that HHS provides a number of essential human ser-
total for medicines to treat psychotic disorders, vices that cover a variety of topic areas such as
and $100,000 used to treat bipolar disorders. food and drug safety, prevention, diseases, health
Psychiatric drugs are reimbursed at various rates, insurance, and public health. The agency’s pro-
depending on the product and the individual; chil- grams are administered by the Office of the Sec-
dren, the elderly, and people with chronic diseases retary, and the federal department comprises 11
may receive 100 percent reimbursement. operating divisions, including Administration for
Children and Families (ACF), Administration for
Sarah Boslaugh Community Living (ACL), Agency for Healthcare
Kennesaw State University Research and Quality (AHRQ), Agency for Toxic
Substances and Disease Registry (ATSDR), Cen-
See Also: Community Mental Health Centers; ters for Disease Control and Prevention (CDC),
Psychiatric Social Work; Psychoanalysis, History and Centers for Medicare and Medicaid Services
Sociology of; Szasz, Thomas. (CMS), Food and Drug Administration (FDA),
Health Resources and Services Administration
Further Readings (HRSA), Indian Health Service (IHS), National
Bolwig, Tom G. “Historical Aspects of Danish Institutes of Health (NIH), and the Substance
Psychiatry. Nordic Journal of Psychiatry, v.65/2 Abuse and Mental Health Services Administra-
(2011). tion (SAMHSA). Sixteen staff divisions provide
Dixon, Andrea L. and Nanja Holland Hansen. additional support to the Office of the Secretary.
“Fortid, Nutid, Fremtid (Past, Present, Future):
Professional Counseling in Denmark.” Journal of The Federal Role in Shaping the
Counseling and Development, v.88 (2010). Mental Health System
World Health Organization (WHO) Regional Office Despite the various agencies at the disposal of the
for Europe. Policies and Practices for Mental federal government, attention to mental health
Health in Europe: Meeting the Challenges. services in the United States had been negligible
Copenhagen, Denmark: WHO Regional Office for compared to other health initiatives prior to
Europe, 2008. World War II. After the war, returning soldiers
emerged with myriad psychological illnesses (a
number of them had previously existing men-
tal conditions), only to be met by a tremendous
shortage of trained professionals to address their
Department of Health mental health condition. In order to address the
large population of mentally ill returning from
and Human Services, U.S. the war, the federal government intervened with
the passing of the National Mental Health Act
The U.S. Department of Health and Human Ser- (1946), calling for the establishment of a National
vices (HHS) is the nation’s principal agency pro- Institute of Mental Health (NIMH), which aims
viding support and services to millions of Ameri- to better understand and treat mental illness.
cans who may have complex health conditions. In 1963, President John F. Kennedy proposed
Representing a quarter of all federal outlays, a national mental health program to assist in this
HHS promotes health and quality of care through newly focused attention on mental health. With
program support, grants, preventive services, and federal programs limited, states were tasked with
192 Department of Health and Human Services, U.S.

taking care of their mentally ill. Accordingly, and living in other settings such as nursing homes.
Congress passed the Community Mental Health Critics maintain that the current mental health
Act to provide federal funding for community system delivers costly and fragmented care, sug-
mental health centers as well as an expansion of gesting that the responsibility of providing care
clinical, laboratory, and field research in mental for the mentally ill may simply be too significant
illness and mental health. A societal shift accom- of an undertaking for the federal government.
panied this deinstitutionalization. With the first
antipsychotic drugs coming out in the 1950s, the Two Prominent Divisions
public began viewing psychotic patients as man- Of the 11 operating divisions within HHS, NIH
ageable, and increasing efforts to abolish their and SAMSHA are widely considered the most
neglect soon followed. Accordingly, individuals prominently involved in efforts to improve mental
were no longer isolated in asylums, leading to the health in the United States. Among the 27 insti-
widespread deinstitutionalization. tutes and centers within NIH, NIMH is the lead-
Over 50 years later, the effects of deinstitution- ing federal agency conducting research on mental
alization are still being observed. The shift away and behavioral disorders. Due to its critical roles,
from inpatient spending in the 1960s has rendered scientific progress in mental health research by
numbers of individuals homeless, incarcerated, NIMH has been certain but time consuming. To
this end, NIMH acknowledged that a full over-
haul is necessary to address issues regarding the
fragmentation, poor access, and substandard
quality of mental health care. Researchers advise
that NIMH can ill afford not to get leaner with
its resources. The prevalence of post-traumatic
stress disorder (PTSD) in the United States is
an exemplary instance of this recommendation.
PTSD, a disorder affecting approximately 7.7
million adults and one that fueled the inception
of NIMH, is still pervasive in the country. How-
ever, PTSD treatment options have increased sub-
stantially over the past few decades via new med-
ications, psychotherapy, and other approaches
tested through clinical trials.
As the largest federal agency studying mental
health, NIMH’s urgency as well as funding meth-
ods have been scrutinized. With nearly $1.5 billion
in its 2013 budget, several researchers maintain
that more of NIMH’s funds should be allocated to
studying the most serious mental health illnesses
(SMIs) such as schizophrenia and bipolar disor-
der. SMIs are classified as mental, behavioral,
or emotional disorders (excluding developmen-
tal and substance abuse disorders) that meet the
diagnostic criteria specified in the 4th edition of
the Diagnostic and Statistical Manual of Mental
Disorders (DSM-IV) and result in serious func-
A patient sits under a magnetoencephalography brain scanner tional impairment. Diverting funds away from
at the National Institute of Mental Health (NIMH). The U.S. NIMH’s acquired immunodeficiency syndrome
government established NIMH after World War II. Within the (AIDS) research program (allotted $178 million
National Institutes of Health, it is the leading federal agency in the fiscal year 2013 budget) may help stream-
conducting research on mental and behavioral disorders. line SMI research within NIMH.
 Department of Health and Human Services, U.S. 193

NIMH retorts that progress and treatment for Mental health encompasses an array of the
these conditions are stifled because the science has biological, social, functional, and psychological
not yielded a thorough understanding of many of issues that affect one’s mental well-being. In 2011,
the disorders. Twenty years prior, NIMH did not according to epidemiologists, there were an esti-
view mental disorders as brain disorders. Conse- mated 45.6 million adults aged 18 or older who
quently, developing new and better interventions had a mental illness in the prior year. According
before symptoms manifest themselves is well to SAMHSA, this represents 19.6 percent of all
defined in NIMH’s strategic plans. The use of neu- adults in America. These claims are controversial,
roimaging and identification of biomarkers and being seen as examples of psychiatric overreach
other detection techniques may help identify when and the loose diagnoses encouraged by successive
to intervene along the prevention-treatment con- editions of the DSM, but they have nonetheless
tinuum and possibly reduce disease progression. been used in mental health planning. Moreover,
Outreach is also important for further improve- while SAMHSA scope of services lends itself to
ments in mental health care. Public engagement the multifaceted nature of mental illness, it does
helps assess the effectiveness of interventions and not address serious mental illnesses such as schizo-
promotes dialogue between NIMH and those phrenia and bipolar disorder. Further, conditions
benefiting from their research. NIMH has an out- such as these are not mentioned in SAMHSA’s
reach partnership program that works to increase most recent strategic initiatives.
the public’s access to science-based mental health The framing of behavioral health by SAM-
information through partnerships with national SHA can also be seen as contentious. SAMHSA
and state nonprofit organizations. While national refers to behavioral health as a state of mental/
initiatives that call attention to the need for better emotional being and/or choices and actions that
mental health care abound in other organizations, affect wellness. This definition fails to acknowl-
outreach programs should promote a personal- edge that observed behaviors are often the result
ized approach to mental health care treatment. of underlying brain disorders, a viewpoint shared
Such an approach leads away from the medical by NIMH. Accordingly, its focus on empowering
model—where medication is the sole focus of individuals is reflected in the large scope of sup-
intervention without addressing potential under- portive services it provides. These services can be
lying causes and accounting for one’s personal very instrumental in improving quality of life for
history—when diagnosing mental illness. individuals with mental illnesses.
NIMH does not provide direct mental health In summary, NIMH is research focused and
services beyond its research. HHS relies on other emphasizes biological linkages to mental health,
agencies such as the SAMHSA to support the while SAMHSA frames this same subject around
improvement of America’s mental health sys- behavioral health and provides supportive ser-
tem by offering supportive services. Established vices. However, other federal agencies within
in 1992, SAMHSA’s mission is to reduce the HHS also share an interest in improving mental
prevalence of substance, and mental illness by health. For example, the Centers for Medicare
implementing programs, policies, and grants that and Medicaid Services launched an initiative in
increase prevention and treatment of conditions 2012 that uses a multidimensional approach to
of mental health or substance abuse. SAMHSA improving behavioral health and safeguarding
has undertaken four initiatives to improve the nursing home residents from unnecessary antipsy-
nation’s behavioral health in its most recent 2011 chotic drugs. While there may be some overlap in
to 2014 Strategic Plan. Taken together, these ini- the strategic plans across HHS agencies, there are
tiatives cover a variety of action steps, including differences in their missions, program focus, and
collaborating with other agencies to focus on even language regarding mental health.
appropriate drug prescription, promoting emo-
tional health, and ensuring that supportive ser- The Affordable Care Act’s Impact
vices such as permanent housing are available for on the Mental Health System
individuals with or in recovery from mental and The mental health care system has evolved sig-
substance use disorders. nificantly over the past few decades. While it
194 Department of Health and Human Services, U.S.

remains a work in progress, the amount of pro- See Also: Assessment Issues in Mental Health; Costs
gram resources that the federal government has of Mental Illness; Health Insurance; National Institute
provided through HHS is somewhat significant. of Mental Health; Policy: Federal Government.
History has shown, however, that it may not be
sufficient to establish new programs overseen by Further Readings
the federal government. Researchers suggest that Cameron, J. M. “A National Community Mental
the scope of treating and providing mental health Health Program: Policy Initiation and Progress.”
services is too large for a national agenda to be In Mental Health Policy in the United States, D.
able to improve mental health care in America. Rochefort, ed. Westport, CT: Greenwood Press,
Rather, the responsibility should be shifted back 1989.
to the states, which should have a better under- Centers for Disease Control and Prevention. “Health,
standing of their local needs. United States, 2011” (2011). http://www.cdc.gov/
Moreover, HHS should ensure that those suf- nchs/data/hus/hus11.pdf#130 (Accessed December
fering from mental illness are placed in appropri- 2012).
ate care settings, as people with mental illness are Davis, L., A. Fulginiti, L. Kriegel, and J. S. Brekke.
three times more likely to be in the criminal jus- “Deinstitutionalization? Where Have All the
tice system than hospitals. SAMHSA has diverted People Gone?” Current Psychiatry Reports (2012).
many of those with mental illnesses from pris- National Institute of Mental Health. “Prevalence of
ons through their Community Support Program Serious Mental Illness Among U.S. Adults by Age,
Branch. In addition, NIMH has collaborated with Sex, and Race” (2012). http://www.nimh.nih.gov/
the Bureau of Justice Statistics to assess the lack statistics/SMI_AASR.shtml (Accessed December
of mental health services in incarcerated popula- 2012).
tions. However, much work is needed to provide National Institute of Mental Health. “Strategic Plans”
appropriate care supports for the many Ameri- (2008). http://www.nimh.nih.gov/about/
cans who suffer with mental illness. strategic-planning-reports/index.shtml (Accessed
The Affordable Care Act of 2010 is set to December 2012).
bring further changes within HHS as access to National Institute of Mental Health. “Turning the
essential health benefits such as mental health Corner, Not the Key, in Treatment of Serious
services will expand to an estimated 32 million Mental Illness” (2010). http://www.nimh.nih.gov/
presently uninsured Americans. Under the terms about/director/2010/turning-the-corner-not-the
of the act, insurance companies must provide a -key-in-treatment-of-serious-mental-illness.shtml
core set of essential health benefits and cannot (Accessed December 2012).
deny coverage for individuals with pre-existing National Institute of Mental Health. “Use of Mental
mental health conditions. Mental health and sub- Health Services and Treatments Among Adults”
stance use disorder benefits and federal parity (2012). http://www.nimh.nih.gov/statistics/3USE
protections will also be expanded to 62 million _MT_ADULT.shtml (Accessed December 2012).
more Americans. This legislation also gives states National Institutes of Health. “National Institute of
the flexibility to define essential health benefits Mental Health: Mission.” (2011). http://www.nih
in a way that would best meet the needs of their .gov/about/almanac/organization/NIMH.htm
residents. Proponents claim that such a change (Accessed December 2012).
eases the duties of the federal government to pro- Substance Abuse and Mental Health Services
vide services to the entire nation and may help Administration. “Results From the 2011 National
streamline continuity of care issues, leading to a Survey on Drug Use and Health.” NSDUH Series
lower prevalence of mental illness in the crimi- H-45, HHS Publication No. (SMA) 12-4725.
nal justice system and improved access to mental Rockville, MD: National Survey on Drug Use and
health services. Health, 2012.
Substance Abuse and Mental Health Services
Israel Cross Administration. “Transforming Mental Health
Tara McMullen Care in America: Federal Action Agenda: First
University of Maryland, Baltimore County Steps.” Publication No. SMA-05-4060, v.14/3
 Depression 195

Rockville, MD: National Survey on Drug Use and order to be diagnosed as having a major depressive
Health, 2012. episode. These symptoms include depressed mood
U.S. Department of Health and Human Services. (dysphoria), diminished interest or pleasure in
“Health Care Law Allows Consumers to Easily most activities (anhedonia), significant weight loss
Find and Compare Options Starting in 2014” or gain, change in appetite, insomnia or hypersom-
(2013). http://www.hhs.gov/news/press/2013pres/ nia, psychomotor agitation or retardation, fatigue
02/20130220a.html (Accessed December 2012). or energy loss, feelings of worthlessness or guilt,
U.S. Department of Health and Human Services. diminished concentration or indecision, and recur-
“Health Care Law Increases Number of Mental rent thoughts of death or suicide. Other common
and Behavioral Health Providers” (2012). http:// symptoms not included in these criteria, but that
www.hhs.gov/news/press/2012pres/09/20120925a can be associated with depression, are frequent
.html (Accessed December 2012). crying spells, early awakenings, psychosis, halluci-
Woolf, Steven H. and Laudan Aron, eds. “U.S. Health nations, hopelessness, helplessness, worthlessness,
in International Perspective: Shorter Lives, Poorer anxiety, irritability, pessimism, feelings of empti-
Health.” National Research Council and Institute ness, memory problems, changes in libido, and sui-
of Medicine Panel on Understanding Cross- cidal ideations and attempts. Physical symptoms
National Health Differences Among High-Income such as persistent pain, gastrointestinal distress,
Countries; Committee on Population, Division of and headaches are also common in many patients.
Behavioral and Social Sciences and Education; and “Specifiers” are accepted modifications to the
Board on Population Health and Public Health commonly accepted diagnostic criteria for depres-
Practice, Institute of Medicine. Washington, DC: sion (i.e., chronic, catatonic, melancholic, or
National Academies Press, 2013. atypical features; postpartum onset; and seasonal
pattern) and help clarify its course, severity, and
special features. Common specifiers include the
notations: mild, moderate, severe without psy-
chosis, severe with psychosis, in partial remission,
Depression in full remission, and unspecified. Other specifiers
include mood-congruent psychotic features when
The term depression is commonly used to describe the content of hallucinations and delusions are
a mood or state of feeling unhappy, persistent sad- consistent with typical depressive themes (e.g.,
ness, lack of enjoyment of normally pleasurable death or loss) and mood-incongruent psychotic
activities, and lacking energy. The Oxford English features when the content of delusions and hal-
Dictionary (1999) defines depression as “a state lucinations are inconsistent with common depres-
of extreme dejection or morbidly excessive mel- sive themes (e.g., persecution).
ancholy, often with physical symptoms. A reduc-
tion in vitality, vigor or spirits.” Depression as a Cultural Differences
state of mood was described by Hippocrates, who Although DSM criteria are relatively widely
is noted for writing about “melancholia,” or a accepted, criticism has often been raised regard-
sad condition he conceptualized as related to the ing the integration and application of culturally
humors of the body. Although the Diagnostic and relevant information in the assessment of symp-
Statistical Manual of Mental Disorders (DSM) toms and assignment of a diagnosis. For example,
formally lists a set of generally accepted criteria White Kress and colleagues have noted that a
for the diagnosis of depression, the disorder can strict application of current DSM nomenclature
have much more complex presentations, especially for depression often results in over-, under-, and
in individuals from diverse cultural backgrounds. misdiagnosis of patients from underrepresented
Thus, these symptoms can, and often do, manifest and marginalized groups within and outside of
in unique ways among individuals. Western cultures, which may be attributable to a
In its next to most recent revision, the DSM-IV- failure to account for certain culturally consistent
TR specifies that an individual must exhibit five of variations in normal and pathological presenta-
nine typical symptoms for at least two weeks in tions of mood.
196 Depression

A subculture can be functionally defined as a Americans and Native Americans in the United
self-identified or socially associated group within States, direct eye contact is often thought of as
which an individual identifies, such as endorsing a sign of aggression, disrespect, and an invasion
Hispanic or African American ethnicity within a of personal space and boundaries. For women in
more dominant culture (e.g., Western). Based on many of these cultures, direct eye contact with
shared mores, values, celebrations, and rituals, gaze can be a sign of sexual or intimate interest,
these groups may also share common perceptions lust, and disrespect. For many Western-trained
and manifestations of pathology. In the United clinicians, the lack of eye contact is interpreted as
States, Hispanics and African Americans can vary dishonesty, poor self-confidence, personality dis-
significantly from their Caucasian counterparts, order, and affective disturbances such as depres-
especially in regard to emotional experiences, sion. The culture of origin associated with the
daily stressors (e.g., discrimination and rac- observed presentation is an essential element in
ism), and in the expression of affect states (e.g., determining whether a symptom is relevant in the
response to startle, happiness, and anger). These diagnosis of depression.
factors may also exert influence on how depres- While the DSM currently encourages clinicians
sion is manifest and expressed. to incorporate cultural factors in assessment, case
For instance, there may be significant variations conceptualization, and treatment considerations,
in the idioms of distress within a cultural group, little guidance is provided in the way of execut-
and the use of such idioms in a context in which ing such a requirement. The encouragement to
they are not easily translated can lead to misiden- include cultural factors shifts the responsibility
tification. Idioms surrounding harm to others for understanding alternate presentations from
are some of the easiest to identify. For example, the written criteria to the observer/clinician and
among some African Americans and Hispanic implies that presentations other than those specif-
populations, aggressive language is common, ically written are cultural deviations, rather than
along with extremely expressive physical postur- commonly expressed cultural norms. Culture
ing as a normal mode of communication that is influences what members of a group respond to,
not associated with an increased risk for physical what they perceive as distressing, and how distress
violence. However, those same verbal challenges is manifested within that group. For example,
that include “the Dozens,” a commonly spoken evidence suggests that in both African American
series of insults and aggressive communications and Hispanic subcultures in the West, psycho-
about another’s mother or physical features—also logical distress is frequently exhibited as physi-
known as “snapping” or “sounding”—may lead cal/somatic complaints in the absence of more
to assumptions of violence, risk for physical harm, traditional symptoms. Whereas depression may
or depression when perceived by those from the include anhedonia, tearfulness, appetite changes,
dominant culture or those unfamiliar with this and the subjective perception of dysphoria for the
practice. Even more common among minority majority, it is not uncommon for African Ameri-
men, this language and physical presentation may cans to display fewer of these classic symptoms
denote affective dysregulation, a disconnection when depressed, according to C. L. Edwards et al.
from social norms, disrespect, aggression, low Similarly, Asians may see depression as a personal
frustration tolerance, and a range of other symp- weakness and be much more inclined to endorse
toms that can be misinterpreted as clinical depres- stress, nervousness, loneliness, or irritability than
sion and affective disturbance. depression.
Gazing or persistent eye contact, a behavior
that is valued in Western and some American Assessment and Treatment
cultures and is often seen as an index of hon- African Americans may underreport and minimize
esty, attentiveness, and strength with significant their symptoms of depression, as noted by A. Y.
clinical overtones, can easily be misinterpreted in Zhang. Mental illness, despite its prevalence in
individuals from other cultures and subcultures. the African American community, is stigmatized,
For example, among many Asian, Hispanic, and and the diagnosis of a mental illness is perceived,
Middle Eastern cultures, and among African as within Asian cultures, to represent personal
 Depression 197

weakness. As a result, symptom denial and lack of of related factors should be considered as normal
awareness of behavioral changes are not uncom- and culturally appropriate when understanding
mon presentations associated with depression. factors associated with the etiology of depression.
African Americans may also be hesitant to report For example, the concept of familismo, or a strong
psychotic symptoms, such as auditory and/or familial relationship that emphasizes reliance on
visual hallucinations, which can manifest in severe and connection to the family unit, becomes an
depression. Common assessment techniques, such important consideration. Being able to ascertain
as direct questioning, may not yield sufficient clin- the individual’s engagement within his or her fam-
ical data to aid in conceptualization and symptom ily unit may provide clinical insights into discrep-
identification. Often, changes in mood or poor ancies between clinical and nonclinical behaviors.
responses to emotional challenges are attributed Clinicians working with this and other
to external sources such as changes in how friends depressed populations must often attend to mat-
and relatives perceive and treat the individual, or ters unique to acculturation. Age may influence
even to supernatural forces (i.e., the devil). Factors who will be most susceptible to these particular
such as alcohol use and/or other substance abuse issues and what the reactions will be. Younger
may further complicate matters of identification individuals may experience pressure from peers
of depression in African American, Hispanic, and to adopt host culture norms, and may respond
Native American populations. Globally, appro- with feelings of inadequacy, whereas persons of
priate assessment of depression requires that the older generations may perceive such acts as disre-
clinician/counselor/assessor be familiar with the spectful to familial norms, and may respond with
multiple nuances that may influence not only pat- anger. Both groups are susceptible to accultura-
tern of endorsement of symptoms but also the var- tive stress and subsequent depression.
ious ways in which depressive symptoms may be Latino populations within the United States also
manifested in these individuals. suffer from abnormally high rates of substance
Responses to treatment may also differ among abuse, which is believed by some to be related to
culturally diverse individuals. For example, self-management of affective disturbances driven
whereas European Americans appear more com- by acculturation and risk for depression. Clini-
fortable with pharmacological interventions cians seeking to work with Latino populations
to treat depression, other cultures do not. Spe- will need to be prepared to attend to the range
cifically, both Hispanics and African Americans of potential causal and reactionary acculturative
report greater comfort with psychotherapy com- consequences of depression.
pared to other modalities, as cited by A. A. Ault- An individual’s culture establishes a guideline
Brutus. Yet, referrals for psychotherapy may be of norms for behavior. In order to determine if an
a secondary consideration for many nonpsychiat- individual is experiencing distress in a domain of
ric providers of care. With the primary care sys- life, a clinician must be aware of what the culture
tem as the initial mental health contact source, and subculture define as adaptive and maladap-
and the tendency of that system to make phar- tive behavioral and social patterns in response
macological recommendations that many diverse to distress. It is important to understand these
populations do not favor, the likelihood of mis- guidelines for cognitive, affective, behavioral, and
matching patient factors to available resources is social responses before applying a generic metric
high, and the subsequent mistreatment of mental of evaluation based on a composite of cultures or
health issues, to include depression, is substantial an inappropriate cultural reference. For instance,
in diverse populations. individuals who belong to a collectivist culture
For example, high rates of depression among may typically place great emphasis on famil-
Hispanics in the United States have been attrib- ial engagement and may make decisions about
uted to stress associated with finances and social personal and individual autonomy that appear
and economic mobility. Other stressors include incongruent with the majority decision making.
health care insecurity, language barriers, and sepa- Understanding such norms and expectations may
ration from family in some cases. In working with provide great insight into sources of depression,
Hispanic populations, these and a constellation and even themes for psychosis. Defining normality
198 Deviance

is the only way to truly determine pathology, or Zhang, A. Y. “Discord of Biological and
thoughts, emotions, behaviors, and social interac- Psychological Measures in a Group of Depressed
tions that may represent mental illness. African American and White Cancer Patients.”
Depression is a culturally mediated psychopa- Open Nursing Journal, v.5 (2011).
thology that is expressed and manifested differ-
ently as a function of culture and must be evalu-
ated and treated based on factors associated with
cultural norms of adaptive functioning. Under-
diagnosis and misdiagnosis of depression are Deviance
common outcomes of the failure to sufficiently
integrate issues of culture and may lead to under- The concept of deviance is relevant to activities,
treatment and mistreatment of depression and the beliefs, processes of thought, and numerous other
exacerbation of health disparities in the manage- aspects of cultures and societies. Across its many
ment of mental health issues. Effectively manag- applications, sociologists have defined deviance
ing issues of culture is a skill that must be acquired in various ways. Deviance can be understood
by clinicians who are interested in working with from at least three different perspectives—statis-
diverse populations. tical, medical/illness, and sociocultural. From a
statistical perspective, deviance can be defined as
Christopher Edwards anything that varies greatly from the average or
Duke University is uncommon. Examples of deviance within this
Melanie McCabe framework include numerical minorities, such as
North Carolina Central University being color-blind or having curly hair. This defini-
Mary Wood tion does not address other valuable aspects of
Miriam Feliu deviance, such as value judgments about ways
LaBarron K. Hill of being or appearing. Within this approach,
Duke University Medical Center the extent to which one must deviate from the
Keisha O’Garo norm is not explicitly specified. From a medical
Yale University and mental health vantage point, deviance can be
defined as the presence of disease or illness. This
See Also: Diagnosis; Diagnosis in Cross-National definition is subjective because certain behaviors
Context; Ethnicity; International Comparisons; viewed by some people as healthy are viewed
Measuring Mental Health. by others as markers of illness. Historically, as
physical and psychological experiences began to
Further Readings be classified as symptoms and illness, formerly
Ault-Brutus, A. A. “Changes in Racial-Ethnic benign processes became deviant.
Disparities in Use and Adequacy of Mental Health From a sociocultural perspective, deviance can
Care in the United States, 1990–2003.” Psychiatric be defined as ways of being that are inconsistent
Services, v.63 (2012). with the dominant culture and values. The domi-
Edwards, C. L., et al. “Depression, Suicidal Ideation, nant culture and values vary between societies and
and Attempts in Patients With Sickle Cell Disease.” across periods of time. In this model, behavior
Journal of the National Medical Association, that is acceptable in one setting may be considered
v.101/11 (2009). deviant in another, and similarly across histori-
Fox, J. A. and Y. Kim-Goodwin. “Stress and cal epochs. For example, cigarette smoking, now
Depression Among Latina Women in Rural considered deviant, was a normative behavior
Southeastern North Carolina.” Journal of in American culture 40 years ago. Similarly, the
Community Health Nursing, v.28 (2011). Diagnostic and Statistical Manual of Mental Dis-
Stacciarini, J. R. “A Review of Community-Based orders (DSM) included homosexuality as a mental
Participatory Research: A Promising Approach to disorder until 1974, yet it is no longer classified
Address Depression Among Latinos?” Issues in as a psychiatric disorder. Deviance is relative in
Mental Health Nursing, v.30 (2009). the extent to which it threatens the values of the
 Deviance 199

principle, cheering loudly for a favorite athlete

is appropriate in the context of a baseball game
but is likely to be met with disapproval at a golf
tournament. Across cultures and societies, social
groups create norms and enforce them under
specific circumstances. Sometimes, the power to
enforce norms is bestowed upon specific people,
such as police or lawmakers, and other times the
power is granted to the people as a collective
group, such as classmates or an entire commu-
nity. Specifically, three types of norms exist within
societies: folkways, mores, and laws.
Folkways are norms that a society or group
values; however, breaking them does not result
in harsh punishment. For example, in the United
States, a firm handshake and calling someone by
his or her name are essentials to a proper greeting;
however, a punishment does not exist for break-
ing these norms. Mores are norms that are cher-
ished by a society or group because of their moral
and ethical importance to society and its function-
The Massachusetts Department of Mental Diseases exhibited ing. Mores may change with time, as exemplified
this display of “50 Criminal Brains” in the 1920s. The theory of by the concept of premarital sex’s acceptability
biological determinism justified the eugenic movement’s call for today as compared to the 1950s. Laws are norms
compulsory sterilization of criminals and other deviants. as defined by people within a government and are
punishable. Even within the United States, differ-
ent areas prohibit different acts according to their
population’s values and situational context. For
culture. For example, while both a jaywalker and example, “dry” counties do not allow liquor sales
a rapist are labeled “deviant,” the deviance of the within their jurisdiction.
rapist is of greater concern to societies. Addition- The person labeled by the group as deviant
ally, there have been times in history when indi- may experience their behavior or identity in a
viduals did not conform to the predominant value different way from the group’s experience. The
set and refused to label a behavior as deviant, even individual may believe that the rule or norm is
when the dominant culture did. In such cases, something that does not need to be followed, that
those nonconformists were often grouped as devi- those imposing the rule do not have the compe-
ants. For another example, during the Holocaust tence or authority to judge the behavior as devi-
in Nazi Germany, individuals who opposed the ant, or may be unaware of the rule or norm. In
Nazi party did not view themselves as deviant but situations like these, the rule breaker may per-
may have been labeled in that way by members ceive the group doing the labeling as outsiders,
of the Nazi party and others outside Germany. In or deviants, as Howard Becker proposed in his
summary, social scientists largely define deviance 1963 book Outsiders. Regardless of the man-
in ways that exceed numerical classification and ner in which the individual perceives the people
emphasize that deviance is dictated by historical, enforcing the rules, the individual is likely to
social, and cultural context. experience anxiety and a feeling of being labeled
As explained by sociologist Peter Conrad in his as an outsider or deviant. A key contribution to
2002 book Deviance and Medicalization: From understanding how individuals labeled as deviant
Badness to Sickness, the existence of deviance is view themselves was the distinction between pri-
universal, but there are few specific acts that are mary and secondary deviance put forth by Edwin
defined by all societies as deviant. Applying this Lemert in the 1950s and 1960s. T. Scheff applied
200 Deviance

this concept of labeling theory to understanding A number of prominent sociologists have stud-
mental illness. Primary deviant behaviors break ied deviance through the symbolic-interactionist
norms that the individual has not previously bro- lens. Charles Horton Cooley’s early theory of the
ken. These behaviors do not create an internal- looking-glass self and George Herbert Mead’s
ized image of deviance in the individual; there- distinction between the “I” and the “Me” pro-
fore, the deviant’s self-conception is not altered. vided the foundation for a symbolic-interactionist
However, the population’s reaction to the primary approach to deviance. Those frameworks laid the
deviant act may change the individual’s internal groundwork for understanding how individuals
image and provoke him to continue committing who are labeled deviant may view themselves as
deviant acts, which is defined as secondary devi- how others respond to them. In 1939, sociologist
ance. When individuals act according to second- Edwin Sutherland developed the theory of differ-
ary deviance, they have accepted and internalized ential association, which suggested that criminal
the image that the group has placed on them. behavior is not innate, but that criminals learn
Individuals and groups can be viewed as devi- deviant behavior similarly to any other behav-
ant or label others as deviant. Definitions of ior, through interactions with significant oth-
deviance that are rooted in values and classifica- ers. Through repeated exposure to interactions
tions of behaviors are fallible to the extent that that reinforce the violating of laws, the spectator
the source of judgment comes from within the becomes the actor and commits criminal acts.
person/group/society making the judgment, and A specific area of inquiry in which the sym-
that individual or group may be inhibited from bolic interactionist approach to deviance has
seeing the situation outside his/her/their internal been applied is the study of mental illness. This
beliefs and biases. As Becker revealed in Outsid- scholarship is considered an exemplar of labeling
ers, when encountered with situations labeled as theory, a theory that describes the extent to which
deviant, one must always question who is making individuals enact behaviors or ways of being that
the judgment, the process that the person is using have been labeled in a certain way. Viewing devi-
to create the judgment, and the situation in which ance, and perhaps mental illness itself, as a social
the judgment is made. construction, Thomas Szasz theorized in his 1961
work, The Myth of Mental Illness, that mental
Deviance Through Sociological Lenses illness is a term of masquerade for behavior that
Considering deviance through the primary others do not like and/or accept.
theoretical lenses of sociology provides a more Also writing on the subject of mental illness,
nuanced understanding of this concept. Devi- Bernard J. Gallagher explains in his Sociology of
ance can be understood through the theories Mental Illness (2002) that mental illness is the
of symbolic interactionism, functionalism, and result of the experience of an individual lacking
conflict theory. in social power who committed a deviant act, but
The symbolic-interactionist lens is concerned because they were caught by the socially power-
with the struggle of the deviant-labeled individual ful, they were assigned the deviant label of being
against the larger population. Within this frame- mentally ill. This theory presents the notion that
work, deviance arises from the existence of the mental illness is simply a set of behaviors that the
rules—the rules set boundaries on what behaviors in-group has labeled as mentally ill.
or ways of being are acceptable for the culture Another scholar working to understand the
and time. Deviance is socially constructed and construction of mental illness was Thomas Scheff,
reified through the ways that others respond to whose 1966 text, Being Mentally Ill, suggests that
individuals classified as deviant. According to mental symptoms are residual deviance that soci-
this belief, the deviant has the free will to defy ety cannot find another label for, and that these
the label. Research in this tradition focuses on symptoms come from a variety of sources. One
how the definitions of deviance are formed, how weakness of the labeling theory, as presented in
they are attached to people, and what the con- Gallagher’s 2002 text and evident in its applica-
sequences are for labeled deviants and those in tion to mental illness, is its presumption that the
power who label others. person labeled (in this case as mentally ill) will
 Deviance 201

accept the label bestowed upon him or her by the work of Durkheim’s anomie theory. The strain
those in power. theory, as described in Inderbitzin et al.’s 2013
The lens of functionalism provides an alternate text, consists of three core assumptions: the idea
view of the role and place of deviance in society. that social order is the result of a set of norms that
Within this framework, deviance serves a neces- are formed for cohesion among society, that the
sary role in the functioning of interdependent norms are shared by community members, and
parts of society that work together for its survival. that deviance and community reactions to devi-
According to Émile Durkheim’s work in the late ance are necessary components of maintaining
1800s, deviance is a necessary component for the order. Within that framework, people with more
functioning and well-being of society. Durkheim, power create and impose rules on the less power-
highly regarded as the father of sociology, studied ful. Means used may include conformity, innova-
suicide and argued that the degree of community tion, ritualism, retreatism, and rebellion. Merton
unity and the amount of social regulation within furthered Durkheim’s theory when he argued
a community affect suicide rates, independent that anomie is not simply the result of unreal-
of the individuals within the community. These ized goals, but that there is a broken relationship
findings suggest that lack of integration into the between society’s goals and the means necessary
community is related to deviance and support to achieve them. A relevant example of this idea
Durkheim’s understanding that social change is the phenomenon of medicating of children by
and interaction are two vital components of their elders for the purpose of control.
deviant behavior. In their current text, Deviance In 1970, Richard Quinney proposed his social
and Social Control, Michelle Inderbitzin, Kristin reality of crime theory, in which he describes the
Bates, and Randy Gainey note that when a society creation of norms to oppress people whom soci-
undergoes rapid change, a state of normlessness, ety labels as deviant. According to this theory, the
or anomie, will result, which leaves individuals truly malevolent people are not the criminals but
without limits on their goals and expectations those who make laws to protect their personal
for their achievements. According to Durkheim’s interests, without regard for those who are pow-
findings and theory, deviance affirms cultural erless. Modern scholars of deviance have noted
norms and values and defines moral boundaries. that Quinney’s propositions incorporate work
Theorists of this lens view social norms and laws from Sutherland’s differential association theory,
as a tool utilized to carry out the interests of those Becker’s labeling theory, and others who have also
in power. This framework focuses less on the eti- contributed to the field of social deviance.
ology of deviance, and more on how it is related Similarly, in the 1980s, the Left Realists in
to the universal subject of class stratification. Great Britain emerged. They believed that an
Karl Marx’s economic and social theories of the effort should be made to prevent crimes, and not
1800s laid the ground for conflict theory and con- to repress people who have committed crimes. In
tinue to serve as an example of social deviance in his theory, he labels the working class as crimi-
the context of conflict theory. Marx proposed that nals in this framework because of their position
consumption leads to crime in both socialist and in society in relation to those with power who
capitalist societies. The proletariats, or working- are labeling and using oppressive power to main-
class citizens, are exploited by the upper class, tain control.
ruling bourgeoisie. The class conflict that arises On the heels of Quinney, in 1975, Michel Fou-
from this economic disparity creates envy among cault proposed in his book Discipline and Pun-
the lower class and a desire to conquer the rule ish: The Birth of a Prison that knowledge is pro-
of societal norms put in place by the bourgeoisie, duced to maintain a hierarchical class system that
thus causing the proletariats to deviate from soci- rewards those who have knowledge with power,
etal norms and laws. thus keeping those without knowledge out of
Other sociologists have furthered this line of power. Similar to a system of government, those
thinking about deviance as originating in conflict with power create ideologies and norms that gov-
between social classes. In the late 1930s, Robert ern the rest of society, determining who and what
Merton proposed his strain theory, grounded in is defined as deviant.
202 Deviance

While all of these theories are concerned with the Sumner, who postulates in his work Sociology
idea that powerless people are labeled as deviant of Deviance: An Obituary that deviance did not
by the elite and powerful, the primary difference have a core of general theories and was therefore
among these theories is their conception of what not able to prosper as a research specialization.
causes crime. The proposed causes of consump- The broad use of this theory as an explanation of
tion, power created from knowledge, self-interest, everything from smoking to suicide, legal and ille-
and repressing those labeled as deviant, all validly gal behaviors, also made some skeptics wary of its
explain the phenomenon of deviance, and in par- validity. Sumner cites the beginning of the study
ticular crime, as a conflict among classes. of deviance with Durkheim’s work and claims
Sociologists have historically focused on docu- that the study of deviance thrived in the 1950s
menting the existence and forms of social deviance and 1960s with the conception of labeling theory.
rather than understanding its underlying causes However, others in the late 1960s and early
and motivations. Merton’s theory of self-fulfilling 1970s believed that sociologists were ignoring the
prophecy states that accepting what others think roles of the people in power who assign labels.
about a person or their situation causes the person Responding to Sumner’s claim that deviance is
to act in such a way as to live up to the prophecy. dead, criminal justice scholars J. Miller, R. Wright,
Also, the idea of embracing the deviant identity as and D. Dannels argue that the decrease in schol-
access to a group, even if the group is considered arly work performed in the field of sociology of
deviant, is appealing to some deviants, who feel as deviance suggests that while the field of research
though they do not belong to a social group. may not be “dead,” it has lost momentum and
Austrian sociologist Frank Tannenbaum (1938) appeal in the scholarly community. Sociological
explained in his “Definition and the Dramatiza- theories of deviance remain relevant and continue
tion of Evil” that two definitions of a deviant situ- to be used to analyze social problems. The theo-
ation arise, each according to a differing perspec- ries of deviance also served an influential role in
tive. One definition of the situation is formed by the development of the critical feminist theory
the actor, while the other, and usually more delin- and postmodernism.
quent-labeling perspective, is taken by the group, Most of the often-cited sociologists and social
providing structure and norms, who view the act theorists in deviance today conduct research in
differently. Over time, the view of the community specific areas, using their understanding of devi-
shifts “from definition of the specific acts as evil to ance to frame their research questions and to
a definition of the individual as evil,” as cited by guide their research. Studies of deviance have also
E. J. Clarke. The person judged as delinquent feels been essential in the development of more specific
as though he or she has been served an injustice. fields of research such as criminal justice studies,
The sense of injustice that emerges differentiates social psychology, and cultural studies.
the individual from the community, and the indi- The field of criminal justice aids in creating clear
vidual eventually takes on the label of delinquent distinctions between behaviors that are truly det-
and may even go as far as to join a culture or sub- rimental to society versus behaviors that are more
group that supports and engages in the delinquent arbitrarily constructed as deviant. Criminal justice
activity. As a result of this self-fulfilling proph- specifically uses the theories developed by Suther-
ecy, the deviant comes to identify with the role, land, Durkheim, and other notable sociologists to
and may even go as far as to continue the role by explain criminal behavior. These theories provide
means of career choice as a deviant or criminal. insight into the process of becoming a criminal
Tannenbaum’s explanation further explains not deviant, as well as the social processes external to
only society’s role in the creation of deviants, but the criminal that influence the illegal behavior.
also the cyclical nature of deviance and deviance’s Studies of deviance have shaped the field of
continued presence in the life of the deviant. social psychology in multiple ways. First, con-
tinuing in the sociological tradition of exploring
Current Trends in Deviance Thought the construction of mental illness, sociologists
The study of deviance seems to have faded away have enhanced understandings of mental health
after 1975, as declared by sociologist Colin with their theories regarding the medicalization
 Deviance 203

of what they perceive to be natural human emo- certain cultures create meaning and acceptability
tions. In “The Discovery of Hyperkinesis: Notes of behaviors. However, much like deviance, cul-
on the Medicalization of Deviant Behavior,” Con- tural studies have also been labeled by some as a
rad analyzes the clinical and social aspects of the passing fad with an overly broad application.
medicalization of children diagnosed with ADHD.
He hypothesizes that not only does the medical Conclusion
profession have a monopoly on the conceptual- In recent years, there has been an effort in Ameri-
ization of mental illness but that the tendency to can culture to refrain from labeling behaviors as
medicalize emotional and behavioral problems deviant, and instead naming atypical behaviors as
causes people to deflect what may be societal or “unconventional.” While the usage of the term
institutional problems, and instead attribute the unconventional acknowledges the deviant acts of
individual’s problems as personal. In the case of others as not fitting within the group’s norms, it
children, this often involves medication. Social does not reflect an active attempt of the group to
scientists Allan V. Horwitz and Jerome C. Wake- accept these deviants. The word only serves as a
field support this claim in their work, The Loss of more universal label to be applied to deviants of
Sadness, in which they theorize that psychiatrists all natures. It seems as though the phrase uncon-
are diagnosing patients as suffering from major ventional is only a phrase used to mitigate soci-
depressive disorder and other conditions when, ety’s strict adherence to norms and judgment.
in fact, the patient is suffering sadness and other Deviance’s advantage is also its disadvantage.
symptomologies associated with sadness as the While the field of deviance may be written off
result of a situation or life event. by some critics as obsolete, its universality and
A second outgrowth of early scholarship on pervasive nature among all societies and cultures
deviance is the trend to understand prosocial highlights the importance of its study. Other fields
behavior with the social psychological literature. with more narrow lenses have developed because
Prosocial behavior is voluntary goodwill behav- of the criticism that the field of deviance is too
ior performed by a member of a larger organiza- broad and does not have a central set of theories
tion for another individual or organization. This to ground it. Nevertheless, deviance’s connection
specific type of behavior assumes the outcome of to all societies and persons suggests its strength
the action before it has occurred, with the pre- and powerful force of unity. This positive aspect
sumption that the action will benefit the person of deviance affirms not only its legitimacy but
toward whom the action is directed. Some proso- also its importance. From the perceptions of the
cial behaviors are functional, meaning that they deviant to the comprehensions of the labeler/
are also for the purpose of the larger organiza- larger social group to the lens of the sociologist,
tion; and some are dysfunctional, disregarding the diverse understandings of deviance provide a
the purpose and function of the larger organiza- rich field of study that will continue to provide
tion. However, in either manner, prosocial behav- powerful insight into human interaction and
iors often conform to the authority of the orga- social features.
nization and discount the efforts of the antisocial
to react against the authority of the organization. Alexis T. Franzese
The transition from wanting to understand nega- Anna Patterson
tive deviance to wanting to understand positive Elon University
deviance aligns with the growth of the field of
positive psychology. See Also: Conduct, Unwanted; Labeling;
On the part of a globalizing and politically Medicalization, Sociology of; Mental Illness Defined:
correct society, efforts have been made to rela- Sociological Perspectives; “Normal”: Definitions and
bel behaviors formerly called deviant as uncon- Controversies.
ventional and to explore the extent to which the
acceptability of behaviors is culturally dependent. Further Readings
With fields such as gender and Asian studies, inter- Clarke, E. J. “The Interactionist, Societal Reactions,
disciplinary research is performed to assess how or Labeling Perspective.” In Deviant Behavior: A
204 Diagnosis

Text Reader in the Sociology of Deviance. Delos when it was recognized that some form of stan-
H. Kelly, ed. New York: Worth, 2008. dardization was necessary, and the American
Conrad, P. Deviance and Medicalization: From Bad Psychiatric Association (APA) took charge of
to Sickness. Philadelphia: Temple University the task. The APA decrees that the DSM should
Press, 2002. only be used by clinically trained individuals with
Gallagher, B. J. The Sociology of Mental Illness. 4th practical experience to support their diagnostic
ed. Upper Saddle River, NJ: Prentice Hall, 2002. skills. In order for practice to keep pace with
Inderbitzin, M., K. Bates, and R. Gainey. Deviance research, the manual is updated periodically. The
and Social Control. Thousand Oaks, CA: Sage, DSM–IV was published in 1994 with a text revi-
2013. sion (DSM–IV-TR) released in 2000, while the
Miller, J., R. A. Wright, and D. Dannels. “Is Deviance fifth edition, the DSM-5, was published in the
‘Dead’? The Decline of a Sociological Research spring of 2013.
Specialization.” American Sociologist, v.32/3 In other nations, health care workers may rely
(2001). on the International Classification of Diseases
(ICD), first created by the International Statisti-
cal Institute in 1893 and entrusted to the World
Health Organization (WHO) in 1948. The most
current manual is the ICD-10, the 10th edition,
Diagnosis published in 1990. In order to use the ICD but
especially the DSM most effectively, clinicians
Until recently, most Western-educated psychia- are trained to organize information on symptoms
trists and other mental health professionals were (subjective sensations, or changes in functioning
not formally trained to consider cultural factors self-reported by the individual or perceived by
when diagnosing or treating mental illness. This other informants), signs (objective indications of
was the case despite significant academic publica- the presence of a mental illness), and events (rec-
tions documenting the fact that culture influences ognizable patterns or other time specific features)
how individuals manifest illness, discuss symp- before applying diagnostic criteria to any specific
toms, anticipate treatment, and plan for possible case.
outcomes with healers (e.g., physicians, shamans, In fact, the APA considers mental disorders
and clergy). Nonetheless, this body of work was behavioral or psychological syndromes that
commonly discounted by mental health special- cause clinically significant distress, disability, or
ists until 1994, when new diagnosis standards impairment in functioning. Psychiatric disorders
were published that incorporated culture-bound consist of trait clusters rather than a single pecu-
syndromes. liar characteristic, and generally a person should
In marked contrast to this situation of a few demonstrate several facets of a syndrome before a
decades ago, a concerted effort is now made by diagnosis is considered or applied. Ideally, when
mental health professionals to assess their patients’ clinicians are diagnosing mental illness, they are
ethnic and linguistic backgrounds and to provide viewing beliefs and behavior truly outside normal
culturally appropriate diagnoses and treatments. parameters rather than merely slight eccentricity.
This style of working with patients will become When this aspect of diagnosis is considered, it is
increasingly important as the demographic com- apparent how culture may play a role in the per-
position of Western nations continues to change. ception of mental illness, its formal diagnosis, and
The United States is typical of this trend, increas- the treatments considered.
ing its diversity with an ongoing influx of new
citizens from all regions of the world. Defining Culture
In the United States and other Western nations, Culture consists of all the nonmaterial aspects of
clinicians use the Diagnostic and Statistical Man- people’s lives, their beliefs, ideas, and views about
ual of Mental Disorders (DSM) to diagnose men- their environment. It informs how people under-
tal illnesses. This is the latest iteration in a long stand themselves, their interactions with others,
series of DSM publications, beginning in 1952, and their place in the world. Different cultural
 Diagnosis 205

backgrounds may be signified by use of a differ- Culture and Psychopathology

ent language, origin in another country or region, The APA recognizes that mental health clinicians
or a difference based on gender, sexual orienta- will use the DSM-IV-TR with diverse popula-
tion, religious affiliation, age, or socioeconomic tions. Thus, the DSM-IV-TR includes informa-
status. Individuals absorb this information when tion on cultural variations on the clinical presen-
they are young from their caregivers, sometimes tation of specific disorders that are found across
family, sometimes non-kin, and in turn, they different groups, a glossary of culture-bound syn-
teach this to their children. As youth mature, dromes, and inclusion of specific ethnic psycho-
they learn to express their ideas about the world ses as examples in the “Not Otherwise Specified”
in their material culture and other social arrange- categories.
ments, including religious and health practices. Culture influences how individuals communi-
While cultural practices have an internal logic, cate and express symptoms. It shapes the nature
they may seem puzzling for outsiders, and it can of psychopathology by endorsing certain reaction
be challenging to elucidate the inner meaning of patterns to stressful situations and life events. In
unfamiliar ideas or behaviors, which is why it addition, culture influences how people respond
may be quite difficult for mental health practitio- to and label particular disorders. For example,
ners to work with patients from different cultural in many parts of west Africa, such as Mali, ideas
backgrounds. about witchcraft pervade small villages, and cer-
Despite the challenges, mental health profes- tain ailments may be viewed as the result of witch
sionals often evaluate and diagnose individuals doctors’ influence. Newcomers from rural Mali to
from different cultural backgrounds, and in these the United States may find it difficult to explain
situations, they are aided by cultural relativism. their symptoms and mental health needs to West-
This perspective prioritizes understanding how ern-trained doctors, who have limited experience
other people interpret their world, without judg- working with west African patients.
ing their viewpoints as bad or wrong just because Not only is it challenging for new immigrants
they are different. For example, in the case of a to describe mental health symptoms to cultural
Navajo woman living according to traditional outsiders, but for prognoses of specific mental
values on Navajo land, it may be culturally inap- illnesses, including schizophrenia and schizoaf-
propriate to be asked for the names of dead rela- fective disorder, individuals may perform better
tives by a mental health specialist. However, a in their less-developed homeland than in modern
depressed resident of Denver, Colorado, may find industrialized nations such as the United States. A
it easy to discuss feelings of grief about a dead par- number of social, cultural, economic, and political
ent and have no difficulty in naming the deceased factors, including current theoretical assumptions
family member. on the etiology, or causes of particular mental
Despite consensus across different disciplines health disorders, often determine how well people
on developing cultural and linguistic competence are integrated and accepted into their communi-
(skills that allow for effective cross-cultural inter- ties, influencing health status.
actions), Western-trained clinicians may employ Cultural background typically shapes the
approaches to assessment that are not respectful manifestation and content of symptoms. They
or responsive to the needs of individuals seek- may be exaggerated in some groups, while com-
ing behavioral health services in emergency and pletely absent in others; thus, mental illness does
outpatient settings. In fact, mental health pro- not present itself consistently across different
fessionals may incorrectly judge specific beliefs, cultures. Often, hallucinations, delusions, obses-
behaviors, and experiences that are considered sions, and phobias are influenced by social and
normal in a different culture as psychopathology, environmental factors. For example, individu-
a psychological condition that is pathological als with grandiose delusions often select figures
or abnormal. To avoid this type of error, men- who are popular or important to their society.
tal health clinicians are encouraged to consider a An example in the United States would be that
number of factors before diagnosing individuals mentally ill people might identify with Jesus
with a mental disorder. and believe that they have been chosen by this
206 Diagnosis

religious icon, or are a new savior, merely need- While ethnic identity provides culturally sup-
ing public recognition. ported cures, in some cases, it also reinforces
In addition to shaping symptoms, culture may pathological behaviors. Culture, in fact, may con-
also prescribe acceptable forms of treatment. For tribute to specific stressors that cause psychopa-
instance, lobotomies were considered suitable thologies that are unique to certain cultural envi-
for Americans diagnosed with schizophrenia, ronments and ethnic groups. In addition to all of
especially during the 1940s. Now, psychotro- these situations in which culture plays a strong
pic medications are used to treat schizophrenia role in mental illness, there are also culture-bound
and other mental illnesses in the United States syndromes.
and other Western nations. In addition to ongo- Culture-bound syndromes are considered men-
ing research informing new treatments, there tal disorders, although the individuals who pres-
has also been incorporation of aboriginal, or ent culture-specific diagnostic criteria for a par-
minority community–endorsed, cures. It is not ticular condition may label them in other terms.
uncommon for individuals receiving treatment These problems are identified by members of
for a mental illness to use traditional healing specific cultural groups and are named in their
practices, including interventions performed by language. These folk maladies have specific symp-
shamans and medicine people, in conjunction toms, causes, and treatments. The DSM-IV-TR
with Western therapies. This may be especially includes a glossary of culture-bound syndromes
the case in urban locations with high diversity, and inclusion of specific culture-bound syn-
or in rural locations with minority populations, dromes as examples in “not otherwise specified”
such as American Indians. categories. Despite the extensive documentation

Witch doctors in Mali, April 2011. Culture influences how symptoms are communicated and expressed, which in turn affects diagnosis.
For example, in the small villages of Mali in west Africa, certain ailments are viewed as the result of witch doctors’ influence. Mali
immigrants to the United States would therefore find it difficult to explain their symptoms and mental health needs to a Western doctor.
 Diagnosis in Cross-National Context 207

of many culture-bound syndromes, there are Diagnosis in Cross-

still challenges in how to incorporate them into
extant DSM categories, with varying success and National Context
acceptance.
Health care systems in the United States and Mental health diagnosis is difficult to conceptual-
other Western nations recognize the importance ize and compare across national contexts because
of providing culturally informed services. Men- of differences in diagnostic systems, clinicians’
tal health clinicians heavily rely on cross-cultural diagnostic preferences, issues involving diagnos-
skills to shape interactions between them and tic and assessment methodologies, and the dif-
their patients. Interactions between the healer and ferential development of mental health systems.
client are influenced by various factors, including Further complicating cross-cultural comparisons
cultural attributes, which limit or enhance the of mental health diagnosis are issues involving
therapeutic relationship and eventual outcome stigma, the role of somatization, and culture-spe-
of treatment. Empathy, self-awareness, cultural cific mental illnesses. Researchers and profession-
sensitivity, and the acquisition and apprecia- als labor to disentangle objective differences from
tion of cross-cultural knowledge are basic pro- differences in terminology and methodology, and
fessional qualities that are essential for working to understand the possible role of inadvertent cul-
with diverse populations. Accurate diagnoses tural biases.
informed by clinical formulations that take into Mental health clinicians in different countries
consideration cultural factors are vital for pro- utilize the World Health Organization’s Interna-
viding effective interventions, and will increas- tional Statistical Classification of Diseases and
ingly become important as American populations Related Problems, 10th edition (ICD-10), the
continue to diversify. American Psychiatric Association’s Diagnos-
tic and Statistical Manual of Mental Disorders,
Susan J. Wurtzburg fourth edition, text revision (DSM-IV-TR), and
Christopher C. C. Rocchio the Psychodynamic Diagnostic Manual (PDM),
University of Hawai‘i at Manoa developed by a group of U.S. psychodynamic
organizations. The American Psychological Asso-
See Also: Acculturation; Anthropology; Assessment ciation estimates that 70 percent of clinicians
Issues in Mental Health; Cultural Prevalence; worldwide prefer the ICD-10, 23 percent the
Treatment. DSM-IV, and 7 percent the PDM or another sys-
tem. The fifth editon of the DSM (DSM-5) was
Further Readings published in the spring of 2013 and involves the
Castillo, Richard J. Culture and Mental Illness: A addition of entirely new disorders, the reconfig-
Client-Centered Approach. Pacific Grove, CA: uring and removal of some disorders, a regroup-
Brooks/Cole, 1997. ing of the disorders under 20 headings, and other
Eshun, Sussie and Regan A. R. Gurung. “Introduction changes. There was no plan to change the funda-
to Culture and Psychopathology.” In Culture and mental principles of a descriptive, symptom-based
Mental Health: Sociocultural Influences, Theory, classification that lists diagnostic criteria for each
and Practice, Sussie Eshun and Regan Gurung, eds. disorder, which has existed since the third edition.
Malden, MA: Blackwell, 2009. There are substantial overlap and important
Fadiman, Anne. The Spirit Catches You and You Fall differences between the ICD-10 and the DSM-
Down: A Hmong Child, Her American Doctors, IV-TR. Both favor behaviorally over etiologically
and the Collision of Two Cultures. New York: based descriptions of mental health disorders;
Farrar, Straus & Giroux, 1997. however, the ICD-10 is based on notions devel-
Guarnaccia, Peter J. and Lloyd H. Rogler. “Research oped by a cross-national group of clinical scien-
on Culture-Bound Syndromes: New Directions.” tists, where the DSM-IV-TR was developed by a
American Journal of Psychiatry, v.156 (1999). U.S. group, primarily psychiatrists. The DSM-IV-
Tseng, Wen-Shing. Clinician’s Guide to Cultural TR has been adopted in many countries, primarily
Psychology. San Diego, CA: Academic Press, 2003. Westernized and industrialized, but is reflective of
208 Diagnosis in Cross-National Context

the consensual professional standards and socio- stress disorders, and many childhood behavior
cultural context of the group that crafted it. disorders. In some national contexts, they are
ICD-10 and DSM-IV-TR diagnostic nomencla- less frequently diagnosed or are not thought to
tures are based on a mixture of scientific evidence be mental disorders; in other national contexts,
and practice-based and professional judgment they are viewed as prevalent and risk overdiagno-
of the editorial committees and their sponsoring sis. There is emerging evidence that some of these
organizations. In some areas, this leads to differ- disorders are growing in prevalence as countries
ent diagnostic conceptualizations: for example, (such as China) industrialize and Westernize and
the ICD-10 preserves the concept of neurosis, or as awareness of these disorders spreads.
mental disorder based on underlying intrapsychic Mental health symptoms are expressed and
conflicts; the DSM-IV-TR does not. The PDM dif- understood within the value system of a given
fers from the other systems in focusing on issues national context and culture. Societies’ values
of personality and intrapsychic underpinnings of affect the expression of symptoms according to
mental conditions. Some clinicians, mostly those how individualistic or collectivistic a society is,
favoring psychoanalytic theory, use it to comple- power based on status or income, how masculin-
ment the ICD-10 or DSM-IV-TR. All three major ity and femininity are perceived, and how soci-
diagnostic systems are in the process of develop- eties view avoidance of uncertainty or unclear
ing updated revisions. Thus, cross-national com- situations. Culture influences causes of distress,
parisons of mental health diagnosis are compli- methods of coping, types of illness and symp-
cated by ongoing evolutions of both objective toms, importance attributed to symptoms, help-
conditions and professional opinion. seeking behaviors, and social responses to distress
and illness. A universalistic approach to diag-
Patterns of Mental Health Diagnosis nosis emphasizes differences in the severity and
Across National Contexts frequency of mental illnesses worldwide through
Disorders shown to have a more biological com- standardization, validation, and utilization of
ponent, such as schizophrenia, carry a relatively assessment instruments. A relativistic approach
stable prevalence worldwide. However, several highlights the span of cultural variation in relation-
factors complicate reliable comparative estimates. ship to a specific disorder and does not attempt to
One set of factors involves diagnostic prefer- measure or quantify differences between cultures.
ences in specific national contexts. For example, Both views have adherents. Misidentification of
many persons diagnosed with manic depression mental illness, from a universalistic perspective,
in the United Kingdom would be diagnosed with may result from a cross-cultural misattunement
a schizophrenia-spectrum disorder in the United of the evaluator to normative presentation within
States. Clinicians in the two national contexts a specific culture; misidentification of mental ill-
might describe symptoms similarly in a given ness, from a relativistic perspective, may result
patient but denominate the resulting diagnosis dif- from under-recognition of mental illness within a
ferently. Cross-national differences in risk factors given culture, perhaps because of stigma or con-
for biologically based mental disorders further flict with the society’s values.
complicate comparisons. Because stress triggers
vulnerabilities (called diatheses) for biologically Methodologies of Mental Health
based mental illnesses, conditions of war, depriva- Diagnosis and Assessment
tion, unsafety, and underdevelopment can lead to Most often, clinical diagnosis is based primarily
greater prevalence of disorders in some national on clinical interviews of patients and/or their fam-
contexts. So do differences in access to treatment, ily members and caretakers, including evaluation
education, somatic health care, and rehabilita- of current behavioral and emotional presenta-
tion. It is difficult for researchers to separate the tion and relevant past history. It is not possible
role of these factors from professionals’ diag- to diagnose most mental health disorders apart
nostic decisions and preferences. Some disorders from this qualitative, subjective process. Depend-
are inseparably nested in sociocultural context, ing on clinician training and skill, which varies
such as attention deficit disorders, post-traumatic depending on the development of professions in
 Diagnosis in Cross-National Context 209

different countries, this process may be thorough treatment; and some seek mental health diagnoses
or schematic, careful or imprecise. Further, a cli- to qualify for accommodations on standardized
nician may hew closely to national professional educational tests. Public health systems also affect
norms or depart from them based on subjective cross-national mental health diagnostic compari-
judgment and preference. Research on mental sons. In some countries (e.g., in Scandinavia), reg-
health diagnosis tends to employ observer rating istries of mental health disorders facilitate research.
scales, patient self-report measures, and psycho- In others, such infrastructure is lacking.
logical tests. Because this approach departs from
standard clinical practice, it introduces a degree Stigma
of distortion, which can be attenuated, but not Stigma, or negative perceptions attributed to a
eliminated, by careful description and quality mental illness, exists cross-nationally in varying
control of data sources. degrees and manifestations. Studies have found
While valuable, quantitative research methodol- that mental health professionals are not immune
ogies also contribute to variation in diagnosis cross- to culturally based views that persons with mental
nationally. To standardize results in cross-national illness should be feared, are irresponsible, and are
studies, questionnaires are often translated. Trans- not capable of making their own choices; are prone
lation imprecision and culturally/nationally based to prostitution, addiction, and criminality; and
research instrument content are potential sources that mental illness, unlike physical illness, is the
of error in cross-national studies; some concepts responsibility of and controllable by the individual.
and symptoms do not directly translate or prove Clinicians, like others, can react to persons suffer-
equally meaningful across national contexts. ing from mental illness with anger, dislike, lack of
Again, methodological care can attenuate these sympathy, and neglect. These feelings and preju-
problems; those consuming research study results dices, despite clinical training, can color diagnosis,
must independently appraise methodology before in ways mediated by cultural and national context.
assuming that results are applicable. Measures advocated to attenuate the impact of
Diagnosis takes place in the context of a coun- stigma-based biases on diagnosis of mental illness
try’s mental health system. This can be based in have included systematic use of formal diagnostic
private practice models, national health systems, or systems and structured/objective assessment tools,
mixed models. Independent of model but related to improvements in clinical training about issues of
issues of national development and income level, culture and stigma, and clinical supervision of
countries differ in access to mental health care and diagnosticians. However, evidence of the effect of
thus diagnosis as a first stage in care. In countries these measures has been difficult to document.
with poor or limited access to care, most mental Somatization, or physical symptoms represent-
health disorders either go undiagnosed or may be ing psychological distress, may reflect a culture’s
diagnosed by those with little or no training in attitude toward and acceptance of mental illness.
mental health diagnosis. This can lead to prob- Studies in various national contexts convey the
lems of underdiagnosis and misdiagnosis, and to universality of somatization, but the nature and
cultural or religious perceptions coloring diagnos- significance of somatic symptoms of mental etiol-
tic decision making. For example, dissidents or ogy widely vary across cultures. Somatization is
women can be diagnosed as mentally disturbed variously understood as presentation of physical
for not conforming to prevailing values. In coun- symptoms in the absence of organic pathology, in
tries with more developed mental health systems, place of emotional or social problems, or as pat-
other distorted patterns of mental health diagnosis terns of behavior influenced by emotions. Because
can emerge, sometimes based on issues of objec- somatic symptoms may or may not reflect soma-
tive or perceived privilege. In the United States, tization, evidence permitting accurate cross-
for example, disproportionate diagnosis of mental national comparison of somatization diagnoses is
health disorders among minority groups has been difficult to obtain.
attributed to racial and ethnic prejudice; clinicians Some explain somatization by cultural differ-
have been found to misstate mental health diagno- ences in the way that the mind-body connection
ses to prevent insurers from foreclosing access to is perceived. Some cultures express emotions in
210 Diazepam

a way that merges body and mind; others dis- Draguns, J. G. and J. Tanaka-Matsumi. “Assessment
tinguish between the two. What may look like of Psychopathology Across and Within Cultures:
physical symptoms masking mental illness to a Issues and Findings.” Behaviour Research and
Westerner may be a natural fusion of body and Therapy, v.41 (2003).
mind illness to a non-Westerner. Somatization has Kirmayer, L. J. “Culture, Affect, and Somatization.”
alternatively been understood as emotional sup- Transcultural Psychiatry, v.21/4 (1982).
pression in cultures where emotional displays are World Health Organization. “Cross-National
thought to be signs of weakness or violation of Comparisons of the Prevalences and Correlates of
social etiquette; bodily metaphors for emotional Mental Disorders.” Bulletin of the World Health
states in cultures lacking vocabulary for emotional Organization, v.78/4 (2000).
states; or a reaction to stigma surrounding mental
illness, contrasting with the relative acceptance
of physical ailments. Researchers debate whether
mental illness is manifested differently in indi-
viduals across cultures or whether mental illness Diagnostic and
presents physically because of a cultural prefer-
ence to avoid discussion of psychological matters. Statistical Manual of
Cross-national studies of somatization highlight
its variable nature and presentation. Because of
Mental Disorders
this, as well as the multifaceted role of culture in See DSM-III; DSM-IV; DSM-5
somatization, differences in cross-national preva-
lence of somatization are difficult to interpret and
are a focus of continuing study.
A limited number of mental health disorders are
culture-specific. Examples include hysteria in sexu- Diazepam
ally repressive societies, culture-specific substance
abuse disorders such as glue-sniffing opium addic- Diazepam is a benzodiazepine that is utilized for
tions, amok (sociopathic psychotic rage) in Malay treatment of anxiety disorders, agitation, tremors,
cultures, and affective and psychotic syndromes delirium, seizures, alcohol withdrawal, seizures,
based in beliefs in witchcraft or spirit possession. and muscle spasms. The first benzodiazepine,
Clinicians working in countries where these may chlordiazepoxide (Librium), was introduced in
be prevalent, indigenously or among immigrants, 1960, and many other benzodiazepines were
must become familiar with their characteristics introduced within the first 15 years of this drug
and diagnosis so they are not inadvertently con- class. In 1977, the mechanism of action for benzo-
fused with other mental or physical disorders. diazepines in the nervous system was established
with diazepam, and subsequent studies showed
Richard Ruth significant effectiveness of the medication for
Ayelet Krieger treatment of anxiety. Diazepam works by promot-
Andrea Liner ing gamma-aminobutyric acid (GABA) functions
George Washington University that inhibit activity in neural pathways, particu-
larly in the limbic system, thalamus, and hypothal-
See Also: Cross-National Prevalence Estimates; amus. With a relatively short half-life, diazepam
Diagnosis; Ethnopsychiatry; International is metabolized quickly and effectively. While fre-
Comparisons; Mental Illness Defined: Historical quently used to treat conditions of anxiety, side
Perspectives; Somatization of Distress. effects include risks for ataxia, drowsiness, and
fatigue. Like other benzodiazepines, consumers of
Further Readings diazepam are at increased risk of substance depen-
Corrigan, P. W. and D. L. Penn. “Lessons From Social dence. As a minor tranquilizer, diazepam can be
Psychology on Discrediting Psychiatric Stigma.” used nonmedically by addiction-prone individuals
American Psychologist, v.54/9 (1990). for intoxicating euphoric sensations.
 Diazepam 211

Diazepam is a colorless compound that can deficits can be irreversible. Sedative effects of
be administered in tablet, solution, injection, diazepam appear to be from increased GABA
and rectal gel formats. Chemically, diazepam is effects in the cerebral cortex. Additionally, diaz-
7-chloro-1,3dihydro-1-methyl-5phenyl-2H-1, epam is effective as a muscle relaxant because of
4-benzodiazepine-2-one. Particularly in the lim- inhibition of synaptic activity in the cerebellum,
bic system, benzodiazepine receptors tend to be spinal cord, and brain stem. Diazepam has addi-
located in proximity of GABAA receptor sites. tionally been known to be an effective anticonvul-
GABA is an inhibitory neurotransmitter that sant, and it is postulated that the desired effect is
decreases nervous system activity—particularly achieved through suppression of synaptic activity
in anxiety and limbic system pathways—by open- in the cerebellum and hippocampus.
ing chloride ion channels in the aforementioned
receptor sites. Diazepam binds to benzodiazepine Therapeutic Uses
receptor sites on the GABAA receptor, and the Regarding therapeutic uses, diazepam is indi-
chloride ion channel is opened further; thus, diaz- cated for treatment of anxiety disorders, and it is
epam increases GABA’s inhibitory effect on neural also utilized for short-term management of acute
synapses. As benzodiazepine receptors tend to be anxiety symptoms. Diazepam and other benzodi-
most dense in the limbic system, such inhibitory azepines are also often used to assist with anxi-
effects decrease activity in anxiety pathways of ety, agitation, and tremors associated with alco-
the brain, yielding a calming effect. hol withdrawal. While diazepam is useful as an
With regard to pharmacokinetics, diazepam is anticonvulsant, it is not typically effective as the
marketed for use as a sedative, anxiolytic, muscle sole intervention. While diazepam is effective in
relaxant, anticonvulsant, and intravenous anes- treating a number of concerns, it is contraindi-
thetic. With regard to absorption in the body, diaz- cated for individuals who are pregnant because
epam reaches peak concentration in the blood in of increased risk of birth defects. Most adverse
about an hour when taken orally. Diazepam’s half- effects of diazepam are related to dosage. These
life is approximately 24 hours, which allows for include drowsiness, lethargy, ataxia, sedation,
its long-acting effects for enhancing GABA activity. confusion, slurring of speech, disorientation,
Diazepam is metabolized by the liver into the inter- amnesia, and psychomotor retardation. Although
mediate active metabolite nordiazepam. However, a depressant, diazepam does not diminish respi-
nordiazepam has an average half-life of 60 hours. ration or vital functions to fatal levels, even at
Given this extended half-life, paired with increased higher doses, but it can be fatal when paired with
difficulty in metabolism because of aging, it could an additional depressant. Because of sedation
take an elderly individual as long as two months and drowsiness, increased risks for vehicular and
to completely metabolize and excrete a single dose work-related accidents are present during usage.
of diazepam. Nordiazepam is eventually further Sleep disturbances have also been observed.
metabolized into the inactive glucuronide-conju- With regard to addiction, benzodiazepines pres-
gated metabolite, which is excreted in the urine. ent a number of risks. First, an increased risk of
Diazepam has been marketed in the United chemical dependence is present when diazepam
States as Valium as an oral medication, and it has is taken for extended periods. Additionally, with-
been marketed as a rectal gel by the trade name drawal symptoms of insomnia, nausea, vomiting,
of Diastat. In Australia, diazepam is marketed as and headaches can follow termination of long-
Antenex. Lower doses of diazepam decrease anxi- term use at therapeutic dosage levels. When depen-
ety, agitation, and fear through the previously dence is present, the use of tapering dosages can
mentioned inhibitory amplification of GABAA allow effective discontinuation of the drug. While
receptors located in the hippocampus and amyg- tolerance can develop, it is not as pronounced as
dala. At higher doses, diazepam can have amnes- it is with some depressants. In addition to conven-
tic effects because of suppression of activity of tional use of diazepam, nonmedical use by poly-
neurons in the hippocampus and frontal cortex. drug abusers occurs for enhancing the euphoric
Amnestic effects can last as long as six months effect of narcotics, for compensating for effects of
after discontinuation of use, and some cognitive cocaine toxicity, and to reduce anxiety that can be
212 Disability

experienced during opioid addiction. Nonmedical that were “natural” or “normal” and contrasted
use likely peaked in the mid-1970s, but it remains these with what was considered “monstrous” or
a concern today. Women are prescribed more “defective.” As scientists catalogued the variations
diazepam each year than men because of higher in people’s bodies and capacities, they made judg-
prevalence rates for anxiety among women, lower ments about the value of the lives of the people
frequency of professional help seeking among they studied. In the 19th century, as the theory of
men, and the higher percentage of men that self- evolution mixed with the era’s crude racial ste-
medicate with alcohol. reotypes, researchers began to describe both non-
white races and disabled people as regressions or
Gerald E. Nissley, Jr. throwbacks.
East Texas Baptist University For example, the physician who first identified
Down syndrome called it Mongolism because he
See Also: Anxiety, Chronic; Benzodiazepines; Clinical understood it as a biological reversion by Cau-
Psychology; Minor Tranquilizers. casians to the Mongol racial type. This mode of
thought, called social Darwinism, set the stage for
Further Readings the eugenics movement and the Nazi Holocaust
Julien, Robert. A Primer of Drug Action: A Concise, and also played a role in immigration laws that
Nontechnical Guide to the Actions, Uses, and Side forbade entry, both to members of ethnic groups
Effects of Psychoactive Drugs. New York: Freeman thought to be prone to criminality or deformity
and Co., 1996. and to people with mental or physical defects.
Preston, John, John O’Neal, and Mary Talaga. The mission of state institutions for people with
Handbook of Clinical Psychopharmacology for mental illness and developmental disabilities
Therapists. Oakland, CA: New Harbinger, 1999. also changed. Promoted in the 1840s as moral
Ricketts, Karl, et al. “Long-Term Diazepam Therapy reforms, by the early 20th century, the institu-
and Clinical Outcome.” Journal of the American tions were more frequently described as a means
Medical Association, v.250/6 (1983). of social control. They kept members of produc-
tive society safe and separated ordinary citizens
from those now described as subnormal. People
receiving care in these institutions suffered a type
of social death. They were rendered powerless,
Disability totally dependent on the professionals in charge
who dictated treatment and subject to the actions
The modern concept of disability includes three of the “orderlies” who controlled daily life.
linked components. One aspect concerns visible The rediscovery of human rights and civil rights
or invisible differences between people compared among people with disabilities that commenced in
to “normal.” A second aspect relates to a person’s the second half of the 20th century followed on
capacity to perform a range of tasks at home or the heels of struggles for racial and gender equal-
work. The third aspect relates to the social regard ity in the United States. Key pieces of federal leg-
for persons in such circumstances. The term dis- islation include the Rehabilitation Act of 1973,
ability has additional technical meanings in legis- which established a right of reasonable accom-
lation relating to employment, civil rights, insur- modation in federally funded programs; the Indi-
ance, or public benefits. The concept of disability viduals with Disabilities in Education Act (IDEA),
has changed over time. which guaranteed children with an enumerated list
Human society has always included people of disabilities access to a “free, appropriate public
who could not see, walk, or hear, and people with education”; and the Americans with Disabilities
limited mobility, intellect, or other reduced func- Act (ADA) of 1990. Although the ADA’s impact
tioning, yet the concept of disability as a phenom- in the area of employment rights was subsequently
enon that might be studied or discussed arrived restricted by the federal courts, Congress over-
relatively recently to Western society, in the mid- turned these judicial restrictions in 2008. The U.S.
19th century. People initially spoke of conditions Supreme Court’s 1999 Olmstead v. L. C. decision
 Disability 213

limited state policies that segregated people with Stigma is deeply attached to stereotype: it tends
disabilities from communities, establishing a fed- to disappear when people actually get to know
eral right to care in “the least restrictive setting.” each other. Antistigma efforts that use a social
inclusion model have shown greater effectiveness
Stigma than those based purely on public education or
Disability connects with stigma, an “attribute that messaging.
is deeply discrediting” and that reduces the bearer
“from a whole and usual person to a tainted, dis- Legal Aspects
counted one,” in the words of sociologist Erving The disempowering effects of disability-con-
Goffman. Stigma originates from a process that nected stigma often lead to questions about what
involves labeling, linking to negative stereotypes, is best for people, and even whether a person
separation of “us” from “them,” and status loss with a disability is to be accorded authority when
and discrimination that leads to unequal out- speaking or writing about his experience of life.
comes. Ultimately, stigma leads to partial or com- Disempowerment issues frequently arise with
plete disempowerment. respect to people with mental illness. It is one
Stigma is a bundle of concepts. Concealability thing to say that a person’s choices about behav-
relates to whether the condition is visible or can be ior or lifestyle should be respected, even if the
more easily hidden. Course involves whether the choices are idiosyncratic or disagreeable, but it is
condition is reversible or subject to improvement. another matter when a medical or mental health
Disruptiveness relates to how the condition affects condition affects a person’s capacity to be safe.
relationships with others (this includes such fac- To respond to such circumstances, every state
tors as unpredictability or the potential for socially has processes for compulsory treatment and for
inept or embarrassing actions). Aesthetics relates to guardianship or other forms of substitute deci-
how pleasing or displeasing a condition is, as well sion making.
as the potential to generate feelings of disgust. Ori- In a legal context, disability issues commonly
gin refers to how the condition came to be; there is arise when courts and legislation must determine
usually more stigma attributed to something that is who is to be deprived of civil rights, absolved of
regarded as a person’s fault. The final dimension is blame for otherwise criminal behavior, afforded
peril, the extent of the potential threat attributed to protection related to education or employment,
the condition. This can be actual fear of contagion or issued government benefit payments. Different
involving a disease like leprosy or human immu- legal definitions of disability apply in each context.
nodeficiency virus and acquired immune deficiency Procedural and evidentiary standards also vary. In
syndrome (HIV/AIDS) or exposure to uncomfort- the United States, the most stringent definitions
able feelings by witnessing someone else’s vulner- with the highest evidentiary standards (typically
ability (e.g., watching a person’s painful struggle to “beyond a reasonable doubt”) and the most formal
climb a flight of stairs). procedures apply in criminal law cases. Decisions
Stigma relating to mental illness plays out in about mandatory treatment, substitute decision
three main patterns. Public stigma, private stigma, making, or civil commitment involve somewhat
and label avoidance. Public stigma involves others reduced degree of impairment, an enhanced evi-
who endorse the stigma and discriminate against dentiary burden (“clear and convincing” evidence),
people with mental illness. Self-stigma involves plus prompt initial review and periodic review by
a person who internalizes negative stereotypes an independent person or by civil courts.
impacting self-esteem (“I am not worthy”) and In employment and education discrimination
self-efficacy (“I am not able”) leading to self-blame, cases, definitions of disability are more inclusive,
hopelessness, and helplessness. Label avoidance and evidentiary burdens are usually reduced (“a
refers to people who seek to avoid stigma by not preponderance” of evidence). Very specific mea-
seeking services. For caregivers and professionals, sures of impairment apply in government benefits
there is a fourth pattern called “courtesy stigma,” cases. These cases also feature a very structured
when a person is devalued by association with bureaucratic process, plus more limited access to
people who have mental health problems. court review.
214 Disasters

In discrimination cases, the most frequently Disasters

encountered definition of disability is the one set
out in the Americans with Disabilities Act. The The terms hazard, emergency, disaster, and catas-
ADA protects people who have, or are regarded trophe are often interchangeably used, although
as having, “a physical or mental impairment that they have different meanings. The response
substantially limits a major life activity.” The to and potential short- and long-term mental
“regarded as” language protects people who are health effects of these different events vary based
thought to have limits, even if their condition on event type, speed of onset, and duration of
does not actually limit them in that way. Under impact; characteristics of the affected population,
the ADA and similar antidiscrimination statutes, community, and cultural context; and availabil-
covered entities must provide “reasonable accom- ity of resources and informal and formal support
modations” to allow people with disabilities to mechanisms.
participate in employment or education. A hazard is a threat to people and the things
The IDEA goes beyond mere antidiscrimination. they value. Hazards are often described by their
It requires states to provide a “free and appropriate origin and may include natural hazards such
public education” (which can involve an expensive as hurricanes, earthquakes, tornadoes, floods,
array of services) to a more limited population of or wildfires; technological hazards such as dam
students with more severe medical conditions. The failures, toxic spills, or chemical releases; public
Social Security Administration uses one of the most health hazards such as influenza outbreaks or
restrictive definitions of disability. To qualify for waterborne diseases; and willful acts of mass vio-
monthly payments, a person must be “totally dis- lence such as school shootings or terrorist attacks.
abled.” Section 223(d)(1) of the Social Security Act These different hazards arise from the interaction
defines disability as an inability to engage in any between social, technological, and natural sys-
substantial gainful activity by reason of any medi- tems. Each hazard type has the potential to cause
cally determinable physical or mental impairment harm to health, life, safety, and/or the built and
that can be expected to result in death or which has natural environments. Cascading hazards include
lasted or can be expected to last for a continuous complex situations where one hazard triggers one
period of no less than 12 months. or more additional hazards. Examples of cascad-
ing hazards include a hurricane that generates an
Paul Komarek oil spill, or an earthquake that causes a tsunami
Independent Scholar that leads to a nuclear release.
An emergency is an event that moves beyond
See Also: Labeling; “Normal”: Definitions and the potential of a hazard and poses an imminent
Controversies; Patient Rights; Policy: Federal threat to people and property. Emergencies are
Government; Stigma. situations that require an immediate response
but can be adequately managed at the local level
Further Readings by designated responders, such as police offi-
Baynton, D. “Disability in History.” Perspectives, cers, firefighters, emergency medical technicians,
v.44 (2006). and public health officials, using local resources.
Goffman, E. Stigma: Notes on the Management of These events are often classified as routine emer-
Spoiled Identity. London: Penguin Books, 1990. gencies or accidents because of their frequency of
Link, B., et al. “Measuring Mental Illness Stigma.” occurrence. A fire that requires a fire department
Schizophrenia Bulletin, v.30/3 (2004). response occurs every 24 seconds in the United
Rosiak, Luke. “Discrimination Lawsuits Double as States. Most communities prepare for emergen-
Definition of ‘Disability’ Expands.” Washington cies and have dedicated fire stations and other
Times (May 31, 2012). emergency management systems meant to han-
U.S. Social Security Administration. “Annual dle such events. Further, most individuals in the
Statistical Report on the Social Security Disability United States, at some point in their lives, will
Insurance Program, 2011.” Baltimore, MD: U.S. participate in fire drills or other event-specific
Social Security Administration, 2012. training exercises.
 Disasters 215

Two Moore, Oklahoma, residents comfort each other after an exhausting day of sifting through debris to find belongings, May 22,
2013. The Moore area was struck by an F5 tornado on May 20. In the immediate aftermath of a disaster, it is normal for people
to experience powerful emotional reactions: shock, horror, disbelief, anxiety, fear, anger, and the need to find and help family, pets,
neighbors, and friends. The size, closeness, and activeness of a person’s social network is directly related to mental health functioning.

Disaster Definitions distinguish disasters: speed and duration of onset,

A disaster is a potentially traumatic event that predictability and length of advance warning,
is collectively experienced and is concentrated frequency or probability of occurrence, intensity,
in time and space. The World Health Organiza- and scope. Disasters may also produce a range of
tion defines a disaster as an event involving 100 impacts. Potential direct effects include deaths,
or more persons, with 10 or more deaths, and injuries, property damage, crop losses, and popu-
an official disaster declaration or an appeal for lation displacement. Secondary disaster impacts
assistance. Disasters are of a qualitatively and include damages and losses that are triggered
quantitatively different magnitude than emer- by the initial precipitating event. Indirect losses
gencies. Although disasters occur less frequently include ripple effects that result from short- and
than emergencies, they cause more widespread long-term disruptions to social, economic, cul-
destruction and tend to disrupt people’s lives and tural, and physical systems caused by disasters.
communities for much longer periods of time All of these elements have implications for plan-
than more common emergency situations. For ning and recovery and can be used when develop-
this reason, disasters are often referred to as low- ing all-hazards plans.
probability, high-consequence events. Most all-hazards approaches recognize four
However, disasters are not uniform events. phases of a disaster. The first phase, mitigation,
Differences exist between disasters (e.g., natu- seeks to minimize the effects of a potential future
ral versus technological) and variability exists disaster. Mitigation may be structural (e.g., ret-
within any specific type of disaster (e.g., some rofitting buildings in earthquake zones, or ele-
earthquakes are bigger and more damaging than vating houses in floodplains) or nonstructural
others). A number of additional parameters (e.g., planning and zoning to avoid building
216 Disasters

infrastructure in hazardous regions). Disaster a catastrophe, most if not all of the everyday
preparedness, the second phase, includes a vari- community functions are sharply and simultane-
ety of actions taken by families, households, and ously interrupted. In a catastrophe, businesses,
communities to prepare for disasters. Prepared- schools, places of worship, and other centers of
ness actions may take the form of devising disas- community life are entirely shut down in response
ter plans, gathering emergency supplies, train- to the extensive disruption of lifelines and criti-
ing response teams, and educating children and cal infrastructure. Fourth, in catastrophes, help
adults about hazards. The third phase, response, from nearby communities cannot be provided.
involves taking action to reduce the harm and Catastrophes tend to affect multiple communities
losses created by a disaster. The response phase and tend to have a regional character. Hurricane
often entails warning and evacuating people, Katrina, for example, directly affected five south-
rescue activities, and relief operations. The final ern states and led to massive population displace-
phase is recovery, which implies putting a disas- ment across the remainder of the United States.
ter-stricken community back together, lasting Catastrophes require more resources than
from weeks to years. are available in the immediate geographic area.
Much of the available research on disasters in Essential services such as food, water, housing,
the social and behavioral sciences has focused on health care, and sanitation are usually disrupted
sudden-onset, acute disaster events. Yet, in recent for prolonged periods of time. The psychologi-
years, some scholars have argued for a broader cal effects of a high death rate, combined with a
definition of disaster that would also encompass surge in those seeking assistance and services, can
more slow-evolving disasters. The 2012 drought easily overwhelm available systems of care. The
is one such example. Below-normal precipitation ability of relief workers, disaster response person-
resulted in more than one-half of the contigu- nel, and medical and mental health providers to
ous United States experiencing severe to extreme quickly mobilize and the availability of needed
drought. The federal government declared coun- resources such as water, food, and shelter, affect
ties in 29 states as federal disaster areas to allow the recovery of the surviving population. Private
farmers to apply for low-interest loans to the resources may be commandeered by government
U.S. Farm Services Agency. Inability to maintain agencies as the needs of affected groups of people
quality of life in these drought-stricken areas take precedence over individual needs.
exacted an emotional toll on residents and had
far-reaching impact on those living in nonaf- Disasters and Mental Health
fected states as food costs rose and water supply In the immediate aftermath of a disaster, it is nor-
dwindled. mal for people of all ages to experience power-
ful emotional reactions: feelings of shock, hor-
Catastrophe Definitions ror, and disbelief; concerns that the event has not
A catastrophe is a sudden and extreme event that ended; intense personal emotions such as anxiety,
causes an upheaval in the order of communities fear, and anger; and the need to find and help fam-
and requires an extensive recovery process that ily, pets, neighbors, and friends. The size, close-
may fundamentally alter the surrounding envi- ness, and activeness of a person’s social network
ronment. The magnitude of a catastrophe is much is directly related to mental health functioning.
greater than a disaster. These socially protective resources are particu-
There are four primary elements that distin- larly at risk of disruption and decline following
guish a catastrophe from a disaster. First, in a a disaster.
catastrophe, all or most of the community infra- Although social support is often mobilized
structure is significantly damaged or destroyed. In when a person’s life or health is threatened after a
contrast, only parts of a community are typically disaster, assistance is less available when property
impacted in disasters. Second, during and fol- is damaged or destroyed and electricity or phone
lowing a catastrophe, local officials are unable to communication is lost. It is likely that many mem-
undertake their usual work roles, and this often bers of the social support network will also be
extends well into the recovery period. Third, in survivors of the same disaster and will be unable
 Disasters 217

to assist because their immediate needs exceed Mental health researchers have classified disas-
their current resources. ters into low-impact, moderate-impact, and high-
Relief workers can provide temporary support impact events, based on the levels of impairment
and assistance in re-establishing and strengthen- in the sample populations who experienced them.
ing support networks by providing education High-impact events cause the most severe rates
about the range of normal psychological reactions and enduring levels of mental health impairment
to disaster, sharing strategies to manage stress and among affected populations. Events that cause the
enhance coping, and making timely referrals to most severe destruction and disruption tend to lead
needed resources. The challenge to mental health to the most serious mental health impacts. More-
professionals and trained volunteers is to find over, disasters caused by malicious human intent,
a balance in responding to the special needs of such as terrorist attacks, are generally more dis-
vulnerable populations, as well as supporting the turbing than natural or technological disasters. In
resiliency of others in the larger affected commu- these high-impact events, there may be a greater
nity or region. Effective screening measures need need for delivery of psychological first aid and cri-
to be validated so that those at risk for postdi- sis counseling to avoid lasting, severe, and perva-
saster psychopathology can be quickly and accu- sive psychological disturbances. Crisis intervention
rately identified. Programs to reduce stigma and is now widely recognized as an effective treatment
enhance attractiveness of mental health interven- modality for emergency mental health care to indi-
tions need to be developed. viduals and groups. However, for the majority of
Regarding long-term mental health con- adults, most untreated psychological distress that
sequences, in many instances, disaster survi- occurs shortly after a disaster will abate in time.
vors may have to adjust to a new normal. In
the case of a tornado, entire communities may Lisa M. Brown
be destroyed in a matter of minutes. Personal University of South Florida
belongings, homes, community institutions, and Lori Peek
tree-lined streets may disappear during a single Colorado State University
storm. Even though the replacement structures
that are built after the storm will be new and See Also: Bereavement; Community Mental Health
perhaps better than what existed, these buildings Centers; Post-Traumatic Stress Disorder; Stress;
will not be the same as what was standing before Trauma: Patient’s View; Trauma, Psychology of;
the tornado. People grieve the loss of what was, Vulnerability.
and some will have difficulty adjusting to the
new normal. People may be reluctant, ashamed, Further Readings
or embarrassed to admit and discuss mental Cutter, Susan L., ed. American Hazardscapes:
health problems, given the mass devastation, The Regionalization of Hazards and Disasters.
injury, and deaths in the aftermath of disaster. Washington, DC: Joseph Henry Press, 2001.
Education to decrease misattribution of somatic Kaniasty, Krzysztof. “60,000 Disaster Victims Speak:
symptoms and increase acceptance of mental Part I. An Empirical Review of the Empirical
health treatment should be provided. Literature.” Psychiatry, v.65/3 (2002).
Characteristics of affected populations also Mileti, Dennis S. Disasters by Design: A Reassessment
influence postdisaster mental health outcomes. of Hazards and Disasters in the United States.
Age is one of many predisaster, within-disaster, and Washington, DC: Joseph Henry Press, 1999.
postdisaster risk factors that mediate the severity of Norris, Fran H., Matthew J. Friedman, Patricia J.
adverse consequences. Analyses of the relationship Watson, Christopher M. Byrne, Eolia Diaz, and
of age and disasters reveal that children and youth Sandro Galea. Methods for Disaster Mental Health
are the most vulnerable to severe mental health Research. New York: Guilford Press, 2006.
problems after disaster. People living in poverty, Tierney, Kathleen J., Michael K. Lindell, and Ronald
and especially those in developing countries, are W. Perry. Facing the Unexpected: Disaster
more at risk for adverse outcomes, as are women, Preparedness and Response in the United States.
ethnic minorities, and middle-aged people. Washington, DC: Joseph Henry Press, 2001.
218 Dissociative Disorders

Dissociative Disorders that are culturally forbidden. Dissociation, trance,

and possession are ways to express those aspects
Identity, memory, and consciousness/perception of self within the community in culturally sanc-
are integrated systems. Dissociation, or dissocia- tioned ways. It is also a way to emotionally cope
tive episodes, are moments when that integration with oppression for those in the community with
is altered or disturbed. Dissociation is also termed little power.
an altered state of consciousness. These states Twin studies have demonstrated that some of the
may arise as part of cultural rituals. variability in pathological dissociation is genetic.
Dissociative states exist on a continuum. On The variability of dissociative states across cul-
the lower-intensity end, there are short periods tures, and their fluctuation dependent on changes
of focused attention where all other awareness in the sociocultural environment, or acculturation
falls away, episodes of daydreaming, or periods of immigrants, suggests that there is also a largely
of highway hypnosis. The higher-intensity end cultural etiology to dissociative expression.
ranges up to prolonged and extreme alterations of
identity, such as is seen in persons with multiple Nonpathological Dissociative States
personality syndrome (dissociative identity disor- Dissociation is less pathologized in cultures where
der), which causes marked distress and would be the self is not fully internal but rather permeable
considered disordered by the culture in which the or integrated with the larger community or uni-
individual exists. verse. In these cultures, disturbances in conscious-
The majority of cultures the world over have ness can be seen as an increase in connection to
current or historical reports of dissociative states, others/spirits rather than a breakdown of the self.
so the existence of dissociation is universal. The Many of these dissociative states arise from
appearance of dissociative states is largely shaped rituals (communal coping). Some have a reward-
by culture, including cultures that believe in pos- ing effect on either the person or the community
session. There are two proposed etiologies for dis- affected. In north and east Africa, Egyptian and
sociative states. One is a medical model and the Sudanese women use ritual dissociation to cope
other is anthropological. with unhappiness, oppression, and patriarchy.
The medical model primarily deals with dis- The Kung bushmen in Africa participate in trance
ordered dissociation. A prime factor in etiology dances led by the tribal shaman, where trance is
under this model is trauma, particularly childhood induced in the tribesmen as they dance. This dem-
sexual trauma, which is related to many types of onstrates tribal oneness with nature.
disordered dissociation across multiple cultures. Other societies have used ritual dissociation for
This causal link is absent for ritualized dissocia- healing specifically, such as the Nigerian Tuareg.
tion, nonpathological dissociation, or possession They use music and dance to induce trance (disso-
trance. Under this theory, dissociation is a defense ciation) to heal tamazai, a physical and spiritual
against the experience of trauma when a person illness. Trance dances with ritual music and move-
cannot physically escape it. ment are also found in Native American tribes,
The anthropological understanding of disso- Australian indigenous people, and the Indonesian
ciation relates to the role that dissociation plays Balinese. Trance in these cultures involves emo-
in the community, particularly as a language of tional expression sanctioned by the community.
healing or distress. Dissociative states can com- In addition to healing, some cultures use ritual
municate something to the audience, whether that dissociation/trance to protect from evil. In Israel,
audience is other tribesmen in a ritualized dance Tunisian immigrants perform a trance dance
or medical professionals in a diagnosed dissocia- called stambali to protect and heal. In Indone-
tive disorder. sia, the Tana Toraja perform a ma’maro ritual to
For some ritualized dissociation, one can under- increase prosperity and ward off misfortune.
stand the behaviors performed in the dissociative
state as an expression of parts of the self that are Dissociation and Religion
unacceptable to the community. They are behav- Many religious and spiritual communities have
iors such as eroticism, aggression, or vulgarity ritualized understandings of dissociation. Jewish
 Dissociative Disorders 219

Hasidim chant and dance in order to remove the is called latah. Sometimes, it is considered enter-
boundaries between self and God. Sufism has taining and harmless by others.
a similar practice called zikr, where chanting Pibloktoq is a dissociative episode in the Arctic
and movement allow one to become one with native peoples, lasting up to 12 hours and involv-
Allah. Non-Hasidic Judaism teaches prayers that ing aggressive and dangerous acts, seizures, and
involve movement and focused attention. Some coma. Because of the many cultures among the
Christian traditions, notably Pentecostal, ritual- native peoples, there are multiple names for this.
ize speaking in tongues as a form of nonpatho- It typically involves amnesia.
logical dissociative state. Other religious tradi- In Latin America, susto/el espanto is a dissocia-
tions that incorporate altered consciousness into tive state explained by the loss of the soul from the
a ritual connection to God include Thaipusam body following a stressful or frightening event.
(dissociation from physical pain), the Yoruba In the southern United States and the Carib-
religion that uses trance to increase spiritual bean, a dissociative episode involving collapse
power, and Afro-Brazilian and Afro-Caribbean and temporary inability to see, move, or respond,
cultures that use ritual trance to manage anxiety though with the ability to hear and understand, is
and other emotions. called “falling-out” or “blacking out.”
Possession trance is a specific form of dissocia- Recognized by the Chinese Classification of
tion where one’s identity is replaced. The etiology Mental Disorders, a “Qi-gong psychotic reac-
is believed to be a spirit, deity, or other person tion” is a dissociative episode involving paranoia
taking control of the physical body of a person. and psychotic symptoms related to the practice of
In some cultures, this can include demonic posses- Qi-gong.
sion, where evil spirits take control. Whereas in A “possession and trance disorder,” recognized
some cultures, possession is ritualized and sanc- by the International Statistical Classification of
tioned, typically demonic possession is seen as Diseases (ICD-10), is a distressing experience,
involuntary and unwelcome. In addition to many either single or episodic. Trance involves altera-
regional or ethnic cultures believing in posses- tion of identity, and possession is replacement of
sion, it is also a common religious belief appear- identity, typically with amnesia for the episode.
ing in Christianity, Islam, Judaism, Confucianism, Also recognized by the ICD-10 and the Diag-
Shintoism, Buddhism, Hinduism, and faiths that nostic and Statistical Manual of Mental Disorders
include ancestor worship. Spirit possession may (DSM-IV-TR), dissociative fugue is character-
involve some amnesia. ized by running/flight from home community and
There is evidence that possession trance exists amnesia. It is similar to the practice of pibloktoq
in about half of the world’s cultures, though its and amok, as well as grisi siknis in Honduras and
presence also fluctuates with sociopolitical mores, Nicaragua, and “frenzy witchcraft” among the
so is not a static element of a culture or religion. Navajo.
Recognized by the ICD-10 and DSM-IV-TR,
Dissociative Disorders “depersonalization disorder” is a persistent feel-
Whether a dissociative state is considered disor- ing of disconnect from one’s mental processes.
dered is highly culture dependent; what is consid- It should be distinguished from nondisordered,
ered harmless within a culture may be considered community-sanctioned trance states and from
disordered by external observers. Many dissocia- psychotic disorders. This is diagnosed more fre-
tive disorders are culture bound. quently in women.
In Malaysia, Laos, the Phillipines, Polynesia, Also recognized by the ICD-10 and DSM-IV-
Papua New Guinea, Puerto Rico, and among the TR, “dissociative amnesia” is a significant mem-
Navajo tribes, an episode of aggressive dissocia- ory loss for autobiographical information, also
tion preceded by brooding is called amok. Return known as “psychogenic amnesia.”
to premorbid functioning following the attack is Also recognized by the ICD-10 and DSM-IV-
typical. Primary prevalence is among males. TR, dissociative identity disorder is the dissocia-
In Indonesia, dissociation involving exaggerated tive disorder formerly called multiple personality
startle response, obscenity, and hypersuggestibility disorder because of the salient feature of multiple
220 Dopamine

distinctive personalities or alters inhabiting the considered to be precursor of the neurotransmit-

same physical body. Though it has been found ter norepinephrine.
in multiple cultures, it is most prevalent in North Carlsson developed a technique to isolate and
America and is most common among women. It measure dopamine in brain tissues and subse-
began to appear in Western cultures in the 19th quently demonstrated that this neurotransmitter
century and is distinct from possession trance was present in high concentrations in the basal
in its chronicity, high trauma correlation, and ganglia, an area of the brain that is heavily involved
multiplicity of identities. Significant controversy in bodily movements. He then made use of the
remains around this diagnosis, with various theo- drug reserpine, which had been isolated from the
ries positing that it is a culture-bound syndrome, dried root of rauwolfia serpentina (Indian snake-
it is a product of the cultural pathology and frag- root), a traditional folk remedy for insanity, fever,
mentation in American culture, or that it should and snakebites, to reduce dopamine levels in this
not be a diagnostic category at all because symp- region of the brain. Reserpine had been isolated
toms can be explained by suggestibility of trau- in 1952, and researchers had examined the com-
matized clients. pound for its possible antipsychotic effects. For
a time, it was utilized alongside chlorpromazine
Laura Johnson (Thorazine), and it also found some uses in the
Chicago School of Professional Psychology management of hypertension, though ultimately,
its side-effect profile led physicians in most coun-
See Also: Hypnosis; International Classification tries to abandon its use entirely or to regard it as
of Diseases; Post-Traumatic Stress Disorder; strictly a second-line medication in the treatment
Schizophrenia; Stress. of hypertension.
As Carlsson was aware, reserpine’s effects on
Further Readings the body included the ability to deplete mono-
Cardeña, Etzel. “Trance and Possession as amine neurotransmitters in the synapses, block-
Dissociative Disorders.” Transcultural Psychiatry, ing the action of norepinephrine, serotonin, and
v.29 (1992). dopamine, and these effects last days or weeks.
Lewis-Fernanadez, Roberto. “A Cultural Critique Blocking dopamine in this fashion produced a
of the DSM-IV Dissociative Disorders Section.” loss of movement control similar to that seen in
Transcultural Psychiatry, v.35 (1998). Parkinson’s disease. He then administered L-dopa
Somer, Eli. “Culture-Bound Dissociation: A (a precursor to all three of these neurotransmit-
Comparative Analysis.” Psychiatric Clinics of ters) to the animals he was experimenting on.
North America, v.29 (2006). Unlike dopamine itself, L-dopa crosses the blood-
brain barrier, albeit in small quantities (5 to 10
percent of the dose given), and its administration
alleviated the Parkinson-like symptoms. George
Cotzias (1918–77) and his team subsequently
Dopamine developed L-dopa as a treatment for Parkinson’s
disease, and it remains the standard treatment for
Dopamine is a neurotransmitter discovered Parkinsonian symptoms.
by the Swedish neuroscientist Arvid Carlsson Cotzias’s work relied upon gradually increas-
(1923– ) in 1957. The discovery eventually led ing the dose of L-dopa orally till he achieved a
him to be awarded the Nobel Prize in Physiology therapeutic dose, an approach that got around
or Medicine in 2000, an award he shared with the problem that had stymied earlier researchers,
Eric Kandel (1929– ) of Columbia University for the severe toxicity associated with administering
his work on the physiological basis of memory L-dopa via injection. Unfortunately, as Parkin-
storage in neurons, and Paul Greengard (1925– ) son’s disease progresses and dopaminergic neu-
of Rockefeller University for his work on the rons continue to be lost, L-dopa loses its effective-
molecular and cellular function of neurons. ness. It tends to produce the writhing movements
Prior to Carlsson’s work, dopamine had been called dyskinesia and is also associated in some
 Dopamine 221

cases with the development of hallucinations and hypothesis. Further problems with this hypoth-
delusions as well as a variety of behavioral side esis emerged with the growing popularity of sec-
effects that exist alongside the depression and ond-generation or atypical antipsychotic drugs
anxiety and cognitive deterioration that are regu- among psychiatrists. It was widely (though per-
lar features of Parkinson’s disease. haps wrongly) claimed that these drugs were as
effective at controlling schizophrenia and were
Modern Neuroleptic Drugs supposedly more effective in reducing its negative
The introduction of modern neuroleptic drugs in symptoms, such as flattened affect, apathy, pov-
the early 1950s, such as Thorazine, was a seren- erty of speech, anhedonia, and social withdrawal.
dipitous process, and there was no clear under- But, these drugs are known to have lower affini-
standing of why these drugs had the effects that ties for dopamine receptors than for a variety of
they did on psychotic symptoms. The fact that the other neurotransmitter receptors.
drugs clearly had a variety of effects on schizo- The Anglo-Irish psychiatrist David Healy has
phrenia encouraged many psychiatrists to view suggested that the promulgation of the dopamine
the disorder as purely a brain disease, though hypothesis was actively sought by the pharmaco-
philosophically speaking, that conclusion does logical industry because it provided excellent mar-
not follow. There was obviously intense inter- keting copy that its aggressive sales force could
est in etiological questions, particularly because use to promote its products. That suggestion has
the drugs’ therapeutic action might provide clues been highly controversial, but at best, the connec-
to the underlying causes of this form of mental tions between dopamine levels and schizophrenia
disturbance. It became apparent that one of the are far more complex than the original hypoth-
effects of these first-generation antipsychotics was esis suggested, and it is quite apparent that the
to act as dopamine-receptor antagonists. Carlsson etiology of the schizophrenias cannot readily be
and others suggested the hypothesis that, in light reduced to any simple correlation with elevated
of these findings, schizophrenia might be attrib- levels of dopamine. Nor have those attempting
uted to a disturbed and hyperactive dopaminer- to link dopamine and schizophrenia been able to
gic signal transduction. That, in their view, could provide even plausible, let alone well-supported,
provide a rational explanation for why drugs that explanations of how shifts in dopamine levels
acted to antagonize dopamine binding might have account for the highly varied clinical features that
the therapeutic effects psychiatrists observed. psychiatrists are referring to when they speak of
Evidence marshaled to provide indirect support schizophrenia or the schizophrenias. Nevertheless,
for this hypothesis included the observation that the attractions of the hypothesis are perhaps sug-
amphetamines and cocaine increase the levels of gested by the fact that, between 1991 and 2009,
dopamine in the brain and that one of the side as many as 6,700 articles sought to address the
effects of the ingestion of these drugs is psychotic issue of the possible relationship between dopa-
breaks that mimic those found in schizophrenia. mine and schizophrenia. Given the uncertainties
Schizophrenics tend to be heavy smokers, and it associated with the diagnosis, and the markedly
was suggested that they were in the process self- different clinical features and courses followed by
medicating with nicotine, a drug that affects the those given this label, the complexity of uncover-
take-up of dopamine. ing what changes in their brains may be correlated
Later research cast severe doubt on this seduc- with schizophrenia, let alone which ones may be
tive hypothesis. Studies undertaken using posi- related causally to the onset and progress of the
tron emission tomography (PET) scanning that disorder, are likely to provoke an even larger lit-
attempted to link the degree of dopamine block- erature over the next decade and more.
ing to clinical benefits from treatment with phe-
nothiazaines could not show any relationship Andrew Scull
between the proportion of receptors blocked by University of California, San Diego
the drugs and observed clinical state—or rather,
a tendency for the effects to be the reverse of See Also: Atypical Antipsychotics; Schizophrenia;
those predicted by those holding to the dopamine Thorazine and First-Generation Antipsychotics.
222 Double Bind Theory

Further Readings he was introduced to cybernetics, which was a

Carlsson, M. and A. Carlsson. “Schizophrenia: model for guidance systems for missiles in which
A Sub-Cortical Neurotransmitter Imbalance feedback loops communicate data to the navi-
Syndrome?” Schizophrenia Bulletin, v.16/3 (1990). gation system, promoting adjustment and stabi-
Healy, D. Pharmaggedon. Berkeley: University of lization as appropriate. Bateson’s research team
California Press, 2012. became particularly interested in what happens in
Kahn, R. S. and K. L. Davis. “New Developments learning when contradictory feedback is delivered
in Dopamine and Schizophrenia.” In simultaneously. He contended that these contra-
Psychopharmacology: 4th Generation of dictory messages can lead to positive behaviors,
Progress. New York: American College of including creativity, humor, and play; or nega-
Neuropsychopharmacology/Raven Press, 1995. tive ones, including pathological symptoms. In
Richtand, M., et al. “Dopamine and Serotonin 1954, Bateson and his colleagues transitioned
Receptor Binding and Antipsychotic Efficacy.” to specifically investigating the manner in which
Neuropsychopharmacology, v.32/8 (2007). people suffering from schizophrenia communi-
cate in a contradictory fashion. In 1956, Bateson
and his colleagues wrote a preliminary report on
their interpersonal theory for the etiology and
maintenance of schizophrenia. This paper, called
Double Bind Theory “Towards a Theory of Schizophrenia,” intro-
duced the double bind concept and its supposed
The double bind theory is a concept born out of implications for understanding schizophrenia.
communication theory in which contradictory Bateson and his colleagues suggested that a dou-
messages are expressed to another simultaneously. ble bind occurs when one person (typically a child)
Gregory Bateson and his colleagues hypothesized receives repeated, conflicting messages from one
in the 1950s that frequent expression of double or more people (typically, a mother) with whom
bind messages could both cause and maintain the child has an important, ongoing relationship.
schizophrenia. Although research eventually dis- The double bind typically involves a primary neg-
confirmed the double bind theory of schizophre- ative communication message, and the secondary
nia, his research challenged both the intrapsychic message is typically an abstract, positively simu-
model proposed by psychodynamic clinicians and lated message, paired with a threat if disobeyed.
biopsychological reductionism that were popular The function of the first message, according to
in the 1950s. Bateson’s research was particularly Bateson’s group, is to express hostility or with-
important in the advancement of cybernetics and drawal when approached by the child. The second
family therapy. message served to distance the sender of the mes-
sage from their act of hostility or withdrawal. The
Gregory Bateson’s Research and Theory third aspect of the double bind message was that
Bateson, as an anthropologist leading an interdis- the adult demanded a response, but the child was
ciplinary research team, offered a controversial not allowed to escape the contradiction through
theory that was perceived to blame parenting for clarification, commenting, or questioning.
the onset of schizophrenia—particularly mothers. When double bind messages occur, the the-
However, his model spurred consideration and ory suggests that the child cannot discriminate
additional research, expanding the investigation between the simulated message and the authentic
into how social factors of communication and message of the mother’s expression. With an inabil-
interpersonal dynamics influenced onset, course, ity to effectively discriminate, the child is unable
and intervention for mental illness. to determine the appropriate response and feels
In the 1940s, Bateson rejected evolution- doomed to failure. In response to repeated, con-
ary reductionism and Freudian instinctual drive fused messages, Bateson contended that the child
theory; in turn, he embraced learning theory learns to escape hurt and punishment through his
for explaining human personality development. or her abandonment of reality and expressions
As the result of the Macy Conference in 1942, of incongruence. His group further suggested
 Drug Abuse 223

that paranoid schizophrenia might develop as the double binds, employing incongruence to pro-
patient stops responding to the blatant primary mote change in the form of paradoxical interven-
verbal communication, instead focusing on iden- tions. Although the connection to schizophrenia
tifying the “hidden” meaning in the contradic- was largely disproven, the proposal of the double
tory nonverbal communication. Consistent with bind theory advanced understanding of mental
cybernetics’ influence upon Bateson’s thinking, illness and its treatment.
Bateson theorized that the appearance of schizo-
phrenic symptoms in the child interrupted conflict Gerald E. Nissley, Jr.
between the parents, stabilizing the family system East Texas Baptist University
around the concerns of the schizophrenic child.
In 1963, Bateson left the Palo Alto group that he See Also: Clinical Psychology; Dementia Praecox;
worked with to study porpoises, and he demon- Schizophrenia.
strated how double bind messages from trainers
promoted creativity in dolphins. Further Readings
The double bind theory had significant implica- Bateson, Gregory, Don Jackson, Jay Haley, and John
tions for the understanding of mental illness and Weakland. “Towards a Theory of Schizophrenia.”
the advancement of systemic intervention. Prior Behavioral Science, v.1/4 (1956).
to the 1950s, schizophrenia and other mental Cullin, Joel. “Double Bind: Much More Than Just
illnesses were conceptualized primarily from a a Step ‘Towards a Theory of Schizophrenia.’”
psychodynamic view as the result of intrapsychic Australian and New Zealand Journal of Family
conflict. With the advent of Thorazine in 1950s, Therapy, v.27/3 (2006).
the drug revolution also promoted a reductionist Ringuette, Eugene and Trudy Kennedy. “An
view of psychopathology, albeit from a biological Experimental Study of the Double Blind
perspective. Hypothesis.” Journal of Abnormal Psychology,
In 1956, Bateson’s group challenged both of v.71/2 (1966).
these perspectives through the double bind theory. Visser, Max. “Gregory Bateson on Deutero-Learning
However, while the double bind theory became and Double Bind: A Brief Conceptual History.”
widely accepted as an etiological explanation of Journal of History of the Behavioral Sciences,
schizophrenia, there were doubts regarding its v.39/3 (2003).
assertions, scope, and the evidence to support it. As
experimental findings suggested that double bind
messages were just as common among families
without schizophrenic members as those with such
members, the popularity of the theory waned. Fur- Drug Abuse
ther research has shown that while communication
patterns can exacerbate symptoms, the etiology of Psychoactive substances have been consumed
schizophrenia may be primarily biological. throughout human history for a variety of reasons
(e.g., recreational, therapeutic, and religious).
Impact on Treatment Concurrently, different cultures have come to
The legacy of the double bind theory—beyond define drug use and drug abuse in drastically dif-
expanding considerations of social factors in the ferent ways, depending on cultural norms of drug
cause of mental illness—is its impact on treat- consumption. In its most basic form, drug abuse
ment. The double bind theory emphasizes sys- is defined as the consumption of a substance by
temic aspects of relationship, interactional pat- an individual in amounts, for purposes, or with
terns, and circularity that are central to family methods that are not approved of or supervised
therapy. The proposal of the double bind theory by medical professionals. The term drug abuse is
spurred clinicians to consider models of interven- often used interchangeably with the term substance
tion that emphasized communication and systemic abuse, with some medical communities choosing
influences. The influence of the Bateson group only to use the latter term to describe forms of
upon Jay Haley also led to the use of therapeutic problematic drug use. Both of these terms have a
224 Drug Abuse

variety of definitions, depending on the context types of drug use. Specifically, in the U.S. criminal
in which they are used. Specifically, drug abuse justice system, drug abuse entails the use of illegal
has legal definitions, medical definitions, public drugs or the misuse of legal drugs (e.g., using a dif-
health definitions, and culturally based definitions. ferent method of administration than prescribed,
Because of the multitude of definitions that allow using a medication for a different purpose than
for varied interpretations, drug abuse is a complex prescribed, or using greater amounts than was pre-
term with no definitive cultural meaning. scribed) for the purposes of altering one’s mood,
In society, drug and/or substance abuse has a perception, behavior, or state of consciousness.
wide array of causes and affects a large proportion Drugs that are regulated by the government are
of the world’s population, with between 150 and known as controlled substances. Countries have
250 million people having used an illicit substance varied regulations regarding what constitutes a
in 2009. Depending on the substance, drug abuse controlled substance. For instance, in some Mus-
can lead to health, social, and fiscal problems; lim countries, the production, sale, and consump-
deaths; homicides; psychological addiction; and/ tion of alcohol are prohibited, while it is legal in
or physical dependence. Because of the widespread the United States for individuals over the age of
effects of drug abuse, a number of treatments have 21. The largest piece of international legislation
been developed to address the problem. to control drug abuse is the Convention on Psy-
chotropic Substances of 1971. This treaty delin-
Definitions eated a drug scheduling system based on a drug’s
In the judicial and legal systems, drug abuse is potential for dependence and therapeutic value. A
defined by legislation that criminalizes specific total of 175 nations are parties to the treaty.

A man in Sana’a, Yemen, enjoys a moment to chew qat, a plant with an amphetamine-like stimulant. Since the word abuse in relation
to drugs carries a moral implication for some, the term drug abuse is complicated by differing moral views held by different cultures. For
instance, qat has been chewed as a social custom for thousands of years, whereas it would be considered more problematic in Western
cultures. In most Western countries, an occasional cocktail is considered social but strict temperance advocates would label it abusive.
 Drug Abuse 225

The definition of drug abuse extends to the the human body, are considered illegal drugs in
medical community. Medical definitions of drug most countries, while caffeine, an addictive drug
abuse are used for the diagnosis and treatment not naturally produced by the human body, is
of drug-related problems. In 1932, the American legal in all jurisdictions worldwide. Furthermore,
Psychiatric Association stated that the term drug there are illicit substances (e.g., cocaine and her-
abuse was defined by legality and social accept- oin), licit substances (e.g., alcohol and nicotine),
ability. More recently, the term drug abuse is seen and prescription substances (e.g., benzodiaz-
as antiquated in the medical community. For epines and Adderall), and there is debate as to
instance, the International Statistical Classifica- whether this taxonomy is based in pharmacology
tion of Diseases (used by the World Health Orga- and risk-benefit analysis or is steeped in subjec-
nization) is a diagnostic tool that does not use the tive, historical precedent. For instance, a 2010
term drug abuse, instead using the term harmful study by the Independent Scientific Committee
use to describe a pattern of substance use that is on Drugs that asked drug-harm experts to rank
causing harm to one’s health. various legal and illegal drugs found that alcohol,
The American Psychiatric Association’s Diag- legal to consume in most nations, was the most
nostic Statistical Manual of Mental Disorders, dangerous drug in terms of its potential harm to
fourth edition, text revision (DSM-IV-TR) has its users and to others.
been the premier diagnostic tool used in the There is also contention as to the binary defi-
United States for the classification of mental dis- nition of use and abuse as they relate to drugs.
orders. (The DSM-5 was published in 2013.) The Some argue that the term abuse communicates
DSM-IV-TR uses the term substance use disorders a moral, as opposed to an objective, judgment,
to diagnose illnesses related to drug use. Substance which is complicated because of differing moral
use disorders is the overarching term for two broad views held by different cultures. For instance, in
categories of problematic drug-using behaviors: most Western countries, an occasional drink of
substance abuse and substance dependence. Both alcohol is considered acceptable; yet, strict tem-
categories are associated with a maladaptive pat- perance advocates view even one drink of alcohol
tern of substance use that leads to clinically signifi- as abuse. The term drug abuse is intricate, and its
cant impairment. In the past, the DSM had used meaning varies depending on the culture or com-
the term drug abuse to describe a medical diag- munity in which it is used.
nosis regarding substances, but has now adopted In the United States, this difference of opin-
the term substance abuse as a comprehensive term ion regarding the utility of the term drug abuse is
that includes drug abuse. long-standing. In 1970, the National Commission
Public health definitions of drug abuse often on Marijuana and Drug Abuse (NCMDA) was
reflect more than just an individual’s use of a founded. The NCMDA was a congressional com-
drug; they also acknowledge societal frameworks, mittee formed to study marijuana and the causes
historical precedent, and cultural preference. In and relative significance of drug abuse. In 1973,
this vein, public health practitioners rarely use the the NCMDA published a report stating that “the
term drug abuse, opting instead for terms such as term drug abuse must be deleted from official pro-
problematic substance use. Moreover, some pub- nouncements and public policy dialogue. The term
lic health advocates use a spectrum of psychoac- has no functional utility and has become no more
tive substance consumption that ranges from ben- than an arbitrary codeword for drug use which is
eficial use to chronic dependence. presently considered wrong.” Many of the findings
of the NCMDA were met with resistance in Con-
Variations in Cultural Terminology gress, demonstrating the historically controversial
For a variety of reasons, some organizations and nature of drug use and abuse in the United States.
individuals take issue with the term drug abuse.
Specifically, there is disagreement regarding Etiology, Epidemiology, and Treatment
what constitutes a drug. For example, dimethy- While no single risk factor accounts for the devel-
trytamine (DMT) and Y-Hydroxybutyric acid opment of substance abuse, there are a variety of
(GHB), both naturally occurring substances in biological, psychological, and environmental risk
226 Drug Abuse: Cause and Effect

factors related to its development. An example of See Also: Alcoholism; Amphetamines; Barbiturates;
a biological risk factor includes a genetic predis- Benzodiazepines; Drug Abuse: Cause and Effect.
position to substance abuse; an example of one
environmental risk factor includes a chaotic home Further Readings
environment. Kuhn, Cynthia, Scott Swartzwelder, and Wilkie
The initiation of drug use often occurs in ado- Wilson. Buzzed: The Straight Facts About the
lescence, with levels of drug use declining as peo- Most Used and Abused Drugs From Alcohol
ple age. Results from the 2011 Monitoring the to Ecstasy. 3rd ed. New York: W. W. Norton,
Future (MTF) survey, an annual study on rates of 2008.
substance use in the United States, found that 50 National Commission on Drug Abuse. “Drug Use in
percent of 12th graders had used an illicit drug at America: Problem in Perspective. Second Report
some point in their lives. In addition, 19 percent of the National Commission on Marijuana and
of 12th graders were current cigarette smokers, Drug Abuse.” Washington, DC: U.S. Government
and 22 percent of 12th graders reported binge- Printing Office, 1973.
drinking alcohol (i.e., having five or more drinks Ruiz, Pedro and Eric Strain. Lowinson and Ruiz’s
in a row on at least one occasion) in the two Substance Abuse: A Comprehensive Textbook.
weeks prior to the survey. Notably, these levels of 5th ed. Philadelphia: Lippincott Williams &
tobacco and alcohol use are the lowest recorded Wilkins, 2011.
by the MTF study since its inception 37 years ago.
The National Institute on Drug Abuse (NIDA)
estimates that each year the abuse of illicit drugs
and alcohol contributes to the death of more than
100,000 Americans, while tobacco is linked to Drug Abuse:
the death of more than 440,000 Americans. In
2010, approximately 22 million Americans were Cause and Effect
classified with substance dependence or abuse in
the previous year, with dependence or abuse of The question of whether drug abuse leads to or
alcohol alone accounting for 15 million of those emanates from mental illness has long been a topic
individuals. of investigation within the medical and psycho-
There are several empirically validated treat- logical community. There have been many models
ments available for substance abuse. For adoles- of drug abuse that have led to various etiological
cents, cognitive behavioral therapy is one of the explanations, including nutritional deprivation,
most efficacious treatments. In addition, phar- brain and neurochemical changes, and biomedical
macological treatments are available, ranging disease processes. At its core, the debate centers
from replacement therapies such as methadone around whether the effects of the drug used are
to antagonistic medications such as naltrexone. the cause of mental illness symptoms or whether
Drug abuse is a complex and controversial term, they are a tool used by the sufferer to ameliorate
as well as a consequential topic that carries vast pre-existing mental illness. The self-medication
implications for society. So long as drugs are used hypothesis has long been used within substance
throughout the world, drug abuse will be perti- abuse treatment to predict the type of underlying
nent to cultures worldwide. psychological distress of users of substances like
heroin, cocaine, and alcohol.
Andrew Ninnemann Substance use has been associated with a host
Brown University of symptoms of mental illness, while substance
JoAnna Elmquist misuse has also been an indication of underlying
University of Tennessee, Knoxville mental health challenges. Interculturally, there are
Lindsay Labrecque different assessments of what constitutes an abu-
Brown University sive pattern of drug use versus what is considered
Gregory L. Stuart appropriate pattern of use. Rates of alcohol con-
University of Tennessee, Knoxville sumption among college students are frequently
 Drug Abuse: Cause and Effect 227

higher than rates among similarly aged adults not report feeling guilty about their use, and this would
in college. Most individuals with binge drinking be an indicator that the substance use had devel-
or problematic alcohol use will decrease their use oped into a problem for these patients. Changes
spontaneously after their college completion. This to the fifth edition of the DSM in 2013 (DSM-5)
series of findings suggests that there are cultural indicate that greater behavioral specificity will
norms around alcohol consumption that influ- now be expected to differentiate problematic use
ence rates of use and predict patterns of abuse. from habitual use. Internationally, there has been
Intraculturally, there are also different standards an overall increase in the number of individuals
for use for women and men, and between chil- who report use of substances ranging from alco-
dren and adults. In some countries, women’s hol, heroin, marijuana, cocaine, amphetamines,
roles are prescribed to that of family and close prescription pain medication, and hallucinogenic
friends; in cultures where women report higher medication. The rate of use has risen among
rates of participation in the paid workforce, there women relative to men, although proportionately,
are increases in the amount of substance use and there are higher rates of use and problem use
abuse reported by women. Substance use and dif- reported among men. Understanding the full rate
ferences in patterns of use are also associated with of use by women is somewhat complicated by dif-
class differences within cultures. ferent cultural taboos around use for women. This
At various times, the rates and patterns of mis- is likewise the case when assessing use patterns in
use will differ from one demographic group to children and adolescents, where different cultural
another. Wealthier individuals have higher rates taboos and legal barriers may limit the degree to
of prescription drug abuse because they possess which a child can honestly report their pattern of
easier access to medications and the health sys- use without fear of reprisal.
tem. Younger individuals will sometimes report A large majority of adults will report some life-
higher rates of economic disadvantage. This time use of alcohol or other substances. Despite
finding seems related both to their limited num- widespread use, the proportion of individuals that
ber of years within the paid workforce and the will report problematic use of these substances in
interruption for them of their skill acquisition as their lifetime is about 10 percent. The majority
they use drugs. Within the United States, research of individuals who report problematic use will
has demonstrated that the degree of accultura- also report concurrent mental health symptoms
tion between majority and minority groups can ranging from anxiety disorders, depressed mood,
serve as a buffer against the risk of substance mis- or psychosis. Alcohol misuse is known to cause
use among minority women. At the same time, symptoms of depressed mood, and withdrawal
models of substance use recovery have revealed from alcohol can lead to anxiousness, suicidality,
the degree to which role identity can serve as a and seizures. Amphetamine use can lead to symp-
positive indicator of adjustment in the recovery toms of anxiety and psychosis. Individuals using
process. hallucinogens might be reported as delusional or
experience intense emotional displays.
Signs or Symptoms? These effects of the substances might be
The degree to which substance use is classified as observed or reported, not only in the first hours
a mental health problem has been debated. Within of use, but for several weeks after. For this rea-
North America, the adoption of the Diagnostic son, it can be hard for health providers to disen-
and Statistical Manual of Mental Disorders (DSM) tangle the aspect of the patient’s experience that
produced by the American Psychiatric Association is related to an underlying mental health condi-
has led physicians to monitor the frequency, dura- tion, and the aspect of their symptoms that is
tion, and consequences of substance use in order attributable to the use of the substance or sub-
to assess whether substance consumption is prob- stances they may have ingested in the past month.
lematic. Other mental health providers have also It is therefore essential that patients be screened
assessed the individual patient’s perception and for their use of substances so that if there are
emotional experience of his or her use. Patients extreme symptoms that need to be treated, then
who report minimal or moderate use might also this can be done in the most conservative way
228 Drug Abuse: Cause and Effect

possible while the patient is recovering from the or counselor in order to avoid using alcohol alto-
substance use. gether. These differences in substance use goals
Recently, a common finding has been the high influence the policies that are established within
proportion of individuals with a mental illness systems of care and even other health agencies.
who also have a concurrent substance abuse Within parts of Europe, a tolerant approach to
disorder. The rates of comorbid post-traumatic needle exchange programs has helped reduce
stress disorder and alcohol addiction are par- the transmission of HIV within certain injection
ticularly high. The relationship between his- drug–using communities. In the United States,
toric methamphetamine abuse and development many communities are opposed to such an
of psychosis has also been consistently found. arrangement, which leads them to instead imple-
Neural plasticity research has consistently dem- ment policies whereby those who use injection
onstrated the impact of substance use on brain drugs are admitted first to treatment programs
structure and function, and this is where a vast but are not offered any needle exchange programs
array of explanations for the link between men- to decrease their associated health risks.
tal illness and substance misuse currently ema- Rates of recovery from substance use disorders
nate. As greater focus on comorbidities has vary greatly depending on substance, years of use,
arisen, there have been increasingly efficacious and treatments. In general, less than 50 percent
treatments created to address the clinical issues of those who participate in drug treatment pro-
presented in each diagnosis. There is still a less grams complete them successfully. The number of
positive prognosis for individuals with comor- individuals new in treatment each year is lower
bidity rather than only a mental health or a sub- than the number of individuals who return to
stance abuse disorder. treatment. At the same time, there are methods
that seem to improve the overall recovery rate for
Interventions individuals with problematic substance use dis-
Interventions for substance use vary cross cultur- orders. Addressing mental health problems that
ally. In the United States, a self-help movement has might lead to self-medication can greatly improve
fueled much of the treatment that has occurred, the recovery rate of addicted individuals. Attend-
first for alcohol use and more recently for other ing to the psychosocial stressors that accompany
substances. Medical interventions for withdrawal long-term misuse, including vocational function-
management have contributed to models of treat- ing, oral and physical health, economic factors,
ment for substances like alcohol and morphine and family functioning, can all increase the effi-
derivatives. Outpatient approaches to controlling cacy of change efforts made on the part of the suf-
use and withdrawal symptoms have also prolifer- fering individual.
ated with the advent of methadone and naltrex-
one. Suboxone has been developed to deal with Loretta L. C. Brady
prescribed pain medication misuse, which is the Saint Anselm College
fastest-growing area of misuse reported in the
United States. See Also: Alcoholism; Amphetamines; Barbiturates;
Goals and methods of treatment also vary. In Benzodiazepines; Diagnosis; Drug Abuse.
the United Kingdom, it is more common for an
individual with problematic alcohol use to be Further Readings
counseled to adopt a habit management approach Volkow, N. D., ed. “Introduction to Special Issue on
to their alcohol use. This approach is designed to Drugs and Mental Illness.” American Journal of
have the individual set a predefined limit to the Psychiatry, v.158/8 (2001).
number of units of alcohol they will consume Weller, M. P., P. C. Ang, D. T. Latimer-Sayer, and A.
that day or week. The individual then works Zachary. “Drug Abuse and Mental Illness: Progress
with a counselor to stay within their target limit. in Understanding Comorbidity.” Lancet, v.1/8592
In the United States, it is more common for an (1988).
abstinence-based approach to be recommended, World Health Organization (WHO). Mental Health
whereby the person works with a support group Atlas. Singapore: WHO, 2005.
 Drug Development 229

Drug Development isolation, whereas in vivo tests allow them to see

how it affects a living organism; notably, results
Drug development is the process of moving a observed in vitro are often not duplicated in vivo.
potentially promising pharmaceutical compound One important focus of preclinical testing is tox-
through the development and testing stages icity, which is determined in part by administering
required before it is approved for therapeutic use. high doses of the compound under investigation
Although the details of this process differ some- to lab animals. Some of the testing done at this
what in different countries, the basic pattern of stage is specific to the intended use of the drug—
the drug development process involves predict- for instance, if it is intended for pregnant women,
able stages, from laboratory research through teratogenicity studies are required to see if the
postmarket monitoring. The drug development drug harms the offspring of the animals to which
and approval process is generally regulated on it is administered.
a national or regional basis. For instance, in the If a drug seems to be promising and safe after
United States, the drug development and approval the preclinical stage, it moves into the clini-
process is regulated by the Food and Drug Admin- cal research stage, during which it is tested on
istration (FDA), while in the European Union, human subjects in a series of clinical trials, fol-
drug approval for marketing is handled in part by lowing strictly regulated protocols. In the United
the Committee for Medicinal Products for Human States, the FDA specifies four phases of clinical
Use and in part by each country separately. Some trials, with some drugs eliminated at each round
efforts have been made to harmonize the drug of trials. In Phase 1, safety and dosage is deter-
approval process across multiple countries and mined in studies of between 20 and 100 healthy
regions, such as the International Conference on volunteers; about 70 percent of drugs pass this
Harmonisation (ICH), in order to reduce duplica- phase. Phase 2 studies the drug’s efficacy and side
tion of effort. effects in humans and involves up to several hun-
dred people who have the condition the drug is
The Five Stages of Drug Development intended to treat; about 33 percent of drugs pass
There are five basic stages in the drug devel- this phase. Phase 3 studies the drug’s efficacy
opment process: discovery and development, and further monitors adverse reactions to it; this
preclinical research, clinical research, official phase lasts one to four years and involves from
review, and postmarket monitoring. The discov- several hundred to several thousand individuals
ery process often begins with basic research in who have the condition the drug is intended to
the research laboratory, when large numbers of treat, and about 25 to 30 percent of drugs pass
molecular compounds may be tested to see if they this phase. In Phase 4, additional monitoring for
are effective against a number of diseases. Dis- safety and efficacy takes place in several thousand
covery may also involve observing that existing volunteers who have the condition the drug is
treatments seem to be effective against diseases intended to treat.
other than those for which they were developed If a drug successfully passes through the previ-
or that new technology provides different ways ous stages, the company developing it can present
to deliver a therapeutic compound to the body. it for official review. In this stage, the company
Once a specific compound is selected as prom- presents the information gathered in the previous
ising, the development phase begins. This phase rounds of testing to the official body authorized
involves gathering information about the com- to review it, for instance, the FDA in the United
pound, including its mechanism of action, how States. The company is required to include all
it is metabolized in the body, what side effects it data from the preclinical through Phase 3 testing,
has, how it interacts with other drugs, and how it along with additional information including pro-
compares with other drugs. posed labeling, safety updates, potential abuse,
In the preclinical research phase, a new drug institutional review board (IRB) certification, and
undergoes both in vitro (test tube) and in vivo directions for use. In the FDA process, a review
(animal) testing. In vitro tests allow researchers team is assigned to each drug and may spend six
to study the compound and its effects on cells in to 10 months deciding whether to approve it. If a
230 Drug Development

drug is determined to be safe and effective, then genetically engineered medicines; orphan medi-
the FDA works with the drug company to develop cines used to treat rare diseases; and advanced
prescribing information (i.e., how best to use the therapy medicines (e.g., gene therapy). National
drug therapeutically). authorities handle the approval process for drugs
The final step in drug development is postmar- not under the authority of the CHMP. Monitor-
ket safety monitoring. This step requires monitor- ing of drugs after approval (pharmacovigilance)
ing of the drug after it is introduced to the market, is carried out by the national medicines agencies
including collecting reports of problems reported within each country, with the CHMP monitor-
by patients taking the drug. Postmarket monitor- ing reports on adverse drug reactions and mak-
ing is necessary because the clinical research phase ing recommendations regarding the suspension
may not have caught potential problems with the or withdrawal of a drug from the market. The
drug, which may show up when a wide range CHMP also publishes a public assessment report
of people use the drug under real-world condi- (EPAR) for each centrally authorized medicine,
tions—for instance, it may have been tested only available on the CHMP Web site, which includes
on patients within a certain age range or without the rationale for approval, the steps taken dur-
serious comorbidities, the drug may cause prob- ing the assessment project, a patient information
lems with elderly patients or those suffering from leaflet, and a summary of product characteristics.
multiple diseases. The FDA can issue restrictions The process of approving a given drug for use
on an approved drug if serious problems are noted in a country is generally handled on a national or
during postmarket safety monitoring. regional basis (e.g., the Committee for Medici-
nal Products for Human Use for the European
Approval for Marketing Union), which can lead to duplication of effort.
In the United States, a drug approved by the FDA The International Conference on Harmonisa-
is granted patent protection and may be marketed tion of Technical Requirements for Registration
and sold. However, an insurance company or of Pharmaceuticals for Human Use (ICH) was
pharmaceutical benefits provider may choose not created in 1990 to exchange information and
to pay for a particular drug or may require copay- help reduce duplication in testing and report-
ments for some drugs; for instance, a branded ing during the drug development process. The
version of a pharmaceutical compound may ICH includes the drug regulatory authorities
require a higher copayment than the generic ver- and pharmaceutical trade associations from the
sion of the same compound. A similar division of United States, Europe, and Japan and aims to
responsibility exists in many other countries. For harmonize the interpretation and application of
instance, in Canada, approval of drugs is handled technical drug registration guidelines in the three
on a national basis by the Therapeutic Products regions, with the goal of creating a common reg-
Directorate, but insurance coverage for individual ulatory language and promoting faster access to
drugs is determined at the provincial level. lifesaving drugs.
The Committee for Medicinal Products for
Human Use (CHMP), part of the European Criticisms
Medicines Agency, is responsible for evaluating Therapeutic drugs play an important role in
medicines on a scientific basis for members of the modern medicine, and regulators must balance
European Union and for issuing an opinion as the desire to make new, potentially lifesaving
to whether a given drug meets requirements for drugs available as soon as possible with the need
safety, efficacy, and quality in order to be approved to ensure that drugs allowed on the market are
for marketing. Not all drugs are handled by the safe. In addition, there is a conflict between for-
CHMP, the approval of which is mandatory only profit pharmaceutical companies, which conduct
for certain classes of drugs, including human med- most of the research leading to new therapeutic
icines to treat cancer, diabetes, human immuno- drugs; the needs of national authorities, insurers,
deficiency virus and acquired immune deficiency and individuals to control costs; and the needs of
syndrome (HIV/AIDS), immune dysfunctions, patients who have rare diseases or those in devel-
neurodegenerative diseases, and viral diseases; oping countries. These conflicting goals often
 Drug Treatments, Early 231

make the process of regulating the drug develop- compared to drugs already available than to spend
ment process a contested activity, with multiple its resources developing drugs for rare diseases or
interest groups all asserting the importance of for diseases mainly common in developing coun-
their needs and desires. tries. One method to combat this is for govern-
The FDA takes a conservative approach to ments to provide subsidies or allow less stringent
new drug approval, in the sense that extensive regulation for the drug development process for
testing is required before a drug may be brought orphan drugs (those used to treat diseases affect-
to market. This approach paid off, for instance, ing a relatively small number of people) or other
in the case of thalidomide, a sedative also used drugs that might not otherwise be profitable; one
to combat nausea; when pregnant women took example is the U.S. Orphan Drug Act of 1983.
thalidomide to relieve morning sickness, many
gave birth to children with severe birth defects. Sarah Boslaugh
This thalidomide crisis of the late 1950s and early Kennesaw State University
1960s affected possibly tens of thousands of chil-
dren (the exact number is not known) in many See Also: Clinical Trials; Economics; Food and Drug
countries in Europe and elsewhere, but the United Administration, U.S.; International Comparisons;
States was relatively untouched because thalido- Psychopharmacological Research; Randomized
mide had not been approved by the FDA for sale Controlled Trial.
in the United States.
On the other hand, in the 1980s, when AIDS Further Readings
was a deadly disease with no effective therapies Berndt, Ernst R., H. Adrian, B. Gottschalk, and
available, activists put pressure on the FDA to Matthew W. Strobeck. “Opportunities for
speed up the approval process and to allow greater Improving the Drug Development Process: Results
access to new drugs while they were still in the From a Survey of Industry and the FDA.” NBER
testing phases. In addition, many activists called Working Paper No. 11425 (June 2005). http://www
for those suffering from disease to be granted a .nber.org/papers/w11425 (Accessed June 2013).
greater voice in the approval process, with the Greenberg, Michael D. “AIDS, Experimental Drug
logic that they had a greater stake in the process Approval, and the FDA New Drug Screening
(perhaps one of life or death) than an agency per- Process.” Journal of Legislation and Public Policy,
ceived as being staffed by bureaucrats. Although v.3/2 (2000).
some of those demanding greater access to experi- Kaitlin, K. I. “Deconstructing the Drug Development
mental treatments may not have understood all Process: The New Face of Innovation.” Clinical
the issues involved (the process of clinical testing Pharmacology and Therapeutics, v.87/3 (2010).
is complex and relies in part on the application Simmons, John and David Bernstein. “Navigating
of statistical theory to estimate outcomes based Differences Between FDA and EMEA
on a small sample of participants), their voices for Regulatory Compliance During Drug
motivated the FDA to reconsider the appropri- Development.” Biopharm International
ate balance between the risk and reward potential (September 2, 2006).
of new medicines. As a result, the FDA changed Tonkens, Ross. “An Overview of the Drug
some policies, including creating a fast track to Development Process.” Physician Executive
hasten the approval process for some drugs. (May–June 2005).
The drug discovery process is largely car-
ried out by for-profit pharmaceutical companies
whose priorities may not be optimal in terms of
improving health on a global basis. For instance,
it is typically more profitable for a pharmaceu- Drug Treatments, Early
tical company to create a drug similar to those
on the market to treat conditions common in the Today, many effective drug therapies are available
industrialized world, even if the new drug is only to treat mental illness. However, most were dis-
a minor improvement (or no improvement at all) covered in the second half of the 20th century or
232 Drug Treatments, Early

later, while prior to that time, a number of thera- the coma by administering intravenous glucose;
pies of questionable effectiveness were often used. the therapy was continued daily over a series
In the 19th century, treatments based on symp- of weeks or even years. Many patients reported
toms, such as administering sedatives or narcotics experiencing extreme discomfort during these
to agitated patients, were common. Experimen- treatments and would sometimes experience con-
tation with somatic treatments for mental illness vulsions before coming out of the coma, but some
accelerated in the early 20th century in part as an also experienced a lucid period after coming out
attempt to apply new understandings of biochem- of the coma, leading to a belief that the therapy
istry and physiology to psychiatric conditions and had successfully addressed their schizophrenia.
to duplicate the success of drug therapies in treat- In addition, the belief that the convulsions were
ing physical illnesses. Although many of these therapeutic led to the development of electro-
treatments may seem misguided today, and most shock therapy (ECT). Insulin shock therapy was
have been abandoned as more effective treatments labor intensive for the hospital and dangerous
have been developed, they represent an attempt to for the patient and was largely abandoned once
find treatments for seemingly intractable psychi- effective antipsychotic drugs were developed in
atric conditions using the knowledge available at the 1970s; today, experts disagree as to whether
the time. insulin shock therapy was ever effective as a psy-
chiatric treatment.
Fever Therapy
Beginning in the late 19th century, Julius Wag- Sleep Therapy
ner-Jauregg attempted to treat general paresis In the 1920s, Swiss psychiatrist J. Kläsi, work-
caused by late-stage syphilis by inducing high ing at the Burghölzli hospital, used sleep therapy
fevers in patients. Among the substances he used to treat patients with schizophrenia and autism.
for this purpose were the streptococcus bacte- In this therapy, a deep sleep was induced by the
ria, which causes erysipelas (St. Anthony’s fire) barbiturate Somnifen; later, other hypnotics were
and the bacteria that causes tuberculosis, but he also used for this purpose. Kläsi’s logic was that
ultimately settled on the malaria parasite; Jau- the drugged sleep would break the cycle of exci-
regg was awarded a Nobel Prize in 1927 for this tation that plagued some schizophrenics and that
work. The logic behind fever therapy was to pro- it would make autistic patients more amenable to
duce a high fever in a patient through deliber- cooperate with their therapy because they would
ate infection with a disease; after the fever had have to reestablish contact with reality after com-
killed the syphilis-causing bacteria, the patient ing out of the deep sleep, and the physicians and
would be treated for the fever-causing disease staff could more easily gain their confidence in
(with quinine in the case of malaria, which helps this state. The therapy usually lasted for a period
relieve malarial symptoms but does not cure the of days, with the length adjusted to the patient,
disease). This mode of treatment is no longer but was not a continuous sleep—instead, patients
used because antibiotics provide effective ther- would be intermittently aroused to eat, drink,
apy against syphilis, and the disease seldom pro- and excrete.
gresses to the later stages. Although sleep therapy became popular, par-
ticularly in German-speaking countries, many
Insulin Shock Therapy question whether it was effective, and it pro-
Insulin shock therapy, also called insulin coma duced dangerous side effects or resulted in
therapy, was developed in the 1920s as a treat- death for a number of patients. Sleep therapy
ment for schizophrenia. Alfred Sakel developed was largely abandoned by the mid-1930s, when
the treatment in Austria, and it was introduced to other treatments including insulin therapy and
the United States in the 1930s, where it became convulsive therapy became available. However,
quite common in the 1940s and 1950s. The pro- an extreme version of sleep therapy continued
cess of insulin therapy involves putting the patient to be used in Chelmsford Hospital in Sydney,
into a hypoglycemic coma by administering injec- Australia, into the 1970s; in this version of sleep
tions of insulin and then bringing them out of therapy, patients (who were being treated for
 Drugs and Deinstitutionalization 233

schizophrenia, drug addiction, and other com- Drugs and

plaints) were kept in a comatose state for days
or weeks and were sometimes administered ECT Deinstitutionalization
while comatose.
Deinstitutionalization can be interpreted as a
Convulsive Therapy process of social change occurring in multiple
Hungarian psychiatrist Laszlo Meduna began domains. Perceived on an idealistic level as a
using drug-induced convulsive therapy to treat humane alternative to long-term hospital care,
schizophrenia in 1934. Meduna injected patients deinstitutionalization encompasses a series of
at the Royal Hungarian State Psychiatric Insti- social policy reforms that resulted in the disinte-
tute with a solution of camphor, increasing gration of state mental hospitals. Deinstitution-
the dosage until convulsions were produced. alization is commonly attributed to a decreased
Meduna later used pentamethylenetetrazol (car- need for such hospitals because of the develop-
diazol), a cardiac stimulant, to induce convul- ment of effective psychiatric medications, com-
sions while avoiding the unpleasant side effects mencing with Thorazine. Thorazine provided a
of camphor that included pain, nausea, and a substantially more successful method of treat-
waiting period (from 1.5 to 3 hours) between the ment and reduced severe symptoms associated
injection and the induction of seizures. Meduna with psychosis. This enabled mentally ill individ-
believed that there was a biological antagonism uals to live in less restricted environments such
between epilepsy and schizophrenia and pub- as group homes or independently within their
lished results claiming significant improvement communities, to obtain employment, and to live
or remission in one-third to one-half of patients relatively productive lives.
treated, although those results have since been Many criticize a deterministic perspective that
questioned. Drug-induced convulsive therapy focuses solely on the new medications, citing a
did not become widespread and was abandoned confluence of contributing factors, most notably
when ECT became available, providing physi- the enactment of Medicare and Medicaid, shift-
cians with better control of the process of induc- ing conceptions of mental illness, and cost-cut-
ing seizures. ting treatment orientations, particularly outpa-
tient care.
Sarah Boslaugh The first American psychiatric hospital opened
Kennesaw State University in 1773, and hospitals devoted to the treatment
of mental illness began to materialize during
See Also: Autism; Barbiturates; Electroconvulsive the 19th century. By 1880, there were 75 pub-
Therapy; Insulin Coma Therapy; Mental Institutions, lic psychiatric hospitals with 41,000 patients. In
History of; Neurosyphilis; Psychoanalysis, History 1890, states assumed primary responsibility for
and Sociology of; Psychopharmacological Research; mental hospitals. During this time, broad social
Schizophrenia. reform efforts within the United States began to
advocate the placement of mentally ill persons in
Further Readings public psychiatric facilities. While a more medi-
Braslow, Joel T. Mental Ills and Bodily Cures: calized conception of mental illness began to
Psychiatric Treatment in the First Half of the emerge, mental health treatments had very little
Twentieth Century. Berkeley: University of efficacy.
California Press, 1997. The population in state hospitals grew steadily
Doroshow, Deborah Blythe. “Performing a Cure and increased fourfold from 1900 to 1955. The
for Schizophrenia: Insulin Coma Therapy on the inpatient population rose from 41,000 in 1880
Wards.” Journal of the History of Medicine and to over half a million in 1955, while the size of
Allied Sciences, v.62/2 (2006). psychiatric facilities also substantially increased.
Gazdag, Gabor, Istvan Bitter, Gabor S. Ungvari, and By midcentury, state asylums were perceived as
Brigitta Baran. “Convulsive Therapy Turns 75.” neglectful, abusive, and ineffective in their treat-
British Journal of Psychiatry, v.194 (2009). ment of mentally ill individuals.
234 Drugs and Deinstitutionalization

Deinstitutionalization Movement inpatient population is considered in relation-

Deinstitutionalization refers to the dramatic shift ship to the population at large. In 1954, the U.S.
in the treatment of mentally ill individuals, begin- population totaled 164 million; whereas by 1998,
ning in the mid-1950s, which entailed replacing this had increased to about 275 million. Over the
inpatient psychiatric care with community-based course of 44 years, the number of occupied beds
alternatives. This treatment orientation represents in state psychiatric hospitals dropped from 339
a marked shift, if not reversal, in long-prevailing to 21 per 100,000 on any given day. The pace as
trends in the provision of care for the mentally ill. well as the timing of deinstitutionalization varied
There are two primary components of deinsti- substantially from state to state.
tutionalization: reducing the inpatient population The majority of patients deinstitutionalized
of state psychiatric institutions and creating a net- from public psychiatric hospitals were severely
work of community-based institutions to provide mentally ill. Over half were diagnosed with
care. The former impacts individuals who are schizophrenia, and roughly 15 percent were diag-
already ill and, because of the reduction in hospi- nosed with manic-depressive illness and severe
tal beds, the latter affects those who will become depression.
mentally ill. Thorazine was the first of a class of medica-
Deinstitutionalization was anchored in the pre- tions known as conventional antipsychotics used
vailing belief that severe mental illness should be to treat psychosis. The drug impacts various
treated in the least restrictive setting. Commu- receptors in the central nervous system and works
nity-based care was seen as more humane and by changing the activity of specific substances in
therapeutic than inpatient hospital care. This con- the brain. Originally discovered in France in the
viction reflected mounting concern for the well- early 1950s, chlorpromazine was licensed in the
being and proper treatment of mentally ill per- United States in 1953 to Smith, Kline, and French.
sons. While a confluence of social, political, and In 1954, the Food and Drug Administration gave
economic circumstances contributed to deinstitu- permission for the company to begin marketing
tionalization, the advent of antipsychotic drugs, its drug under the trade name Thorazine. The
most notably Thorazine, is often cited as a pri- development of Thorazine offered a monumental
mary catalyst. The development and subsequent breakthrough in the treatment of psychosis, rap-
widespread clinical use of new psychiatric medi- idly replacing standard treatments.
cations represented a marked advancement in the Patient response to Thorazine was dramatic.
care of psychiatric patients and simultaneously Individuals who had previously suffered unrelent-
created a set of circumstances ripe for the dein- ing psychosis responded to the drug with signifi-
stitutionalization movement. These treatments cant resolution in symptoms. Upon its introduc-
enabled many persons with mental illness to live tion, Thorazine was used to treat schizophrenia,
outside hospital settings—a level of functioning mania, and various other psychotic disorders. By
unobtainable with previous options. 1964, roughly 50 million people across the globe
The magnitude of deinstitutionalization severely had taken the drug.
altered the mental health care landscape, with
implications continuing today. The nation’s inpa- Multilayered Implications
tient population peaked in 1955, with approxi- The effect of new drug treatments reverberated
mately 560,000 severely mentally ill patients in throughout psychiatric hospitals, with implica-
public psychiatric hospitals, accounting for roughly tions stretching across multiple sectors of society.
half of all mental health patient care episodes. By While the new drugs did not cure mental illness,
1977, the psychiatric hospital census was reduced they reduced some of the most debilitating symp-
to 160,000, representing less than 10 percent of all toms for many individuals. As a result, those with
mental health patient care episodes. psychosis were now able to live independently
The trend continued, and by 1994, the inpa- and participate more fully in society.
tient population was a mere 71,600; and by The drugs also had a substantial impact within
1998, it had fallen to 57,000. The scale of dein- state hospitals. Patients taking them were more
stitutionalization is particularly evident when the cooperative, compliant, and hopeful. This enabled
 Drugs and Deinstitutionalization 235

The introduction of antipsychotic medications is

also associated with the emergence of a new phi-
losophy regarding the provision of mental health
care and the treatment of mentally ill persons.
As patient behaviors improved with the drugs,
public perceptions of persons with mental ill-
ness became increasingly more favorable. This
prompted greater acceptance among the general
public regarding the release of persons with men-
tal illness from state hospitals.
Policy makers viewed the drugs as facilitating
a new era in the needs and the treatment of men-
tally ill persons. The formulation of mental health
policy during this time was heavily reliant on
the use of the new antipsychotic medications—
a sentiment reflected in the Community Mental
Health Act of 1963. The success of the new drug
treatments also generated excitement and clinical
interest among psychiatric providers.
There has been extensive attention to the role
that antipsychotic drugs had in deinstitution-
alization. One prevalent perspective attributes
the widespread introduction of new treatment
options, specifically Thorazine, as integral to the
reduction of state mental hospitals censuses. Oth-
ers critique the emphasis placed on the implemen-
tation of antipsychotic drugs and posit alterna-
tive factors as the primary forces behind the rapid
An advertisement for the antipsychotic medication Thorazine, decrease in inpatient hospitalizations of mentally
circa 1962. The advent of antipsychotic drugs such as Thorazine ill persons.
was one of the primary catalysts for deinstitutionalization, as it While the introduction of new drugs revolution-
reduced the severe symptoms of psychosis and enabled mentally ized care of the nation’s mentally ill and contrib-
ill individuals to live in less restricted environments. uted substantially to deinstitutionalization, there
is much scholarly debate regarding the extent to
which this new treatment orientation directly pro-
pelled declines in hospital census. The evidence
hospital personnel to manage and work with evaluating whether the introduction of new drugs
patients more successfully. The drugs not only led to decreases in inpatient populations has pro-
fostered greater compliance from patients, they duced contradictory conclusions. The drugs were
also offered a treatment available in settings other introduced just prior to the unprecedented declines
than the hospital. The widespread use of the new in hospital census, yet there are many who attri-
drug treatments and their subsequent impacts on bute these declines to other factors—most nota-
patient behaviors also fostered administrative bly, the trend of increasing discharge rates com-
changes. Hospitals began eliminating constraints, mencing in the mid 1940s, fiscal concerns, and the
providing therapeutic treatments, minimizing expansion of federal welfare programs, particu-
security arrangements, and encouraging patients’ larly Medicare and Medicaid, in the 1960s.
release from inpatient settings. Deinstitutionalization is far more than a change
A conceptual shift inclusive of a focus on indi- in the locus of psychiatric care for the nation’s
vidual needs, rehabilitation, and quality of life mentally ill; it is a social process with multidimen-
accompanied declines in hospital census rates. sional implications. It is thus a matter of theoretical
236 DSM-III

consideration. The organization of a society’s psy- The development of specific criteria was designed
chiatric care is responsive to and reflective of pre- to aid clinicians when making a diagnosis and
vailing social, economic, and political ideologies. determining treatment but was also useful for
Systems of care for mentally ill persons have been researchers engaged in work on the causes of
the subject of much debate and scholarly inquiry. disorders or in the evaluation of treatments. The
State hospitals represented institutional responses change helped extend the use of the classification
to public sentiment and beliefs about deviance. well beyond the United States. The DSM-III also
In fact, some of the most influential sociological increased the number of disorders listed from 182
explorations of social control are based on field- to 265. However, the DSM has been criticized as
work in public mental hospitals. a product of political interests, more than sound
science, because many of the final decisions as
Rebekah M. Zincavage to the shape of the DSM resulted from complex
Brandeis University negotiations that were often settled by fiat. It has
also been criticized for broadening the boundar-
See Also: Deinstitutionalization; Mental Institutions, ies of mental disorder, for its use of a categorical
History of; Pharmaceutical Industry; Thorazine and model, and for not enhancing diagnostic reliabil-
First-Generation Antipsychotics. ity or validity to any great extent.

Further Readings Previous Editions

Goffman, Erving. Asylums: Essays on the Social The first DSM was published in 1952 and was
Situation of Mental Patients and Other Inmates. a variant of the 1949 list of mental disorders
Garden City, NY: Doubleday, 1961. that formed part of the International Classifica-
Grob, Gerald N. From Asylum to Community: tion of Diseases, then in its sixth edition (ICD-6),
Mental Health Policy in Modern America. as well as of a list of mental disorders produced
Princeton, NJ: Princeton University Press, 1991. for the U.S. Army. The DSM had a dual purpose
Gronfein, William. “Psychotropic Drugs and of assisting the diagnostic practice of clinicians
the Origins of Deinstitutionalization.” Social in the mental health field and of facilitating the
Problems, v.32/5 (1985). collection of statistical data on individuals with
Paulson, George and John C. Burnham. Closing mental illness to assist service planning and the
the Asylums: Causes and Consequences of the examination of etiology.
Deinstitutionalization Movement. Jefferson, NC: It was developed in a period when an increas-
McFarland & Co., 2012. ing range of problems were brought to the atten-
Scull, Andrew. Decarceration: Community Treatment tion of those working in the mental health field,
and the Deviant. Englewood Cliffs, NJ: Prentice- and when the influence of psychodynamic ideas in
Hall, 1977. psychiatry, particularly in the treatment of those
who were not inpatients, had been strengthened
by World War II, which had provided evidence
of the adverse impact of severe psychological and
social stresses on mental health. The new DSM
DSM-III followed the practice of previous European and
American psychiatric classifications in operating
The third edition of the American Psychiatric with a categorical model derived from infectious
Association’s Diagnostic and Statistical Manual of diseases, listing a set of supposedly discrete men-
Mental Disorders (DSM-III), published in 1980, tal disorders, and providing a brief description of
transformed the classification of mental illnesses each of the 109 disorders.
and marked a major turning point in psychiatry. Despite the influence of psychodynamic ideas,
In order to try to increase diagnostic reliability, as with earlier classifications, including the clas-
which was poor, it introduced a list of diagnos- sifications developed by German psychiatrist Emil
tic criteria for each disorder that it included, pro- Kraepelin in the late 19th century, the DSM-I
viding an operational definition of the disorder. largely concentrated on the severe disorders
 DSM-III 237

found in mental hospital populations, covering a in Britain, forcefully criticized the concept of men-
range of brain disorders and mental deficiency, as tal illness, pointing to the social and ethical judg-
well as psychotic and personality disorders. How- ments involved in identifying someone as men-
ever, it also included a relatively brief list of what tally ill, Szasz arguing that the term mental illness
under the influence of Freudian ideas were termed should be abandoned altogether because “mental
psychoneurotic disorders, and a list of transient illnesses” were either brain diseases or “problems
situational personality disorders. Reflecting the in living.” Such concerns were strengthened by
ideas of American psychiatrist Adolf Meyer, it a study by David Rosenhan published in 1973,
conceptualized many of the nonorganic disor- which appeared to indicate that psychiatrists
ders (then called functional) in terms of reactions. could not distinguish those with mental health
However, notwithstanding the medical assump- problems from those without them, as well as by
tion of the importance of diagnosis in the selec- the controversy as to whether homosexuality was
tion of appropriate care and treatment, psycho- a mental disorder. After strong political pressure
dynamically oriented psychiatrists did not regard from gay rights groups, the disorder was removed
diagnosis as central to their practice; instead, they from the DSM in 1973, although there were two
were keen to focus on identifying the dynamics of residual categories in the list of sexual deviations
the individual psyche and did not set clear bound- under which it could still potentially be included.
aries between mental illness and mental health. Critics also attacked the compulsory detention
The second edition, DSM-II, published in of individuals in mental hospitals and the harsh
1968, was partly prompted by the development and impersonal treatment, as they had for many
of an eighth edition of the ICD in 1965 but did decades. A further significant focus of criticism
not incorporate the explicit definitions of psy- underpinning the changes introduced in the DSM-
chiatric terms set out in a Glossary of Mental III was the very poor reliability of psychiatric
Disorders that had been produced for the first diagnosis, with studies showing the marked lack
time in 1974 for use with the ICD-8. It aban- of agreement between psychiatrists when asked to
doned the language of reactions but not that assign diagnoses to the same set of patients. These
of neurosis (the prefix psycho was dropped). It major challenges, which called the legitimacy of
also listed far more disorders than the DSM-I, psychiatric thinking and practice into question,
182 in total. It added a new grouping of child- provided the context in which psychiatrist Rob-
hood disorders, as well as separate listings of ert Spitzer, who had been the technical consultant
a range of sexual deviations and types of alco- for the DSM-II and had also handled the debate
holism and drug dependence. These additions over whether to remove homosexuality from the
partly reflected the expansion of mental health classification, was asked to plan for a revision of
services outside the mental hospital and, in the the DSM. This revision was considered neces-
case of alcohol problems, the activity of pressure sary because the ICD list of mental disorders was
groups. It also significantly increased the number expected to be modified, and there was a desire
of residual or “other” categories. Whereas the to bring the nomenclature of the two into line.
DSM-I had listed only four, the DSM-II included Spitzer selected a task force to plan for the DSM-
an “other” or “unspecified” subtype for almost III, comprised largely of biologically oriented psy-
every group of disorders, allowing more indi- chiatrists committed to exploring the biological
viduals to be defined as mentally ill because the basis of mental disorders and to making psychia-
individual need not fit the relevant description try more scientific.
exactly to be assigned such a diagnosis. Most were hostile to psychodynamic ideas,
The radical changes that were introduced in the regarding them as unscientific; they were also deter-
third 1980 edition of the DSM need to be under- mined to find ways of enhancing diagnostic reli-
stood in terms of the major challenges to psychia- ability. The latter was important not only for clini-
try in the late 1950s and 1960s, which contin- cal purposes but also for strengthening research,
ued into the early 1970s. The challenges occurred which required the identification of groups with
on a range of fronts. Some psychiatrists, notably a particular disorder, for instance, to evaluate
Thomas Szasz in the United States and R. D. Laing treatments adequately, including psychoactive
238 DSM-III

medications that had become prominent within a list of eight such as loss of energy, fatigability,
psychiatry. The strategy for improving diagnostic tiredness, loss of interest or pleasure in usual activ-
reliability was to try to standardize the diagnostic ities, or decrease in sexual drive, symptoms that
process by moving beyond the ICD-8’s glossary need only have been present for a week. There was
and specifying a list of diagnostic criteria for each no requirement in making a diagnosis to consider
disorder in order to provide a more precise opera- the individual’s personal circumstances, except
tional measure of the presence or absence of each that major depressive disorder was not to be diag-
one, as British psychiatrist, Erwin Stengel, had nosed where the symptoms arose from bereave-
argued as early as 1959. A group of psychiatrists, ment following the loss of a loved one. However,
led by John Feighner at Washington University, other major difficulties in an individual’s personal
had listed criteria for 15 disorders in 1972 in order life, such as being made redundant or major finan-
to facilitate their research. Spitzer then led a team cial difficulties, were not excluded, so that if and
that used this work as a foundation for a set of when they generated misery that met the listed cri-
research diagnostic criteria for 25 disorders, pub- teria, a diagnosis of depression could be made. A
lished in 1978. In turn, this approach was adopted further consequence of the new approach was the
for the development of specific criteria for all the possibility of examining comorbidity, something
disorders included in the DSM-III. that had previously been discouraged by the hier-
archical ordering of disorders, and the view that if
Creation of the DSM-III a more severe disorder higher up the list was diag-
Listing specific criteria for each disorder consti- nosed, this could encompass other psychological
tuted a fundamental change, not least because problems such as anxiety or alcohol problems that
a decision was made that the criteria should were lower down.
mainly focus on symptoms, often occurring over The DSM-III also significantly increased the
a relatively short period of time, and should only number of disorders listed, with 265 included.
include etiology if it was clearly established, as The initial task force had wanted to keep the
with the organic mental disorders such as senile thresholds for disorder relatively high, but dur-
dementia. Consequently, the criteria largely ing its deliberations, the DSM became more
ignored the context of symptoms and the factors inclusive, Sptizer later commenting that they had
that might underpin the nonorganic mental disor- not wanted anyone to feel that their diagnostic
ders. The approach was termed descriptive, and categories were excluded, thereby indicating a
had the advantage for the task force of excluding willingness to accept clinicians’ claims for the
reference to highly controversial issues concern- value of new categories of disorder and a lack of
ing the role of psychological and social processes precision as to what constituted a disorder. The
in generating symptoms (an exception was post- DSM-III for the first time included a definition of
traumatic stress disorder). Such factors were to be mental disorder, but it was of little value in deter-
examined by recording their severity on a sepa- mining where the boundaries of mental disorder
rate axis, Axis IV, as part of a multiaxial evalua- should fall. One of the pressures underpinning
tion, but mostly they did not enter into the diag- inclusiveness was the need in the United States for
nosis, which was indicated on Axis I, or on Axis a diagnosis if insurance companies were to cover
II in the case of personality disorders (Axis III was treatment. Another influence was the activities of
for recording physical disorders, and Axis V for the pharmaceutical companies keen to generate
overall functioning). markets for their products.
However, the exclusion of contextual factors Much of the expansion came from subdivision
from the diagnostic criteria ensured that more of disorders included in the DSM-III, which in
individuals would be identified as having some practice extended the overall boundaries of dis-
pathology, since whether the symptoms consti- order. Oft-cited examples included the differen-
tuted a reasonable response to situational factors tiation of panic disorder from generalized anxiety
was largely ignored. The classic example is major disorder that replaced the DSM-II’s anxiety neu-
depressive disorder (single episode), where diag- rosis, as well as the addition of a new phobic dis-
nosis required the presence of four symptoms from order titled social phobia, which transformed the
 DSM-IV 239

personality characteristic of shyness into a mental See Also: Biological Psychiatry; DSM-IV;
disorder. In theory, the problems delineated under DSM-5; International Classification of Diseases;
these new headings could be diagnosed under the Neo-Kraepelinian Psychiatry.
old labels. However, in practice, they expanded
the boundaries of disorder by reshaping and Further Readings
restructuring what was defined as pathological. American Psychiatric Association (APA). Diagnostic
Some entirely new groups of disorders were also and Statistical Manual of Mental Disorders. 3rd
included, such as the sexual dysfunctions, and the ed. Washington, DC: APA, 1980.
number of the residual categories—the term atypi- Kirk, Stuart A. and Herb Kutchins. The Selling of
cal replacing “other” or “unspecified”—was con- DSM. New York: Aldine, 1992.
siderably increased, with the listed criteria setting Lane, Christopher. Shyness. New Haven, CT: Yale
lower thresholds. All of these changes broadened University Press, 2007.
the terrain of mental disorder.
Once published, the new DSM attracted con-
siderable attention and was soon used in many
countries in the world, particularly in research
contexts, often alongside the ICD, and it also DSM-IV
informed and shaped lay ideas about mental ill-
ness. Many clinicians used the DSM-III to make The fourth edition of the American Psychiatric
a formal diagnosis, although the proportion using Association’s Diagnostic and Statistical Manual
the complex multiaxial approach was smaller. of Mental Disorders, the DSM-IV, published in
It was also the basis of new measures used in 1994, attempted to tighten the criteria that had
research contexts to assess levels of psychiat- first been introduced in the DSM-III for diagnos-
ric disorder in the community. It was, however, ing the presence of a mental disorder by intro-
strongly criticized by some on the grounds that ducing a criterion of “clinical significance” for
clinicians’ varying interests, along with those of many of the disorders. Clinical significance had
pharmaceutical companies, had more impact on been mentioned in the DSM-III’s general defi-
the inclusion of categories than sound, extensive nition of mental disorder but not in the lists of
scientific research, pointing to the weak empirical diagnostic criteria for the different disorders.
foundations of categories, the overlap between The DSM-IV also abandoned the hierarchical
them, their lack of validity, and continuing prob- ordering of groups of mental disorders that had
lems of poor diagnostic reliability. been an important feature of previous psychiat-
Some sociologists and psychologists argued ric classifications, further encouraging the focus
that the categorical approach was mistaken, and on comorbidity. Textual revisions were subse-
that a dimensional approach to mental problems quently made to the descriptive material in the
would be more informative. Others strongly criti- DSM-IV, and the DSM-IV-TR (text revision) was
cized the broadening of the boundaries of offi- released in 2000.
cially defined mental pathology, pointing to the The fourth edition of the DSM was prompted
way that this individualized and depoliticized by research, especially epidemiological studies
social problems by drawing attention away from using the DSM-III that suggested the need for
social and psychological causes, focusing on the some revisions, and by ongoing work on a 10th
individual. A revised edition (DSM-III) was pub- revision of the International Classification of Dis-
lished in 1987, in response to new data and some eases (ICD-10). The task force that was estab-
inconsistencies between categories that had been lished to produce a fourth edition of the DSM was
identified. It also added a further 27 disorders, headed by psychiatrist Allen Frances. It decided
and changed the label “atypical” to “not other- to set tighter thresholds for adding new disorders,
wise specified.” stating that new disorders would only be added if
research had established the need for their inclu-
Joan Busfield sion rather than in the hope that, if included, fur-
University of Essex, Wivenhooe Park ther research would be generated.
240 DSM-IV

However, it also stated that the psychiatric diag- was not included in the criteria for specific dis-
noses included in the ICD-10, which was published orders. The DSM-IV, in contrast, included a cri-
in 1992, should be given more consideration than terion referring to clinical significance in around
other proposals. The result was that whereas the half of the disorders, to the effect that the symp-
revision of the third edition of the DSM (the DSM- toms needed to cause clinically significant distress
III) had added 27 disorders, bringing the total up or impairment in functioning, including social
to 292, the DSM-IV increased the total by only and occupational functioning. This was intended
five, adding 13 and deleting eight. The new disor- to reduce the number of those identified as men-
ders included bipolar II disorder, in which at least tally ill who did not have a disorder—false posi-
one depressive episode is combined with at least tives—with one study showing that applying a
one hypomanic episode, rather than a manic epi- measure of clinical significance to the NCS data
sode as required in bipolar I (a hypomanic episode reduced 12-month prevalence rates from 30 to 20
is less severe than a manic episode). Another was percent, though it has been argued that the par-
Asperger’s syndrome, which had been included in ticular measure of clinical significance used in this
the ICD-10, though its validity was described as study set a higher threshold of significance than
uncertain. that indicated in the DSM. Moreover, as the task
This greater caution about adding to the exist- force recognized, the clinical significance criterion
ing list of disorders was prompted by epidemio- delineated in specific disorders in the DSM-IV
logical research on the prevalence of mental dis- lacks precision.
order. In 1980, the U.S. National Institute for One further change introduced in the DSM-
Mental Health had sponsored the Epidemiologic IV was a final shift away from the hierarchical
Catchment Area (ECA) study. This large survey, ordering of the different groups of disorders in
which measured mental disorder using a struc- which organic disorders had been placed at the
tured diagnostic instrument, the Diagnostic Inter- head of the list, followed by psychoses, the neu-
view Schedule, directly based on the DSM-III cate- roses or common mental disorders, and then the
gories, found 12-month prevalence rates of mental behavior and personality disorders. This change
disorder in the United States of 21.7 percent (i.e., was important because rather than seeing less
over one in five individuals). It also found life- severe disorders as one aspect of a more serious
time prevalence rates of 32.7 percent, nearly one disorder higher up the list and subsumed within
in three, although the reliability of lifetime mea- it, it further encouraged the focus on comorbid-
sures has been questioned, given the length of time ity—the identification of more than one disorder
over which information has to be recalled. When in a given individual, which the DSM-III listing
a similar study, the National Comorbidity Survey of specific criteria for each disorder had already
(NCS), was carried out from 1990 to 1992, this helped facilitate.
time using DSM-III criteria, the rates were consid- Most of the changes in the DSM-IV-TR in 2000
erably higher: the 12-month prevalence rate was involved providing further information about
29.5 percent, and the lifetime prevalence was 48 specific disorders and possible causes as part of
percent. Even the researchers noted that the fig- the description of each disorder rather than any
ures were higher than expected. change to the diagnostic criteria.
Commentators argued, however, that the issue
was not just the expansion of the list of disorders Joan Busfield
but also the focus on specific symptoms, without University of Essex, Wivenhooe Park
any assessment of their impact on the individual’s
life. The DSM-III had for the first time added a See Also: American Psychiatric Association; DSM-III;
general definition of mental disorder, whose first DSM-5; International Classification of Diseases.
clause specified that a mental disorder was a
“clinically significant” syndrome associated with Further Readings
distress or disability or a greater risk of suffering American Psychiatric Association (APA). Diagnostic
death, pain, or disability. However, the reference and Statistical Manual of Mental Disorders. 4th
to clinical significance in this general definition ed. Washington, DC: APA, 1994.
 DSM-5 241

Narrow, William E., Donald S. Rae, Lee N. Robins, the current DSM. A large number of additional
and Darrel A. Regier. “Revised Prevalence Estimates disorders were proposed and many were rejected
of Mental Disorders in the United States.” Archives after subsequent controversy and debate.
of General Psychiatry, v.59 (2002).
Wakefield, Jerome C. “The Concept of Mental Additions
Disorder.” American Psychologist, v.47 (1992). Those that looked very likely to survive the dis-
putes and conflicts include mild neurocognitive
disorder, the word mild indicating that the symp-
toms will not need to be as severe or extensive as
those for the existing cognitive disorders. This is
DSM-5 one of a set of neurocognitive disorders, the first
time the term neurocognitive has been featured
The fifth edition of the American Psychiatric in the DSM’s diagnostic labels. The rationale for
Association’s Diagnostic and Statistical Manual the addition of this particular disorder is that it
of Mental Disorders was released in May 2013. will recognize the clinical needs of those with
The main changes that were proposed involve the milder cognitive deficits, though the proposed cri-
addition of entirely new disorders, such as mild teria note that the individuals in question will be
neurocognitive disorder and disruptive mood able to function independently, often regarded as
dysregulation disorder, the reconfiguring of cer- a significant test of mental health. The rationale
tain disorders or groups of disorders, as well as further points out that these milder deficits can
the removal of some disorders. There was also a occur as a result of accidents and conditions like
regrouping of the disorders under 20 headings, the diabetes, though it seems likely that the condition
general definition of mental disorder was modi- will mostly be identified in the elderly, and the
fied, and the severity of an individual’s disorder advantages of so doing when there is little in the
was assessed, with the addition of a dimensional way of effective treatment can be questioned.
element to the classification. There was, however, A new disorder, disruptive mood dysregulation
no plan to change the fundamental principles disorder, has been added to the group of depres-
introduced in the 1980 DSM-III of a descriptive, sive disorders. This focuses on temper outbursts
symptom-based classification that lists diagnostic in those aged 6 to 17 that are disproportionate,
criteria for each disorder. The resulting classifica- occur on average three or four times a week, and
tion are as much a product of arbitrating between have been common since before the individual
conflicting ideas and interests as of definitive sci- was 10 years old. Its inclusion is prompted by a
entific developments. wish to reduce the use of the diagnosis of bipolar
The fifth edition of the DSM, in a moderniz- disorder for children, which has increased consid-
ing gesture, is called the DSM-5—with the Ara- erably in the United States since the late 1990s.
bic number—rather than the DSM-V. The first This is desirable but will still discourage the
discussions about a new edition began in 1999, search for any social and environmental causes
at a specially organized conference that was fol- underpinning the temper outbursts while further
lowed by a range of developmental work. A task encouraging the use of psychoactive mediation.
force to oversee the new edition was established There are also new disorders of nonsuicidal self-
in 2006, led by psychiatrist David Kupfer, with a harm and suicide behavior disorder, the latter for
large number of working groups covering specific use where suicide is attempted. Also, the highly
sets of disorders. Some key features introduced in controversial premenstrual stress dysphoric dis-
the 1980 DSM-III remain. Most importantly, the order, currently located in the disorders requiring
new edition still lists a set of diagnostic criteria further study, is to be moved from the appendix
for each disorder and, in most cases, these criteria to the main text.
still focus on symptomatology, except where eti- An addition to the list of disorders requiring
ology is clear-cut. The most visible changes are in further research is attenuated psychosis syndrome,
the addition, redelineation, reconfiguration, and, the word attenuated indicating that the symptoms
in some instances, removal of disorders listed in will not need to be as severe or extensive as those
242 DSM-5

for the full psychoses. In this case, the criteria will distinguish between the four. This change therefore
specify that reality testing will still be intact. The eliminates three labels from the DSM, including
rationale is to enable the identification of signs of the well-known Asperger’s disorder—a move that
psychotic disorder in young people and to facilitate had already generated considerable opposition—
early intervention, although the plan to call this by incorporating them under one broad label.
psychosis risk disorder was abandoned because Personality disorders are also reconfigured, and
the evidence indicated that many who would have only six remain: antisocial (psychopathic), avoid-
met the criteria did not progress to psychosis. ant, borderline, narcissistic, obsessive-compulsive,
and schizotypal. Four that did not stand up to
Reconfiguration their empirical scrutiny as distinctive personality
An example of reconfiguration is the approach of disorders have been removed: paranoid, schizoid,
taking a more dimensional view of autism and hav- histrionic, and dependent. Further, alcohol abuse
ing a single autism spectrum disorder to replace and alcohol dependence are collapsed into a single
four disorders: autistic disorder, Asperger’s disor- category of alcohol use disorder, another contro-
der, childhood disintegrative disorder, and perva- versial proposal. In addition, it was planned to
sive development disorder not otherwise specified. eradicate the “not otherwise specified” (NOS) cat-
The rationale is that it was difficult in practice to egories attached to most disorders, which function
as residual categories with lower thresholds. These
have been frequently used and have expansion-
ary implications because they allow someone to
be identified as having a particular mental disor-
der even if they do not meet the standard criteria.
However, now at least some have been replaced by
“not elsewhere classified” (NEC) categories. More
precise criteria than before are listed for each one,
but thresholds will still be lower.

Organization
A number of other changes were planned. First,
the multiaxial approach introduced in the 1980
DSM-III was abandoned. This means a return
to the DSM’s earlier, single-axis model. A single
axis is also a feature of the International Clas-
sification of Diseases, and bringing the two into
greater alignment is one of the stated reasons for
this change. Another reason appears to be that the
multiple axes were little used. The personality dis-
orders currently placed on Axis II are set alongside
the other mental disorders, as are the medical con-
ditions of Axis III. The information on environ-
mental stressors of Axis IV is recorded separately.
That on overall functioning recorded on Axis V
may be handled as part of the World Health Orga-
nization’s disability and impairment classification
A man enjoys a cup of strong coffee in a Bahrain market,
September 2003. If he becomes jittery afterward, he may that is part of its family of classifications.
be suffering from a disorder the DSM-5 calls “caffeine Second, there are changes to the definition of
intoxication,” which are symptoms following the consumption a mental disorder that was first introduced in
of 250 milligrams or more of caffeine. For comparison, a tall the DSM-III and has been unchanged since then.
Starbucks coffee has 260 milligrams of caffeine. The DSM-5’s The new definition, unlike the previous one,
inclusion of mental “disorders” like this has aroused criticism. begins with the statement that a mental disorder
 Durkheim, Émile 243

is a health condition. This is to clearly place the psychological state. Finally, as with earlier revi-
conditions in the medical domain while avoiding sions, the DSM-5 that emerged from the lengthy
the word illness, which is too narrow for the full deliberations is a product of efforts to arbitrate
range of conditions included in the DSM. It then between conflicting ideas and interests as much as
states that a mental disorder is characterized by a of agreed scientific developments.
“significant dysfunction” in a person’s cognitions,
emotions, or behaviors. In contrast, the DSM-III Joan Busfield
definition started by talking of clinical syndrome University of Essex, Wivenhooe Park
or pattern and only later referred to functioning.
Prioritizing dysfunction suggests some acceptance See Also: DSM-III; DSM-IV; International
of Jerome C. Wakefield’s concept of disorder as Classification of Diseases.
harmful dysfunction. However, the new defini-
tion then states that disorders may not be diag- Further Readings
nosable until they have caused significant distress American Psychiatric Association. “DSM-5
or impairment, whereas the previous definition Development.” http://www.dsm5.org (Accessed
states that the syndrome was associated with dis- May 2012).
tress or disability. This means that these harms Kirk, Stuart A. and Herb Kutchins. The Selling of
are no longer to be key indicators of disorder but DSM. New York: Aldine, 1992.
instead a matter of visibility, thereby downplay- Tavris, Carol. “How Psychiatry Went Crazy.” Wall
ing, contra Wakefield, the harm criterion. Street Journal (May 17, 2013). http://online.wsj
Third, there is a change in the grouping of dis- .com/article/SB1000142412788732371630457
orders. Instead of the 17 groupings of the DSM- 8481222760113886.html (Accessed June 2013).
IV, there are 20. These are largely organized Wakefield, Jerome C. “The Concept of Mental
developmentally, starting with those related to Disorder.” American Psychologist, v.47 (1992).
childhood (termed neurodevelopmental) through
those relating to later stages of life, such as senile
dementia, with personality disorders follow-
ing after this developmental listing. In offering
a rationale, psychiatrist Carol Bernstein suggests Durkheim, Émile
that having the new groupings should encourage
the examination of interrelated disorders, rather David Émile Durkheim was a French sociologist,
than single disorders, and facilitate etiological commonly regarded as one of the founders of
work. Finally, there is a severity assessment for modern sociology. He played a particularly impor-
each disorder, introducing a routine dimensional tant role in establishing sociology as an academic
element into the classification. discipline, with a distinct method and focus. He is
Some of the introduced changes are sensible: associated with laying the foundations for func-
for instance, the abandonment of the little-used tionalism and structuralism as approaches to the
multiaxial system. The decision to eradicate the study of social life. Durkheim regarded sociology
NOS categories is welcome, except that at least as the study of social facts. He delineated two sep-
some are replaced by NEC categories, diluting the arate categories of social fact: material and non-
impact. Having a routine assessment of severity material. Material social facts concern the physi-
is also desirable. More worrying is the addition cal social structures that affect individuals within
of yet more mental disorders. This is likely to a society. Nonmaterial social facts refer to the
have a significant impact on lay thinking about values, social mores, norms, and collective beliefs
mental disorders as the new categories and labels of a society. Durkheim wrote several influential
are publicized; it will also increase the use of psy- texts, including Suicide. In this book, he posited
choactive medications and the demands on men- that suicide could be functional for society in that
tal health services as well as stigmatize yet more it is an important indicator of the state of a given
individuals as pathological, drawing attention society. He suggested that suicide could take one
away from any social factors that underpin their of four forms. Within these categories, there can
244 Durkheim, Émile

be two paired forms that fall at the opposite end Suicide was not only an important work in terms
of two distinct spectra. Altruistic and egoistic sui- of its theoretical contributions but also became
cide can form the poles of a spectrum of societal regarded as a pioneering work in establishing a
integration, whereas fatalistic and anomic suicide template for social research in terms of method. A
can form the poles of a spectrum of societal regu- key concern of Durkheim was to establish sociol-
lation. ogy as a discrete science, and Suicide was crucial
in establishing social science as a discipline, dis-
Altruistic, Egoistic, Fatalistic, tinct from both philosophy and psychology.
and Anomic Suicide Durkheim conducted an analysis of second-
Altruistic suicide refers to suicide committed for ary data as the basis for his conclusions in Sui-
the benefit of others. This occurs in societies that cide, using statistics gathered elsewhere for other
are so well integrated that the individual is over- purposes and without conducting any fieldwork
whelmed by the group’s beliefs, and their personal to confirm his conclusions. The work has been
needs become viewed as inferior to the wider criticized as an example of the ecological fallacy,
needs of the society. The classic example given which makes inferences at the individual level
of an altruistic suicide is that of a soldier in war, using solely aggregate group data. The ecological
preventing harm to others by his or her death. fallacy assumes that individuals within the group
The practice of suttee in Indian societies is also carry the average characteristics of the group,
an example of altruistic suicide, whereby a wid- which has been proven false. However, others
owed woman immolates herself on her husband’s have defended the work, denying that Durkheim
funeral pyre as a religious or cultural act of duty. ever committed this fallacy. Instead, they suggest
Egoistic suicide occurs as a result of a deep that Suicide was not intended as an explanation
sense of not belonging to the social group, of hav- of individual behaviors at all but was instead
ing no sense of collective connection or ties. The meant as an explanation of the social environ-
feeling of detachment from the group also leads to ments that can surround the individual act of sui-
detachment from the group’s social norms and val- cide. In other words, Durkheim was not intending
ues, resulting in over-self-analysis. This absence of to explain or introduce individual psychological
any sense of community or social support leads to explanations of suicide but instead to identify the
apathy and depression because social connections sociological influencing forces that could come to
and society are what give life meaning. Egoistic bear upon individuals and that may then influ-
suicide is seen in societies that overly emphasize ence their behaviors.
the individual at the cost of the collective. Durkheim was also criticized for basing his
Fatalistic suicide arises in societies where theories on data drawn from a particular popula-
oppression is all-pervasive, to the point where tion but then applying the findings more broadly,
individuals can see no way to flourish or prog- when the results may not in fact be replicable in
ress. An example of fatalistic suicide might be a other populations. Durkheim was also criticized
slave killing him or herself to escape the oppres- for failing to consider that differences between
sive conditions and inescapable fate of slavery. suicide rates of Catholics versus Protestants, a key
Anomic suicide reflects an absence of social focus of his work, might be explained by artifac-
direction and an excess of moral confusion cre- tual recording rates, rather than truly reflecting
ated by the lack of a restraining social ethic to differences in these groups. For example, suicides
limit individual desire. It is often related to dra- of Catholics could have been recorded as sudden
matic social or economic upheaval, both in terms or unexplained deaths because of the stigmatized
of loss and gain. The upheaval generates a new views of suicide within that version of Christian-
situation that has wiped away all previous expec- ity, rather than reflecting any real reduction in the
tations and requires new expectations and new number of suicides.
limits, but these are not in place quickly enough to Despite the many criticisms, Durkheim’s theo-
match the changed situation. This leaves individ- ries about suicide were highly influential and were
uals in a state of constant disappointment because also taken up by theorists working in other areas.
they do not know where they fit into their society. For example, Vincent Tinto created a theoretical
 Durkheim, Émile 245

explanation of student dropouts from university Further Readings

based on Durkheim, drawing analogies between Durkheim, É. Suicide: A Study in Sociology. Glencoe,
the state of suicide and the act of leaving studies IL: Free Press, 1997.
before course completion. Frans van Poppel, F. and L. H. Day. “A Test
of Durkheim’s Theory of Suicide—Without
Vivienne Brunsden Committing the ‘Ecological Fallacy.’” American
Nottingham Trent University Sociological Review, v.61/3 (1996).
Leach, Mark. Cultural Diversity and Suicide:
See Also: Measuring Mental Health; Suicide; Suicide: Ethnic, Religious, Gender and Sexual Orientation
Patient’s View. Perspectives. New York: Routledge, 2006.
 E
Eating Disorders to describe pathological binge eating, separate
from other eating disorders.
Eating disorders are sometimes classified as a
culture-bound syndrome because they occur Cultural Risk Factors for Eating Disorders
most frequently in affluent, industrialized societ- Exploring cultural risk factors for disordered
ies. With the rise of globalization and increased eating, including the relationship between body
exposure to Western media and ideals, the rate of image dissatisfaction and affluence, provides a
eating disorders in many countries has climbed in useful context for understanding differences in
recent years. Cultural risk factors for eating dis- international prevalence rates of eating disorders.
orders, such as affluence and its relationship to Body image dissatisfaction is an important risk
body image, shed light on international trends of factor for eating disorders. Body image is how an
disordered eating. Within the United States, eat- individual regards his or her body. Cross-cultur-
ing disorders differ in subtle but important ways ally, body image dissatisfaction is positively cor-
among different racial and ethnic groups. Interna- related with affluence. That is, the wealthier his
tionally, the prevalence of eating disorders is bet- or her community, the more likely a person is dis-
ter documented in some countries than in others. satisfied or unhappy with his or her body. Mem-
Small, community-based studies provide evidence bers of the United States and of affluent European
that eating disorders are now recorded in commu- countries have been shown to have greater dissat-
nities where they were previously absent. isfaction with their bodies than members of less
The Diagnostic and Statistical Manual of Men- affluent, non-Western countries like Iran, India,
tal Disorders, fourth edition, text revision (DSM- and Tunisia.
IV-TR) recognizes three eating disorders: anorexia Within Latin American communities, the most
nervosa, bulimia nervosa, and eating disorder not dissatisfaction with body image was found in the
otherwise specified, or ED-NOS. Individuals who highly affluent city of Buenos Aires, Argentina,
experience some symptoms of an eating disorder which also has a heavy European influence. In
but do not meet full criteria for anorexia nervosa Asia, the highest rates of body image dissatisfac-
or bulimia nervosa may receive a diagnosis of ED- tion are in affluent east Asian countries like Japan,
NOS. The DSM-IV-TR does not include a sepa- South Korea, and Hong Kong, and body image
rate diagnosis for binge eating disorder, but this dissatisfaction in Japan appears to be stronger
term is sometimes used clinically and in research than in the United States. In addition to affluence,

247
248 Eating Disorders

these east Asian cultures seem to have other fac- In countries that do not idealize the very slen-
tors that contribute to greater body image dissat- der body type, eating disorders may present with
isfaction, including an emphasis on conformity, a different themes and motivations than in coun-
desire to appear more Western, and a high degree tries with a Western body ideal. In some east
of social mobility. Very little research has been Asian countries, including Malaysia, Singapore,
done on body image in African countries, but a and India, a variation of anorexia nervosa with-
broad generalization is that African countries, out fat phobia was commonly reported during
less industrialized and less affluent, have better the 1990s. Instead of intentional weight manage-
body image satisfaction than European or Asian ment, dietary restriction was attributed to reli-
countries. gious ideals, specific beliefs about nutrition, or
Several theories exist to explain the worldwide a general lack of hunger. As east Asian countries
relationship between body image, globalization, have increasingly become globalized, fat phobia
and affluence. One is that more affluent commu- has increased, and eating disorders occur at gen-
nities have greater access to the Internet, televi- erally similar rates and with similar symptoms as
sion, and other media and are therefore more in Western countries.
exposed to Western idealization of the slim figure
and to new possibilities and trends in diet, fash- Rates of Eating Disorders in
ion, sexuality, and overall lifestyle. the United States
Societal changes may also make individuals Prevalence is the overall likelihood that the aver-
more vulnerable to mental illness, including eating age person will experience a specific disorder dur-
disorders, by challenging existing support systems ing his or her lifetime. The prevalence rate of eat-
and introducing change. Globalization and the ing disorders is usually estimated from community
introduction of Western modes of living may chal- surveys and longitudinal studies. Because symp-
lenge established cultural identities in areas like toms and health status may fluctuate over time, it
gender roles, religious identity, and class mobility. is common for an individual to shift between eat-
As a culture becomes more Western, there may be ing disorder diagnoses or to be initially diagnosed
increasing emphasis on the individual, including with an unspecified eating disorder and then later
his or her physical appearance. In areas of Latin meet full criteria for anorexia nervosa or bulimia
America and in Asia, social mobility is influenced nervosa. Because of this high degree of crossover,
at least in part by physical attractiveness. Physi- lifetime prevalence rates of any eating disorder
cal attractiveness, including slimness, is highly are at best general estimates.
valued, and women have reported a belief that Within the United States, recent epidemiologi-
physical attractiveness makes one a more desir- cal research allows for comparisons of the preva-
able employee. Globalization may also change the lence and presentation of disordered eating in
way that people discuss their bodies. For example, men and women and between white Americans
in certain religions that prize modesty, like Islam, and Latinos, African Americans, Asian Ameri-
it is less socially acceptable to openly comment cans, and Native Americans.
on a woman’s weight or physical attractiveness. Anorexia nervosa is the least commonly diag-
With the introduction of secular influences, this nosed eating disorder in the United States, with
prohibition may be challenged. an estimated 0.6 to 2 percent lifetime prevalence
Affluence is also related to actual body weight. rate. Bulimia nervosa is more common, with an
In developing countries, where lifestyles are less estimated 0.9 to 2.2 percent lifetime incident
sedentary and there is less access to a high-calorie rate for Americans. Binge eating disorder is more
diet, the average person is less likely to be over- common and is reported by an estimated 3.5 to
weight. As a society becomes more affluent, its 5 percent of all American women and by 2 per-
members are more likely to become overweight cent of men. ED-NOS is an elastic diagnosis and
as food becomes cheaper in both price and con- is not as well studied as the other eating disor-
venience. When a person experiences his or her ders, so estimates of its prevalence range widely.
body as different than the cultural ideal, there is It is generally agreed that disordered eating is very
greater potential for poor body image. common and, among those presenting for mental
 Eating Disorders 249

health care, more patients will be diagnosed with Younger Latinos today are at an overall higher risk
ED-NOS than with any other eating disorder. of disordered eating than older Latinos. Anorexia
Females are more likely than males to ever be nervosa, while rare, seems to affect Latinos at the
diagnosed with an eating disorder. Previous esti- same rate as non-Latino Americans. While no dif-
mates found that disordered eating affected about ference in bulimia nervosa rates has consistently
one-fifth to one-tenth as many males as females, been found between Latinas and white women,
but the most current research has found that among men, bulimia nervosa is more common in
about one-third as many men as women will meet Latinos than in non-Latino white or Asian Ameri-
criteria at some point in life for anorexia nervosa can males. Some studies have shown slightly
or bulimia nervosa. Rates of binge eating disorder higher rates of binge eating in general for Latinos
are similar between men and women, although compared to non-Latino Americans, while others
exact findings are mixed. Among all men, utili- have not found a significant difference. For Lati-
zation of mental health care to treat disordered nos, an individual’s level of acculturation seems to
eating is very low. be a risk factor for disordered eating. Second-gen-
Latino Americans include those of Mexican, eration Mexican Americans have a higher risk of
Puerto Rican, Cuban, or other Latino heritage. an eating disorder than first-generation Mexican
immigrants. The risk of bulimia nervosa is higher
for Latinos who have lived in the United States
the longest when compared to the newly immi-
grated, and binge eating disorder is more com-
mon for Latinos born in the United States than
for Latinos born elsewhere.
African American women do not differ from
nonminority women in estimated incident rates
of anorexia nervosa or bulimia nervosa, although
African Americans are less likely to receive clinical
treatment for disordered eating and are therefore
underrepresented in patient populations. Binge
eating is more common in African American
women than in white women. African American
men, like Latino American men, are more likely
to have bulimia nervosa at some point in life than
white or Asian American males. African Ameri-
cans of both genders report significantly greater
impairment and disruption in life from disordered
eating symptoms than other Americans with the
same diagnoses. Historically, studies had found
that African American girls and women reported
greater body satisfaction and less desire for thin-
ness. This effect seems to have weakened, and
most contemporary research has found no signifi-
cant difference in body attitudes between African
American and white females.
Asian Americans experience anorexia nervosa
Marianne Lindberg De Geer’s “Women of Bronze” sculpture and bulimia nervosa at the same rate as white
outside the Konsthallen art museum in Växjö, Sweden, depicts Americans. In terms of specific symptoms, there
an anorectic and an obese woman facing one another in order have been conflicting findings regarding the pres-
to protest modern society’s obsession with appearances. With ence or absence of fat phobia in Asian American
the rise of globalization and exposure to Western media and patients with eating disorders. Some studies have
ideals, the rate of eating disorders has risen around the world. found that Asian American patients are less likely
250 Eating Disorders

to report a specific phobia of gaining weight, nervosa, and 1.9 percent for binge eating disorder.
while others have found an overall pattern of National variations exist, with Finland, France,
underreporting of symptoms, suggesting that if a and Belgium having slightly higher prevalence
patient is afraid of gaining weight, he or she may rates compared to the Netherlands, Germany, and
not directly express the phobia. Spain. European women overall are about 3–8
Relatively little research has been conducted times more likely than men to have ever had clini-
on rates of eating disorders in Native Americans. cally significant symptoms of disordered eating.
Native American young men seem to experience Rates of disordered eating attitudes in Australia
the same rates of disordered eating as other young are similar to the United States. Within Europe
men in the United States. Native American young and Australia, minority or immigrant girls and
women report having been diagnosed with any women are at an increased risk for eating disor-
eating disorder at the same rates as white Ameri- ders. Within Great Britain, south Asian girls are at
cans. Native American girls are significantly more greater risk for having disordered body image and
likely to report symptoms of binge eating disor- to exercise dietary restraint. In Australia, Greek
der than white American girls and are more likely Australian girls are at a higher risk for eating dis-
to report shame and embarrassment because of orders than Greek girls in their native country.
overeating. There are few epidemiological studies of eat-
Within the United States, Latino, Asian Ameri- ing disorders in Africa. Attempts to study eat-
can, and African American patients are less likely ing disorders in Africa, such as in Sudan, have
than white patients to access treatment for eating found extremely low incidence rates. This may
disorders, consistent with the general disparity in be because of cultural factors such as geopolitical
health care utilization by minorities. instability, different cultural conceptions of disor-
dered eating, and lack of access to mental health
Rates of Eating Disorders Worldwide care. Among more affluent communities, racial
There are few epidemiological studies of eating identity may play a role in the presentation of eat-
disorders outside the United States and Europe. ing disorders. Research in South Africa found that
Population-based estimates for the prevalence of black African female college students were more
eating disorders are not yet available for many likely to have disordered eating beliefs compared
countries. Eating disorders are especially hard to white or biracial Africans; and in Zimbabwe,
to diagnose and classify across cultures because anorexia symptoms were more common among
of the wide cultural variations in attitudes and white or biracial schoolgirls than black African
behaviors around food, eating, weight mainte- schoolgirls.
nance, and body image. Different cultures have In the Middle East, disordered eating preva-
different conceptions of and tolerances for binge lence differs among religious and ethnic identi-
eating, fasting, purging through vomiting, laxa- ties. Feminist theorists have noted that eating
tive use, or compensatory exercise. In addition, disorders seem to occur most in cultures where
poverty, famine, or a general scarcity of food may affluence is high and cultural restraint is low. In
contribute to survival-based behaviors that mimic religious cultures where behavior is highly regu-
symptoms of eating disorders, such as hoarding, lated, reported eating disorders are lower. In
food preoccupation, or intentionally undereating regions more influenced by European or Ameri-
so that others may have more to eat. However, can culture, more disordered eating attitudes are
anecdotal and city-based reports from areas with reported. For instance, among Israeli schoolgirls,
previously rare occurrences of eating disorders nearly three-fourths report dieting at some point.
suggest that eating disorders are occurring more Eating disorders were previously rarely recorded
frequently in communities where they previously in South America, and the prevalence was thought
did not exist or were not conceptualized as such. to be extremely low. In affluent, more globalized
In affluent European countries, the estimated regions of South America, eating disorders have
lifetime prevalence of eating disorders for women been documented but at rates much lower than in
is similar to the United States, with 0.9 percent the United States. For instance, adolescent girls in
for anorexia nervosa, 0.9–2.3 percent for bulimia Santiago, Chile, had a 0.4 percent incidence rate
 Economics 251

of any eating disorder over a 12-month period. Economics

Santiago is a relatively cosmopolitan and affluent
city, and it may be assumed that the incidence of Cultural factors play an important role in shap-
eating disorders there is higher than in surround- ing how individuals experience mental illness.
ing regions. The prevalence of major mental disorders var-
Through the 1970s and 1980s, there were rela- ies significantly across cultures, and cultural
tively very few recorded instances of eating dis- factors shape the way patients interact with the
orders in Asian countries. Eating disorders are health care system when they seek treatment. In
now much more commonly seen in clinical set- the United States, for example, immigrants and
tings, with prevalence rates in Japan and urban members of racial and ethnic minorities who
China approaching or even surpassing those in are culturally different from their providers are
the United States. In Bangalore, India, at least often disadvantaged when their experience is
half of psychiatrists surveyed felt that the inci- solely considered as a “universal” expression of
dence of eating disorders was stable or increasing. disorder as defined by the American Psychiatric
Two-thirds of practicing Bangalore psychiatrists Association’s (APA) Diagnostic and Statistical
surveyed had seen at least one case of an eating Manual of Mental Disorders (DSM) and cultural
disorder in the past year. Because Bangalore is a factors are not taken into account in the process
highly affluent area of India that has been strongly of treatment.
influenced by technology and globalization, eat- Culture should not be seen, however, as only
ing disorders are expected to be a more common operating through individual or interpersonal
concern there than in more rural or economically processes. The way health care is organized and
diverse areas of India. financed is also a cultural process that shapes
the quality of care available to all patients.
Elizabeth A. Wangard Health care delivery is influenced by political
George Washington University activities and government regulations, modali-
ties of treatment are influenced by global trends
See Also: Acculturation; Adolescence; Diagnosis in in biomedical innovation and local movements
Cross-Cultural Context; Globalization; Internet and for patient’s rights and community priorities,
Social Media; Peer Identification; Women. and health insurance markets are influenced by
norms of efficiency and profit maximization.
Further Readings These cultural factors can most clearly be seen
Becker, Anne E. “Culture and Eating Disorders in the deinstitutionalization movements in psy-
Classification.” International Journal of Eating chiatry during the 1970s, the rise of community
Disorders, v.40 (2007). health centers and community-based treatment
Holmqvist, Kristina and Ann Frisén. “Body for mental disorders, the rise of managed care
Dissatisfaction Across Cultures: Findings and organizations in the 1980s, and major health
Research Problems.” European Eating Disorders policy reforms to expand access to care such
Review, v.18 (2010). as the 2010 Patient Protection and Affordable
Miller, Merry N. and Andre Pumariega. “Culture and Care Act (PPACA) and the 2006 Massachusetts
Eating Disorders: A Historical and Cross-Cultural Health Reform Law (Chapter 58).
Review.” Psychiatry, v.64/2 (2001). In each of these examples, the health care sys-
Nasser, Mervat, Melanie Katzman, and Richard tem was culturally constituted through social
Gordon, eds. Eating Disorders and Cultures in processes within organizations, between organi-
Transition. New York: Taylor & Francis, 2001. zations, and in society at large. The modern envi-
Stice, Eric, Nathan C. Marti, Heather Shaw, and ronment in which individuals seek treatment for
Maryanne Jaconis. “An 8-Year Longitudinal Study mental disorders is thus a product of the cultural
of the Natural History of Threshold, Subthreshold, features of individual patients and providers as
and Partial Eating Disorders From a Community well as the cultural features of the political, insti-
Sample of Adolescents.” Journal of Abnormal tutional, and economic organizations of the soci-
Psychology, v.118/3 (2009). ety in which they seek care.
252 Economics

Financial Barriers to Equitable Care availability of beds in area psychiatric hospitals is

While equal access to health care is considered restricted to patients with certain forms of insur-
by some to be a fundamental right of citizenship, ance. Some facilities only take private health insur-
access to care significantly varies between racial ance, while others will take those with private or
and ethnic groups and between individuals with public insurance but not those without insurance.
different levels of income and education. Finan- This leaves many patients “stuck” in temporary
cial resources vary across demographic categories, treatment environments, unable to move on to
and those with regular employment and higher inpatient facilities from the emergency room or
salaries enjoy access to more generous health to secure appropriate outpatient arrangements
insurance plans that cover mental health condi- after discharge from the inpatient unit.
tions. Lower-income individuals and the elderly In states with safety net programs that pro-
are more likely to rely on public health insurance vide emergency coverage for severely mentally
programs with less generous coverage. ill patients without a regular form of insurance,
According to the APA, one-quarter of Ameri- care is still difficult to obtain due to a shortage of
cans have inadequate access to mental health ser- facilities that accept safety net coverage. In Mas-
vices and 44 percent either do not have mental sachusetts, for example, the nearest available bed
health coverage through their health insurance for a psychiatric patient with a substance abuse
plans or are not sure if they do. Federal regula- problem can be a 2.5-hour drive away. This leads
tions regarding the inclusion of mental health to a multitiered situation in which mental health
and substance abuse in private and public health providers have to consider finances in their clini-
insurance plans is complex, with limited forms of cal decisions.
mandated coverage existing across various pro- Health insurers also require prior authoriza-
grams, which are made more generous depending tions for particular treatment plans and advance
on state of residence. The PPACA significantly approval of referrals to specialty treatment and
improves mental health parity, as qualified health aftercare placements. These requirements con-
plans offered through government-run health strict the authority and autonomy of mental
insurance marketplaces are required to offer health providers who must file special paperwork,
coverage for both mental health and substance make phone calls, and even go to court to secure
abuse. These dual diagnosis cases are currently approval for their preferred course of treatment.
poorly covered by health insurance; a recent The insurance reviewer responsible for mak-
study conducted by the APA found that nearly ing these decisions has not evaluated the patient
half of individuals with both psychological dis- themselves, and they often do not have the quali-
orders and substance abuse problems go without fications of the clinician. This amounts to a medi-
treatment. Even with the PPACA, the amount of cal doctor having to justify their clinical judgment
coverage available for mental health disorders is to a bachelor’s- or master’s-level social worker.
subject to usage caps, which limit the availability This undermines clinical judgment and can lead
of care below clinical need. to inferior care when inordinate time is spent
Financial considerations are frequently cited by negotiating with insurance companies rather than
clinicians as a major factor shaping the quality of directly providing patient care.
care they can provide to their patients. Access to
certain types of care, particularly mental health The Instability of Insurance Coverage
care, is severely limited by whether one has insur- Health insurance coverage does not guarantee
ance and what type of insurance one has. For continuous access to high-quality mental health
example, if a patient enters a psychiatric emer- care. According to the 2010 U.S. Census, 84
gency room and the staff determines that he or percent of Americans have health insurance and
she needs to be admitted to a full-time psychiatric 16 percent are uninsured. However, this statistic
inpatient facility because of the severity of their masks significant heterogeneity in the source and
symptoms, they are not free to refer them to the stability of coverage. Approximately 55 percent
closest or most convenient facility available that of Americans obtained private health insurance
specializes in their particular needs. Rather, the through their employer, 10 percent purchased
 Economics 253

private insurance on their own, and 31 percent their particular experience. Interviews conducted
were covered (nonexclusively) by some form of by the Kaiser Family Foundation in 2009 found
government insurance (Medicare or Medicaid). that system complexities can lead to gaps in cov-
During times of economic or social instability, erage. With the complex structure of the PPACA,
individuals can cycle in and out of coverage or which is implemented primarily through state-
move from one form of insurance to another. based insurance exchanges, each with varying
This phenomenon, which some have referred eligibility and programmatic rules, residents with
to as “churning,” constitutes another financial fluctuating incomes and employment statuses can
barrier to equitable care that mental health pro- fall through the cracks. These individuals, and
viders face. From one visit to the next it is difficult those ineligible for existing programs (such as
to know which type of coverage any given patient undocumented immigrants), will not have strong
may have. For three months of the year a patient continuity of care, even when the PPACA is fully
may have Medicaid; then, after a slight raise in implemented. As a result, they will still rely on
their salary, they are no longer eligible and must a health safety net to pay for needed care. The
purchase subsidized insurance through a govern- shortfalls revealed by the problem of churning
ment-run health insurance exchange (when the and the continuing difficulties of providing clini-
PPACA is fully implemented in 2014). cally appropriate care to patients with unstable
If a patient’s income decreases, he or she may attachments to the insurance market highlight
cycle off insurance altogether for a period of time, the distinct difference between the availability of
leaving him or her with no access to care until they health insurance and actual access to care.
can once again afford the premiums for private
insurance. In addition, Commonwealth Care (a Cultural Complexity and the
subsidized health plan for low-income uninsured Medical Machine
Massachusetts residents) and Medicaid have differ- The contemporary culture of clinical practice in
ent rules for when eligibility starts and stops, lead- psychiatry and mental health care is character-
ing to gaps in coverage when transitioning from ized by increased bureaucratic efforts to improve
plan to plan. Coverage can also end for procedural cost effectiveness and complex political reforms
reasons, such as when an income-documentation to expand health insurance coverage to the unin-
form is not returned in time. With each change sured. It is also characterized by fundamental
in insurance status, there is a different process for aspects of the culture of medicine that shape the
obtaining prior authorization, different medica- way economic considerations and cultural factors
tions eligible for coverage, and different options intersect in clinical settings.
for referral for aftercare or hospitalization. This In 2002, the Institute of Medicine released its
is especially problematic for psychiatric care, in landmark report “Unequal Treatment,” investi-
which generics are often imperfect substitutes for gating factors underlying differences in medical
name-brand medications and older medications treatment received by members of different racial
may be less effective and have more side effects and ethnic groups in the United States. The report
than newer medications. In addition, fewer treat- argued that financial factors, including access
ment centers exist for psychiatric care, and the to health insurance, were substantially respon-
consequences to discontinuity of care can include sible for the observed differences in the quality
immediate safety risks to patients and others. of care received by racial and ethnic minorities;
Health care reform efforts since the 1960s however, taking these factors into account did not
have dramatically expanded insurance coverage completely eliminate differences between groups.
through a combination of public and private ini- For example, they found significant differences
tiatives, yet the newly insured do not represent in the quality of care between African Americans
a stable and coherent group of individuals. Simi- and whites who had similar incomes, had simi-
larly, the uninsured population is better viewed as lar access to high-quality hospitals, and presented
an aggregate measure of the number of uninsured with similar symptoms. They reviewed a large
individuals at any given time, with particular body of research from across the medical and
individuals cycling on and off care according to social sciences and concluded that conscious and
254 Economics

unconscious negative racial stereotypes led indi- allowed 15 minutes per visit with their patients for
vidual physicians to act in a biased manner when medication management and spend the majority
making medical decisions for patients from dif- of their working day filling out paperwork related
ferent backgrounds. They referred to these differ- to health insurance requirements, regulatory com-
ences in treatment, which could not be accounted pliance, and social welfare documentation for
for by financial factors or clinical appropriate- their patients. When patients come from different
ness, as “disparities” in care and referred to dif- cultural backgrounds, speak languages other than
ferences that were traced primarily to financial English, and have complex social and financial
factors such as personal income and health insur- difficulties, the volume of paperwork grows con-
ance status as “inequalities” in care. comitantly, as does the time needed in face-to-face
There was great debate among the contribu- conversation to understand all the psychological
tors to the report as well as the congressional features underlying their mental health conditions.
committees that oversaw its production about Paperwork documentation, including the famed
How much active racial discrimination was “check boxes” that populate most forms and are
really responsible for the observed disparities in designed to improve efficiency and standardize
care. One of the researchers, Mary-Jo DelVecchio processes to improve quality of care, can actually
Good, was asked by the Institute of Medicine: work to degrade it. One study conducted by psy-
“how could well-meaning people [healthcare chiatrist Antonio Bullon in 2011 found that the
providers] provide inequitable care to minority documentation and record-keeping practices of
and nonminority patients?” Good, who for many contemporary clinical life are often experienced
years had studied the socialization of medical stu- by many mental health clinicians as oversimplifi-
dents and the culture of medicine, concluded that cations of socially complex and chaotic life reali-
the “medical gaze”—the way doctors learn to see ties. Clinicians working with minority and poor
the world and especially the human body—soon patients must fill out managed-care documenta-
becomes the dominant knowledge framework tion templates that do not include crucial social
through medical school, that time and efficiency interventions. These social interventions, such as
are highly prized, and that students are most car- helping their patients apply for food stamps or
ing of patients who are willing to become part process paperwork for Social Security disability
of the medical story they wish to tell and the insurance that clinicians spend much of their time
therapeutic activities they hope to pursue. She providing, are simply not reimbursable by insur-
also found that the medical culture is character- ance companies.
ized by a distinct hierarchy of valued knowledge Bullon refers to the time spent complying with
in which psychological and social data are often documentation requirements as “the paper life,”
regarded as inadmissible evidence by students which is often viewed as alien to the therapeutic
who are learning to hone their case reports and tasks many clinicians view as their main profes-
presentations to focus on the essence of “what sional activities. These practices lead to fragmen-
medicine cares about,” particularly the biomedi- tation of therapeutic work and clinical narratives
cal pathology of disease. without significantly contributing to actions that
In the process of becoming competent physi- are directly related to improving their patients’
cians, the social and cultural concerns of patients lives. According to Bullon, clinicians are required
are often edited out of the clinical decision-mak- to fit complex social dimensions into ultra-
ing process. This can disadvantage patients whom reduced check-box constructs without a comple-
clinicians assess as likely to pose “problems” and mentary official space in the template to record
compromise the efficacy and efficiency prized by their efforts to integrate different aspects of their
the medical world. When these clinicians enter patients’ lives. The most complex patients who
practice, they are confronted with additional are suffering the most social chaos are not easily
external pressures that further limit their ability assimilated into the medical machine; therefore,
to fully consider the complex cultural, social, and they become “invisible.” This process results not
financial realities of their patients. For example, solely from conscious or unconscious processes
academic psychiatrists in Boston are typically of discrimination or bias against racial and ethnic
 Egypt 255

minorities or immigrants—or those who are cul- Pryor, Carol and Andrew Cohen. “Consumers’
turally different—but from the confluence of the Experience in Massachusetts: Lessons for National
culture of medicine itself with recent trends in the Health Reform.” Menlo Park, CA: Kaiser Family
way the institutions of health care delivery are Foundation, 2009.
organized and financed. Shim, Janet K. “Cultural Health Capital.” Journal of
Health and Social Behavior, v.51/1 (March 2010).
Seth Donal Hannah U.S. Census Bureau. “Income, Poverty, and Health
Harvard University Insurance in the United States: 2010.” http://www
.census.gov/prod/2011pubs/p60-239.pdf (Accessed
See Also: Emergency Rooms; Ethnicity; Health June 2013).
Insurance; Medicare and Medicaid; Policy: U.S. Department of Labor. “FAQs About Affordable
Federal Government; Policy: Medical; Policy: State Care Act Implementation Part V and Mental
Government; Race; Social Security; State Budgets; Health Parity Implementation.” http://www.dol
Welfare. .gov/ebsa/faqs/faq-aca5.html (Accessed June 2013).

Further Readings
American Psychiatric Association. “Access to Mental
Health Care.” http://www.apa.org/health-reform/
access-mental-health.html (Accessed June 2013). Egypt
Brandon, William P., Rajeshwari Sundaram, and
Ashley A. Dunham. “Multiple Switching in For the Egyptians who lived from 6,000 to 5,000
Medicaid Managed Care: A Proportional Hazards b.c.e.—as for most societies in general for the next
Model.” Journal of Health Care for the Poor and 3,500 years—mental illness was a magical or reli-
Underserved, v.20 (2009). gious condition, and priests, magicians, and phy-
Cunningham, Peter J., Gloria J. Bazzoli, and Aaron sicians worked on the body to heal the harm done
Katz. “Caught in the Competitive Crossfire: Safety by wrathful gods or evil spirits. The first known
Net Providers Balance Margin and Mission in a mental hospital was a temple complex close to the
Profit Driven Health Care Market.” Health Affairs, Saqqara, a vast, ancient burial ground.
v.12 (2008).
Dorn, Stan, Ian Hill, and Sara Hogan. “The Secrets Mental Illness Prevalence and Types
of Massachusetts’ Success: Why 97 Percent of State Since the 1950s, Egypt has improved child and
Residents Have Health Coverage.” Princeton, NJ: infant mortality, access to general health care,
Robert Wood Johnson Foundation, 2009. and life expectancy. However, high rates of illit-
Good, Mary-Jo DelVecchio, Cara James, Byron eracy (particularly for women), insufficient job
J. Good, and Anne E. Becker. “The Culture opportunities (particularly for the young), lack of
of Medicine and Racial, Ethnic, and Class innovation, overemphasis on military spending,
Disparities in Healthcare.” In Unequal Treatment: and misplaced economic priorities mean medical
Confronting Racial and Ethnic Disparities in problems persist, including in mental health.
Healthcare, Brian D. Smedley, Adrienne Y. Stith, There are no national statistics on mental
and Alan R. Nelson, eds. Washington, DC: problems in Egypt; data on mental illness in
National Academies Press, 2002. the country is derived only from small studies.
Good, Mary-Jo DelVecchio, Sarah S. Willen, Seth Egypt’s population is 70 million people. In 2004,
Donal Hannah, Ken Vickery, and Lawrence T. a survey found that nearly 17 percent of adults
Park, eds. Shattering Culture: American Medicine had mental disorders. A 2001 study recorded
Responds to Cultural Diversity. New York: Russell mental problems for 50 percent of students. And
Sage Foundation, 2011. a 1988 study noted that 4.5 percent of the elderly
Lo, Ming-cheng M. and Clare L. Stacey. “Beyond suffered from dementia and 2.2 percent had
Cultural Competency: Bourdieu, Patients, and Alzheimer’s disease.
Clinical Encounters.” Sociology of Health & The top diagnosis is hysteria, possibly due to
Illness, v.30/5 (2008). modernization, industrialization, and increasing
256 Egypt

and generally disturbing news contribute as well.

Rising rates of crime and violence translate to
insecurity and trauma. While the stigma of men-
tal problems remains, people distrust the mental
health ministry. Therefore, Egyptian patients tend
to conceal mental ailments under physical ail-
ments because there is no stigma in physical ill-
ness. Mentally ill patients thus tend to seek help
from their primary care physician rather than a
mental health professional.
One approach Egypt has taken is to establish
hotlines and radio programs about the availabil-
ity of mental health programs. The hardest-hit
group is the middle class, but they are also the
most likely to get help.

Evolution of Mental Illness Law,

Education, and Care
Egypt’s approach to mental health has under-
gone significant changes. As recently as 1944,
Egypt’s mental health law—with its emphasis on
institutionalization—hearkened back to 19th-
century Europe, with patients locked away and
left for decades. Abbasiya, a former royal palace
Ahmed Okasha, an Egyptian psychiatrist, is a professor of in Cairo, became an asylum synonymous with
psychiatry at Ain Shams University, Cairo, and the first Arab- “mad” or “crazy” in 1883. In the 20th century,
Muslim to serve as president of World Psychiatric Association even patients no longer requiring significant med-
(2002–05). He also writes on psychiatry and mental disorders. ication remained in Abbasiya because there was
Egypt has roughly one psychiatrist for every 70,000 people. no alternative.
The World Health Organization (WHO) chose
Egypt as one of the countries in its 1975 to 1981
effort to improve the scope of mental health pro-
complexity in society. Other illnesses are acute grams and to create programs integrating men-
psychosis and schizophrenia, the most common tal health into basic health care. Egypt’s govern-
chronic psychosis. Anxiety and obsessive-compul- ment and private sector began implementing the
sive disorder are also prevalent. Males are more changes in 1986. A 1978 policy statement indi-
likely to be anxious and hypochondriacal. Two- cated that community and other services were a
thirds of obsessive-compulsive patients are male. priority, and in 2003 the policy was amended to
Depression has an 11.4 percent prevalence in include better community services and more com-
urban settings, with 19.7 percent in the country. prehensive mental hospitals and to incorporate
Egyptians and other Muslims sometimes have mental health into primary care. A 1997 WHO-
suicidal desires but rarely act on them. Cairo’s sponsored plan emphasized a 10-point program
suicide attempt rate is 38.5 per 100,000, with the to promote mental health. Reforms took place
highest rates in the 15 to 44 age group, equally from 1991 to 1996 and from 1997 to 2003 with
split between genders. Single patients comprised an emphasis on training family doctors, incor-
over half of all suicide attempts and students porating mental health into primary care, and
comprised 40 percent. improving public awareness.
The Egyptian revolution that began in 2011 is A 2006 WHO report took another pulse on
stressful, depressing, and an aggravator of mental the state of mental illness care in Egypt. It noted
health issues. Violence, economic deterioration, that funding in 2004 was less than 2 percent of
 Egypt 257

the total government budget for health. Fifty-nine Today, Egypt has about 1,000 psychiatrists, a
percent of these expenditures went to hospitals, ratio of one for every 70,000 people. Most work
primarily in large cities and urban areas, which in the cities, so the rural availability is more
had 6,000 psychiatric beds total. Other govern- restricted than in urban areas. Psychiatric nurses
ment agencies had about 600 more beds, and the total 1,300, clinical psychologists total 200, and
medical schools added an additional 200. Private hundreds of general psychologists work in fields
hospitals totaled only 750 more. The 15 mental other than mental health. Assisting these profes-
health hospitals had 23,047 patients. Community sionals are 1,500 nurses, 241 social workers, and
care facilities were available only in major cities; 61 psychiatric social workers. Social workers in
elsewhere, the family provided care. For patients psychiatric facilities lack specialized training; an
receiving community-based treatment, the coun- effort in 1960 to give social workers psychiatric
try had a single clinic with follow-up services, training failed after two years because of a lack
two day care centers, and one mobile clinic. There of applicants.
were no residential facilities. Egypt’s 17 medical schools all have psychiatric
In July 2008, Egypt’s General Secretariat for departments, including seven departments of neu-
Mental Health reported that occupancy of the ropsychiatry. Egypt has been awarding degrees
five major government mental health hospitals in neuropsychiatry for over 60 years, including a
was almost 80 percent. neuropsychiatry master’s for 25 years and a doc-
The WHO also reported in 2006 that only torate for 20 years. Standards include theses and
5 percent of primary care physicians were receiv- oral, written, and clinical exams.
ing refresher short courses on mental health, less The number of beds total 9,700, one for every
than 20 percent knew protocols for diagnosis and 7,000 people or 15 per 100,000 people. The total
management of mental disorders, and only a few number of hospital beds is 110,000. When Egypt’s
referred patients to mental health professionals. two psychiatric hospitals struggled to handle a
Most primary care practitioners had no contact load of 5,000 patients, three new 300-bed hos-
with mental health practitioners. pitals were built to improve service quality and
availability. The future emphasis is on smaller,
A New Approach medium-stay hospitals of 600 beds and short-stay
In 2009, Egypt enacted its first mental health law hospitals of 100 beds. Outpatient care in all gen-
in 60 years. That changed with the reform of the eral hospitals is also a goal.
Law for the Institutionalization of Those with Of the 62 mental health outpatient clinics, only
Mental Illnesses (Law 141), the 1944 reiteration two specialize in treatment of children and ado-
that made institutionalization the basis for Egyp- lescents. Child and adolescent psychiatry is disap-
tian mental health work. The law of 2009 shifted proved by the general populace.
the focus to community-based treatment with Implementation of community care has
community psychiatric nurses and group homes. reduced inpatient loads, but aftercare services
The law also set a time limit for review of cases, remain inadequate, in part because people do not
gave patients a greater role in defining their treat- understand the need for aftercare after the initial
ment, and instituted safeguards for those who improvement. Community-based and preventive
are involuntarily hospitalized. The system helps services are still woefully lacking. There is no
those ready to leave Abbasiya to move back mental health program on the streets; people have
into the community. Legal assistance is among to seek it out. For most, the preferred remedy
the protections. Seventy percent of patients are remains family and religion.
stable enough to move out of the institution with
assistance. Roughly half of these patients reinte- John Barnhill
grate; the other half remain as outpatients. There Independent Scholar
are still problems with the general public’s per-
ception of mental illness, the stigmatization of See Also: Clinical Psychologists, Training of;
the released, and the unwarranted fears of the Psychiatric Training; Religion; Social Support;
mentally ill. Stigma: Patient’s View.
258 Electroconvulsive Therapy

Further Readings depression when other methods such as psycho-

Bipolar World. “Mental Illness.” http://www.bipolar therapy and medication therapy have failed. How-
world.net/Bipolar%20Disorder/History/hist6.htm ever, there are still a large number of psychiatrists,
(Accessed January 2013). psychologists, and general medical practitioners
Elgerzawy, Ragia. “Mental Health Situation and who consider the treatment crude and invasive.
Services in Egypt.” Egyptian Initiative for Personal Though officially groups like the American Psy-
Rights (March 6, 2010). http://eipr.org/en/report/ chiatric Association consider ECT a safe and effec-
2010/03/06/645/650 (Accessed January 2013). tive treatment for severe depression, this view still
Gittleson, Ben. “The Egyptian Revolution’s Toll On encounters skepticism in other quarters, some of it
Mental Health.” Worldcrunch (October 9, 2012). fueled by sensationalist portrayals of the treatment
http://worldcrunch.com/tech-science/the-egyptian in the mass media, some by patient activists who
-revolution-039-s-toll-on-mental-health/egypt-men protest against what they call its brain-disabling
tal-health-depression/c4s9736 (Accessed January functions. In many jursidictions, its use is hedged
2013). about and inhibited by legal constraints.
Okasha, A. “Focus on Psychiatry in Egypt.” http:// The use of electric shock to treat mental dis-
bjp.rcpsych.org/content/185/3/266.full (Accessed orders began in the 1930s. ECT replaced previ-
January 2013). ous convulsive therapies performed by chemical
“Revolution in Egypt’s Mental Health Care.” BBC injection. Although developed as a treatment for
(May 6, 2009). http://news.bbc.co.uk/2/hi/80345 schizophrenia, the most noticeable improvement
04.stm (Accessed January 2013). as a result of ECT therapy came from individu-
World Health Organization (WHO). “Mental Health als suffering from depressive disorders. Initially
in the Eastern Mediterranean Region: Reaching the popular with psychiatrists for the treatment of
Unreached.” Cairo: WHO, 2006. severe depression, ECT use began to subside in
World Health Organization (WHO) and Ministry of the late 1950s, following reports of the therapy
Health Egypt. “WHO-AIMS Report on Mental being used to subdue and control troublesome
Health System in Egypt.” Cairo: WHO/AIMS, mental patients. By the 1970s, ECT was severely
2006. stigmatized, and treatments were rare and only
used in the most severe depression cases.
As a result of improved equipment and changes
in the treatment procedure, professional interest
was renewed during the 1980s in using ECT as
Electroconvulsive a treatment for severe depression. Although still
tarnished by its somewhat dark and questionable
Therapy past, many mental health professionals today are
in favor of using ECT treatment with persistent
Electroconvulsive therapy (ECT) was one of depression cases. Currently, over 100,000 indi-
a number of shock therapies developed in the viduals in the United States alone receive ECT
1930s. The term shock therapy is no longer used treatments every year.
by psychiatrists and has acquired pejorative
associations. The therapy uses a small burst of Depression
electricity that run either unilaterally or bilater- Despite the controversy surrounding it, ECT is
ally through the temporal lobe(s) to treat severe considered by a majority of psychiatrists as one
depression. ECT treatments are sometimes rec- of the most effective treatments for severe depres-
ommended when depressed individuals have life- sion, a more effective treatment modality than
threatening mental issues such as persistent sui- psychotherapy or medication therapy. Although
cide ideation or are catatonic and unresponsive minimal information is available on cross-cultural
to other treatments. comparisons, most medical professionals report
Extremely controversial, ECT use varies widely that the ratio of female to male treatments closely
across cultures. Many psychiatrists consider follows with the 2:1 prevalence rate reported by
the therapy to be a viable treatment for severe each gender.
 Electroconvulsive Therapy 259

Several studies have indicated that ECT treat- is present. The procedure is available for both
ments are more common among the elderly than inpatient and outpatient settings; it takes approx-
with younger patients, and this may be indicative imately one hour to receive the treatment and the
of the fear factor, or lack thereof, within each subsequent monitoring by medical staff members
group. ECT treatments demonstrate a far quicker in a recovery room. The procedure is only given
response than antidepressant medications, with under the referral of a psychiatrist and must be
improvement sometimes apparent after just one supervised by a licensed psychiatrist.
to two sessions. Psychiatrists who favor the treat- Not all medical facilities are equipped to con-
ment argue that this fast response makes ECT duct ECT treatments, and patients may need to
highly preferable in cases where the patient is travel some distance to find a facility capable of
suicidal, psychotic, or catatonic, and does not conducting the procedure. Facilities capable of
have the luxury of waiting the four to six weeks conducting ECT treatments are reasonably plen-
required by most antidepressants. tiful in the United States and the United Kingdom;
In research trials, ECT is more effective than however, countries with limited medical resources
antidepressants in reducing severe depression may offer few locations for the procedure.
symptoms, and clients who have undergone Because treatments are typically accomplished
the treatment have reported up to an 85 per- in clusters of 12 or more sessions, patient access
cent improvement in the suppression of depres- to the hospital is crucial during the length of the
sive symptoms. Additionally, ECT has been treatment. This accessibility issue can present bar-
reported to improve the quality of life for chroni- riers to rural, homeless, or socioeconomic groups
cally depressed individuals. Patients who previ- that lack transportation to the medical facility
ously were unable to perform the simplest tasks performing the treatment.
improved to the degree that they were able to par- The ECT procedure requires, at minimum, the
ticipate in normal life functions such as work and presence of an anesthesiologist and a psychiatrist.
play. Most reported a renewed interest in activities Typically, monitoring in a recovery room after
that they had once found enjoyable but, because the procedure by nursing professionals is also
of their depression, had lost interest in. One of required. Because of the number of professionals
the best indicators of a probable good response involved, the cost per procedure can be substan-
to ECT is prior ECT treatments with good out- tial. Coupled with the fact that the patient will
comes. Some ECT patients return periodically for need, on average, a dozen or more treatments,
additional treatments to ensure that their depres- ECT treatment can be cost prohibitive for many
sion does not return. cultural groups.
Part of the reason for the continued reluc- Although ECT treatment is covered, at least in
tance by individuals suffering from depression to part, by most health insurance companies, many
undergo ECT treatment, regardless of the reported individuals either lack the ability to pay for insur-
improvements, are the known side effects of con- ance or live in locations where private insurance
fusion and memory loss. Although ECT advocates is unavailable. Even individuals who have ECT
proclaim that memory loss resulting from ECT treatments covered by their insurance plans typi-
treatment is temporary, numerous patients who cally have sizable copays that often make treat-
have undergone the procedure report that at least ments unaffordable for them.
some of the memory loss that they experienced Many psychiatrists, recognizing the finan-
appears permanent. Individuals opposed to ECT cial burden that ECT treatment would place on
therapy cite permanent memory loss as proof of their patients, opt for less expensive medication
brain damage and believe that it is why further therapy. Mental health professionals who regu-
ECT treatments should be discontinued. larly treat minorities and low-income clients are
typically sensitive to the economic hardship that
Availability and Cost their patients live with. Often, these profession-
ECT treatments are prescribed by a psychiatrist als recommend a less effective treatment that their
and take place in a hospital equipped with the nec- clients will participate in over the more expensive
essary ECT equipment while an anesthesiologist ECT treatment that may push their clients away
260 Electrotherapy

and prevent them from returning. The result is contrary. Occasionally, these professionals choose
that ECT treatments are more common for mid- to err on the side of caution and stick with more
dle-income groups than low-income families. conventional medication therapies.

Public Fear and Psychiatrist Resistance Ron Fritz

Horrific thoughts of mental patients tortured as Independent Scholar
their doctors run electric current through their
heads, compounded by the images in a popular See Also: Antidepressants; Depression; Diagnosis;
novel and film by Ken Kesey titled One Flew Over Diagnosis in Cross-National Context; Mood
The Cuckoo’s Nest, have made ECT therapy one Disorders; Serotonin Reuptake Inhibitors.
of the most feared forms of depression treatment
in existence today. Further Readings
Although knowledge levels concerning ECT Abrams, Richard. Electroconvulsive Therapy.
treatment varies widely from one culture to the Oxford: Oxford University Press, 2002.
next, attitude and apprehension are remarkably Fink, Max. Electroconvulsive Therapy: A Guide for
consistent. Individuals from cultures where ECT Professionals and Their Patients. Oxford: Oxford
is more common are more likely to know some- University Press, 2008.
one who has undergone ECT treatment. People Mankad, Mehul V., John L. Beyer, Richard D.
living in cultures where the treatments are rare Weiner, and Andrew Krystal. Clinical Manual
are more likely to learn about ECT through the of Electroconvulsive Therapy. Arlington, VA:
media. Attitudes toward ECT treatment are American Psychiatric Publishing, 2010.
reportedly nearly identical in each case.
Persistent stories about memory loss and con-
fusion, told by individuals who have undergone
ECT treatment, only serve to heighten the pub-
lic’s fear toward ECT. Psychiatrists frequently Electrotherapy
run across resistance from patients when ECT
treatments are mentioned because the individual Over a century ago, therapeutic doses of electric-
conjures up frightening images better suited for a ity administrated as Galvanism (using a battery),
late-night horror film than a medical procedure Faradism (the induction coil), Franklinization (the
that is recommended by their doctor. Sometimes, electrostatic generator), and D’Arsonvalization
the individual’s psychiatrist is able to overcome (the high-frequency generator) were considered
his or her fears, sometimes not. ECT treatments to be an acceptable though controversial part
are almost exclusively the domain of practicing of medical practice. At the outset, two caveats
psychiatrists. Knowledge about and familiar- should be noted. First, electroconvulsive therapy
ity with the ECT procedure plays a strong role (ECT) represents a discontinuity in the history of
in whether a psychiatrist is willing to prescribe electrotherapy in that convulsive therapy’s origins
this form of treatment. Concern over possible side lie in the use of insulin and metrazol injections
effects tends to make ECT therapy a last resort, for psychoses in the early 20th century. Second,
after all other treatment modalities have been emerging new electrical technologies and medical
tried and failed. Even then, within some cultures, science converged in the embryonic discipline of
mental health professionals may be reluctant to neurology from the 1860s onward, though dis-
prescribe ECT treatment for fear that it will make tinguishing neurology from psychiatry remained
them look like a bad doctor to their clients. problematic until World War I.
Many mental health professionals find them-
selves at a moral dilemma when they weigh the Early Electrotherapy
benefits versus the consequences of memory loss Earliest accounts of electrotherapy can be found
with their patients. Research indicating that ECT in recipes for headaches using catfish heads (Mala-
treatments are safe weighs at odds with the indi- pterus) in the ancient Egyptian Eber papyrus
vidual’s personal bias and public sentiment to the (1500–1600 b.c.e.). In Galen’s De Alimentorum
 Electrotherapy 261

(ca. 129 c.e.), the electric torpedo ray from the professor of medicine in Halle, and his student,
Mediterranean Sea is singled out for use in young Christian Kratzenstein (1745), were among the
epileptics. The Roman physician Scribonius Lar- first to write about medical electricity, claiming
gus (ca. 54 c.e.) prescribed the shocks of the live that paralyzed limbs, sciatica, and palsies could
torpedo for chronic head pains. The shocks of the benefit from the stimulating effects of frictional
electric fish were likened to a frigid vapor trans- sparks and shocks or a gentle “electric bath.” In
mitted through the hollow nerves that carried the 1745, Benjamin Franklin noted the successful
animal spirits from the brain’s ventricles to the treatment of a young female hysteric in Phila-
rest of the body. delphia who had been given a course of gentle
Ideas about a nervous fluid or force survived shocks. By the end of the 18th century, electri-
well into the 19th century, which is understand- cal machines could be found in many hospitals. A
able given its identification with electricity in the case report from St. Thomas’s Hospital attests to
17th century. This was not without controversy, the successful employment of light shocks to the
and problems in electrophysiology remained skull to cure melancholia.
until the advent of modern instrumentation in
the 19th century. Eighteenth- and Nineteenth-Century Practice
The development of the electrostatic genera- Both regular and irregular electrotherapeuti-
tor in the late 17th century and the Leyden jar cians flourished in 18th-century England. Rich-
(the condenser) in the 1740s provided a means ard Lovett, a lay clerk at Worcester Cathedral,
for medical practitioners to add a new therapy published the first English textbook on medical
to their armamentaria. Johann Kruger (1744), a electricity, Subtil Medium Prov’d, in 1756. John

Guillaume Duchenne de Boulogne (1806–75), a French neurologist, performs facial electrostimulus experiments on patients, circa
1862. Two new types of electrotherapy in the mid-1800s included Faradism, the application of an interrupted current from the
induction coil, and Galvanism, the application of a continuous battery current. The development of the electrical telegraph, along with
the deleterious effects of industrialization and modernity, inspired views of the body in terms of its defective “telegraph system.”
262 Electrotherapy

Wesley, the founder of Methodism, combined regimes of electricity, water, massage, exercise,
evangelism with electrotherapy. His Desideratum: sunlight, and diet in sanatoria such as the famous
Or Electricity Made Plain and Useful (1760) drew Battle Creek Sanatorium in Michigan.
on prevailing notions about “nervous diseases” to However, the image of the Victorian doctor as
rationalize the application of electricity. (William engineer-cum-businessman was controversial due
Cullen coined the term neurosis in 1777.) Elec- to electricity’s associations with quack remedies
tricity was considered a God-given “elixir” that such as the electric belt and specialism in med-
animated organisms. Mentally depressed people icine-elicited hostile attitudes among conserva-
suffered from a lack of the elixir and maniacs tive doctors. The American neurologist Silas Weir
from excess. Positive or negative electricity (as Mitchell averred that much of medical technol-
defined by Benjamin Franklin) in the form elec- ogy “dementalized” the doctor. Skeptical medical
trical baths or sparks were used accordingly to practitioners often disclaimed electrotherapy on
either replenish or draw off this electrical elixir. the grounds of therapeutic error, patient sugges-
James Graham’s Temple of Health, opened in tion, or natural remission of disease. Sigmund
1780, featured a “magnetico–musico-electrical Freud’s experiences studying hysteria led to
bed” to assist anxious childless couples for £50 the belief that electrotherapy was a “pretence”
a night. In a similar vein, the mysterious aspects treatment. Moreover, psychoanalytical meth-
of “animal magnetism,” a term coined by Anton ods proved to be just as effective as the painful
Mesmer, evolved over the next hundred years into Faradic shocks plus suggestion in the treatment of
hypnotism and Sigmund Freud’s psychoanalysis. shell-shocked soldiers in World War I.
In the wake of the electrical discoveries by
Luigi Galvani, Alessandro Volta, and Michael Zenith and Nadir of Electrotherapy
Faraday in the late 18th and early 19th centuries, The reintroduction of the static generator in
and the clinical studies of Guillaume Duchenne the late 1880s and the development of high-fre-
de Boulogne in France and Robert Remak in quency alternating currents represented the zenith
Germany, two new types of electrotherapy were of electrotherapy. Arsène D’Arsonval claimed the
established by 1850: Faradism, the application physiological effects of high-frequency currents
of an interrupted current from the induction coil (among them electrically induced heat, or dia-
or dynamo, and Galvanism, the application of a thermy) were indicated for metabolic disorders
continuous current from a battery. The plausi- of the nervous system and mental disorders. In
bility of electrotherapy was founded within the asylum patients treated with hydroelectric baths
growing reductionist tendencies of physiology using sinusoidal currents, creatanine clearance
that viewed the body according to the first and markedly increased. Yet ironically, that same
second laws of thermodynamics (conservation of source of electrotherapy’s promise was the source
energy and entropy). of its demise as industrialization and advances in
Plausibility also came in the guise of the electri- science (such as the X-ray) in the early decades of
cal telegraph developed along with the railroad. the 20th century undermined electricity’s individ-
The invidious effects of industrialization and ual potency as it disaggregated into standardized
modernity resulted in fatigue, and medical electri- units of “physico-therapeutics” (along with water,
cians began to view patients in terms of the body’s light, massage, and heat) for injured soldiers in
defective telegraph system. In the 1860s, the Amer- World War I and became increasingly associated
ican George M. Beard coined the term neurasthe- with domestic appliances and a source of power.
nia to explain mental breakdowns associated with
the body’s run-down battery. Victorians could also John E. Senior
suffer from “railway spine,” a form of post-trau- Linacre College, University of Oxford
matic stress from railway accidents. The soothing
and stimulating effects of electricity were delivered See Also: Electroconvulsive Therapy; Freud,
via electrodes directly to the body or via “electric Sigmund; Medicalization, History of; Mental
baths.” Wealthy patients subjected their stressed Institutions, History of; Neurasthenia; Therapeutics,
bodies and minds to naturalistic, “physiological” History of; War.
 Emergency Rooms 263

Further Readings clinician on-site 24/7, as well as designated beds

Finger, Stanley and Marco Piccolino. The Shocking for patients with mental illness or mental health
History of Electric Fish: From Ancient Epochs to needs. Often, patients must be medically cleared
the Birth of Modern Neurophysiology. New York: prior to their mental health assessment, but this
Oxford University Press, 2011. also varies by site.
Jacoby, George W. Electrotherapy. Philadelphia: Some facilities have also developed specific
P. Blakiston’s, 1901. psychiatric emergency rooms or services, also
Rowbottom, Margaret and Charles Susskind. called comprehensive psychiatric emergency pro-
Electricity and Medicine: History of Their grams (CPEPSs). These services are designed to
Interaction. San Francisco: San Francisco meet the needs of people living with mental ill-
Press, 1984. ness in psychiatric crisis and others experiencing
acute psychological distress. CPEPs most often
comprise multiple components or service modali-
ties including emergency room services, mobile
outreach teams, and strong connections to refer-
Emergency Rooms ral services. They may also provide on-site respite
beds for up to 72 hours. Recently, new models of
Emergency rooms are an important component of ER care have been developed to focus on the role
emergency services. These services are often com- of peers, including peer-run respites as alterna-
ponents of hospital emergency departments, often tives to ER services.
called ERs or EDs, but have also been created in Emergency rooms serve as the most common
other settings such as community health centers site for emergency psychiatry services. These
(CHCs) and other primary care settings. While services are provided to patients with multiple
ER services can have many characteristics, they problems but most commonly to patients with
most often are open 24 hours a day, require no depression, psychosis, attempted suicide, and
appointment, and are designed to meet the needs violent or other unusual behavioral changes,
of patients seeking care for acute crises. In the frequently including presentation of substance
United States, they serve as one of the last “open abuse. Care is provided by mental health pro-
doors” to health care services. fessionals from multiple disciplines, including
The Emergency Medical Treatment and Active social work, nursing, psychology, and psychia-
Labor Act passed in 1986 requires U.S. hospitals try, as well as a number of types of licensed men-
to provide care to anyone needing emergency tal health counselors. Increasingly, emergency
health care treatment regardless of citizenship, rooms have “peers” on staff providing services
legal status, or ability to pay. People may bring with lived experience with mental illness or men-
themselves into an ER, be referred by a clinician, tal health problems.
be brought by others (family members, police, Emergency room care for people with acute
treaters), or arrive by ambulance. People with mental health needs is intended to provide a
mental illness or mental health needs tend to use safe environment, a focus on crisis stabilization,
ERs for a wide range of medical and social needs. and referral to an appropriate level of care. This
involves assessing patients, treating symptoms
Types of Emergency Rooms that can be addressed with short-term treatment,
While most ERs share these characteristics, spe- and ideally determining the least restrictive appro-
cialty ERs have developed to provide care most priate treatment option. Dispositions from an ER
frequently to a person with a mental health con- include but are not limited to inpatient hospital-
cern or serious mental illness. These ERs are ization, detoxification programs, referral to a par-
often staffed by physicians trained in emergency tial or day treatment program, and treatment and
medicine and also maintain an on-call team of release. Patients may be treated and released with
specialty clinicians, including mental health cli- referral to outpatient services, prescriptions for
nicians. If the ER has a specific psychiatric or new medications, rehabilitation and vocational
mental health track, there will be a mental health programs, and housing supports.
264 Emergency Rooms

The Use of Emergency Rooms by building relationships with nonspecialty mental

People With Mental Health Needs health providers such as primary care physicians,
People living with serious mental illness have making it difficult for them to engage in preven-
been found to disproportionately seek out medi- tive care and ongoing relationships with medical
cal and social services in the ER setting as the last providers.
open door to care. These patients are seen by gen- Finally, people living with serious mental ill-
eral ER medical staff who are often inadequately ness experience disparities in many medical
trained in the mental health needs of patients conditions. Therefore it is not surprising that
experiencing psychiatric distress. people with mental illness present in ERs more
People with mental illness use ERs when they frequently than those without mental illness for
are in acute psychiatric crisis. Normally, people go medical complaints such as heart attacks or dia-
to an ER knowing that they are in crisis; however, betes crises.
most often this group of service users are referred
to the ER by a treating clinician, police officer, The Importance of Emergency Rooms:
family member, or other community member. System and Research Perspectives
Those referred by others may have limited insight Emergency rooms are an important area of socio-
into the acuity of their mental health problems. logical focus and inquiry for several reasons. Any-
People living with serious mental illness may one, regardless of ability to pay, may present for
also seek ER services when they require stabili- care at an ER. Demand for emergency psychiatric
zation or psychiatric hospital-based care, as the services has risen over the past several decades.
ER is the most frequent entry point to inpatient ERs are often busy and strapped for resources,
hospitalization. At the extreme end of the sever- posing frustrations and difficulties for patients,
ity spectrum, patients who have been deemed to their families, and staff. Staff face the challenges
be potentially dangerous to themselves or others of meeting the diverse and often acute needs of
(most often by a physician but also by police offi- patients and their families while coping with the
cers, teachers, and others) are brought to ERs for enormous pressures on health care systems to
assessment. Thus, the ER is the most common site assess risk and reduce costs. ERs are busy, chaotic
of involuntary hospitalization/commitment. Most settings that serve as a nexus of interaction for
U.S. states require that a clinician determine the people seeking care, their families, medical staff,
patient to be a potential danger to themselves or and community agents. Treatment decisions must
others in order to involuntary hospitalize them. often be made quickly and with little informa-
States vary in specific requirements to involuntary tion available. The stressful work environment
hospitalize a patient; thus, there is little national requires clinical staff to balance multiple and
data on the volume of involuntary hospitalization competing demands from patients, other actors,
in ERs. However, states tightly monitor this use and payers, all with limited resources.
of coercive treatment, and most states have dem- Subjective experiences of care as well as deci-
onstrated decreases in involuntary hospitalization sions made in the ER may strongly influence the
rates in recent years. treatment trajectories of people seeking care. At
Some studies have demonstrated that people best, an ER visit may provide acute psychiatric
living with serious mental illness are more likely care and serve to connect people to services sup-
to seek care in the ER to meet basic medical and/ porting their mental health and wellness; however,
or social needs. People living with serious mental poorly delivered ER care may serve to reinforce
illness disproportionately live in poverty and face resistance to seeking or receiving formal mental
social exclusion. People with mental illness expe- health and substance abuse services. Therefore,
rience many health and social disparities, includ- ER experiences may have long-term impacts
ing higher rates of homelessness and unemploy- above and beyond the treatment provided during
ment, less education, fewer social ties, and greater any one visit.
rates of victimization than those without mental While it is not common for people to receive
illness. Evidence also suggests that people liv- health care treatment against their will, involun-
ing with serious mental illness face challenges in tary hospitalization is one such example, and it
 Emergency Rooms 265

most often occurs in the ER setting. The assertion with mental illness and mental health problems,
of medical authority over individual autonomy like most medical decisions, are influenced by
is the most weighty of medical decisions. Under- both medical and social criteria. In many ways
standing the social context in which these deci- the ER is an ideal place to study medical/psychi-
sions occur is critical. The decision to hospitalize atric decision making because it is in these types
a patient involuntarily has a tremendous impact of busy, chaotic environments—where decisions
on the patient, families, and communities and is must be made quickly and have great potential
made in this context. impact—that clinicians are more likely to rely on
decision heuristics based on previous experience
Areas of Emergency Room Research of shared beliefs. Race, gender, housing status, the
Because of the importance of ERs in the health involvement of social networks, and the amount
care system, their increased use, and the impact of information available to clinicians have all
of the decisions made in these settings, research- been found to predict involuntary hospitaliza-
ers from multiple fields have focused attention on tion decisions above and beyond the clinical and
the care that people with mental illness receive legal criteria. These findings reflect a social con-
in the ER. Medical and clinical researchers have trol framework in which the least desired or most
focused their research on generating knowledge coercive treatment outcomes are disproportion-
concerning how best to assess risk to self and oth- ately experienced by people of lower or marginal-
ers among patients with mental illness in the ER. ized social status.
Research suggests that few individual-level fac- A second area of inquiry has been the exami-
tors are strong predictors of risk. However, sub- nation of the work that is done with people
stance use, previous violence, and specific types of with mental illness in the ER. Work in the ER is
psychotic symptoms can be markers of increased demanding, both emotionally and physically, and
risk for violence. Additionally, research has been often requires managing the competing demands
useful for supporting the development of clinical of multiple actors in determining patient disposi-
decision-making tools designed to standardize the tion. Increasingly, this work has occurred in the
assessment of patients in the ER. Numerous ER context of pressures to reduce cost and conserve
treatment models have been created, including resources. Staff in the ER who work with people
brief interventions for substance-using patients, with mental illness or mental health needs may
the involvement of peer support, and the develop- include general ER physicians, psychiatrists,
ment of trauma-informed models of care. psychologists, mental health counselors, social
Health services researchers have focused atten- workers, or nurses. These staff work to meet the
tion on the service utilization patterns of patients complex medical and social needs of the patients
with mental illness using ER services, paying presenting for mental health care, often within
particular attention to the “frequent users” of highly stressed environments and with an aware-
ER services. People with mental illness have ness of the potential impact of their decisions. The
been found to be disproportionately represented toll of this work on ER providers has been well
among repeat users of ER services. In addition, documented, with high rates of staff burnout and
those who have no permanent home, are sub- turnover, reports of stressful job circumstances,
stance abusing, have few social ties, and live in and potential secondary trauma among staff.
poverty are more likely to be repeat users of ER The experiences of people using ER services
care. This has informed the development of inter- for mental illness or mental health needs have
ventions designed to decrease repeat use of ER been less well documented. Studies have reported
services, including ER diversion programs and mismatches between patient and provider expec-
improved models of ER care. tations of ER visits. Patients with mental illness
Sociologists, and more broadly social science presenting at ERs for medical complaints often
researchers, interested in ERs and mental illness report negative experiences, stating that clinicians
have primarily examined three main aspects of ER focus too much attention on their mental illness
care. First, researchers have documented that clin- and do not properly address their physical health
ical decisions made in the ER concerning people problem.
266 Emotions and Rationality

Finally, researchers across the disciplines have Emotions and Rationality

worked to understand the appropriate use of ER
services by people with mental illness or with men- The boundaries of mental disorder have expanded
tal health needs. While medical/clinical research- across the 20th century, largely as a result of the
ers often agree on definitions or guidelines for growth and differentiation of disorders involving
the appropriate use of ER services and may even the emotions. Both lay and professional under-
be able to identify inappropriate use, social sci- standings of what constitutes a mental disorder
ence researchers find this more complicated. In are historically and socially specific. From the
the U.S. health care system, those using ER ser- perspective of present-day Western society, these
vices may have previously been turned away understandings have been shaped by definitional
from other more appropriate sources of care due shifts and developments in diagnostic classifica-
to ineligibility or inability to pay. Therefore, the tions and, more broadly, by the growth of the
ER serves as a medical and social safety net in mental health workforce and the professional-
many communities. In fact, evidence shows that izing efforts of particular occupational groups
ER visits increase with economic downturns, and (especially following World War II) and by a
for many people with no regular source of medi- range of other social changes, including deinstitu-
cal care, ERs are used for nonacute needs. Thus, tionalization and the rise of psychology.
terming this use as inappropriate is complicated
by the social and economic contexts of the lives Early Framing of Mental Disorder:
of people living with mental illness. Mania and Melancholia
In the 19th century, most people admitted to pub-
Alisa K. Lincoln lic asylums and “private madhouses,” as they were
Northeastern University known, received a diagnosis of “mania” or “mel-
ancholia.” These two opposing and very broad
See Also: Inequality; Law And Mental Illness; Service classifications formed the basis of early efforts
Delivery; Social Control. to map and differentiate mental disorder. The
term mania closely represented lay conceptions
Further Readings of “madness” or “lunacy,” which were held to
Allen, M. H. “Definitive Treatment in the Psychiatric result from a “loss of reason.” Although these two
Emergency Service.” Psychiatric Quarterly, v.67/3 forms of “insanity” were often described in terms
(1996). of emotions, the workings of a person’s mind (his
Lincoln, A. “Psychiatric Emergency Room Decision- or her thought processes and reasoning) were con-
Making, Social Control, and the ‘Undeserving sidered of primary significance in explaining both
Sick.’” Sociology of Health and Illness, v.28/1 the irrational, unpredictable, and sometimes dan-
(2006). gerous behaviors associated with “mania” and
Lincoln, A., A. White, C. Aldsworth, P. Johnson, the passivity, ruminations, and social withdrawal
and L. Strunin. “Observing the Work of an characteristic of “melancholia.”
Urban Safety-Net Psychiatric Emergency Room: Referring to Michel Foucault’s study of the
Managing the Unmanageable.” Sociology of records of a 17th-century English physician, Joan
Health and Illness, v.32/3 (2010). Busfield notes that where mania involved “a per-
Padgett, D. K. and B. Brodsky. “Psychosocial petual influx of thoughts” and “deforms all con-
Factors Influencing Non-Urgent Use of the cepts and ideas,” melancholia imposed “unrea-
Emergency Room: A Review of the Literature and sonable proportions” on a single object. “Mania
Recommendations for Research and Improved was . . . evidenced by the frantic behavior, exces-
Service Delivery.” Social Science & Medicine, sive talk, odd laughter, and the threat or carry-
v.35/9 (1992). ing out of some unacceptable action, behaviors
Stefan, S. Emergency Department Treatment of that suggested in some combination disturbed
the Psychiatric Patient: Policy Issues and Legal thought and irrationality.” The label of “mania”
Requirements. New York: Oxford University Press, was applied to over half of the inmates in asy-
2006. lums and madhouses of 19th-century England,
 Emotions and Rationality 267

probably because the disruptive and potentially population). Substance use disorders, which are
dangerous behaviors that often characterized understood primarily as disorders of behavior
these patients were more likely to result in admis- and frequently involve anxiety and/or depression,
sion, as opposed to other less troubling and less affect a significantly higher proportion of male
conspicuous forms of mental disorder. than female sufferers. In contrast, disorders of
Toward the end of the 19th century, the clas- thought (psychoses) are equally likely in females
sification of psychiatric disorders underwent as males.
major revision, led by the work of Emil Kraep- The higher prevalence of anxiety and depres-
lin. He saw mania and melancholia as different sion in females has been explained as an outcome
forms of a single group of disorders, “manic- of the social shaping of emotional expression.
depressive psychosis,” which he distinguished Assumptions of appropriate femininity hold that
from “dementia praecox”—the earlier term for it is more acceptable for women to express their
schizophrenia. In this new opposition, the dif- sadness and fears and to cry than it is for men,
ferent types of dementia praecox were charac- who are generally expected to maintain emo-
terized by a deterioration of thought processes, tional control. Interestingly, the range of emo-
whereas the different types of manic-depressive tions included in diagnoses of depression and
illness were defined by disordered or exagger- anxiety (fear, sadness) is quite restricted. Other
ated emotions, including extreme sadness and emotions such as jealousy, hate, and anger are not
exhilaration. However, such disordered think- the basis of specific disorders, although there is an
ing as hallucinations might also occur in severe increasing number of treatment programs focused
manifestations of the illness. on the behaviors associated with them; “anger
Although the diagnostic picture of schizophre- management” programs for men are one such
nia includes some references to mood, exempli- example. Joan Busfield, professor of sociology at
fied by “negative symptoms” (lack of motivation the University of Essex in the United Kingdom,
and energy) and “restricted affect,” these symp- has argued that “this selectivity undoubtedly con-
toms are generally seen as secondary to disorders tributes to the gender imbalance of the emotional
of thought and often characterize the prodromal disorders since historically it is the emotions par-
phase of the illness. The main types of thought ticularly associated with women that have been
disorder that typify schizophrenia are halluci- pathologized.”
nations, delusions, thought insertion, thought A further argument for the social shaping of
broadcasting, loosening of associations, and tan- emotional disorders is that many women have
gential and circumstantial thinking. been unable to leave difficult family situations
The new designation of manic-depressive dis- because of their economic dependence on men,
order became, in effect, the forerunner of the cat- although this is less the case now. On the other
egory of “mood disorders” in the American Psy- hand, it appears that disorders of thought have
chiatric Association’s Diagnostic and Statistical not been affected by differential social conditions
Manual of Mental Disorders (DSM), which today and expectations linked to gender.
is one of the most widely used psychiatric clas-
sification systems, along with the World Health Psychological Explanations of
Organization’s International Classification of Mental Disorders
Diseases. Together with a range of other factors, While psychiatry developed as a medical specialty
this designation paved the way for a greater focus in the context of the growth of the asylum system,
on disorders of emotion across the 20th century. the professionalizing efforts and research of doc-
Except for bipolar disorder, a higher propor- tors who worked outside the system also expanded
tion of females than males are diagnosed with the boundaries of mental disorder. The develop-
disorders of emotion. Depression and anxiety are ment of neurology in the second half of the 19th
the two main diagnostic groupings of emotional century was important in this regard. Compared
disorders and, together with substance use dis- with the disorders typically seen by the asylum
orders, constitute the “high prevalence” mental doctors, many of those studied by neurologists
disorders (those that occur most frequently in the concerned the relatively less severe problems of
268 Emotions and Rationality

“nerves” and nervous disorders, which involved and later through the allied professions of social
various and often unusual somatic symptoms and work, psychology, and occupational therapy in
a range of emotions. the decades following World War II, contributed
In 1869, George Beard, an American neurolo- to the expanding terrain of mental disorders. The
gist in private practice, formulated the diagnosis expansion of public and private mental health ser-
of “neurasthenia,” meaning tired or exhausted vices employing these “new” professionals, many
nerves. Widely used as a diagnostic label into the of whom were women, served to reinforce the
early 20th century, it encompassed a very diverse diagnostic classifications that were being enlarged
range of bodily, behavioral, emotional, and cogni- and further refined. Thus, the work of these new
tive symptoms, including drowsiness, headaches, professionals, also shaped by a range of new psy-
dry skin, irritability, hopelessness, poor concen- chological interventions, pharmaceutical treat-
tration, fears, and anxiety. Although neurasthenia ments, and the advent of deinstitutionalization
involved a wide array of essentially unsystematized and community care, opened the way for more
symptoms, it was important in bringing attention individuals to bring a greater array of problems
to the notion of disturbed or disordered emotional to their attention.
states and was effectively a precursor to present-
day understandings of depression and anxiety. The “Emotionalization of Society”
The psychoanalytical work of Sigmund Freud The rise of therapeutic culture, led by psychol-
was also very important to the framing of emo- ogy and counseling, has had a significant impact
tional disorders, notably the idea that memories on the way people make sense of themselves and
of distressing events could give rise to functional their personal problems and what they do about
neuroses, of which hysteria was the most signifi- them. During the second half of the 20th century in
cant form and for which no organic cause could particular, there has been a shift in culturally dom-
be established. In the early 20th century, the con- inant approaches to dealing with personal prob-
cept of shell shock—the distressing aftereffects of lems, from reticence and self-reliance to an empha-
soldiers’ traumatic memories of trench warfare in sis on emotional expressiveness and help seeking.
World War I—further contributed to this fram- The subsequent popularization of psychological
ing of emotional disorders by giving credence to ideas and orientations through self-help literature
Freudian ideas of the psychological origins of and therapy culture provided a new language of
mental disorders. This diagnosis was renamed selfhood, which called attention to emotional inju-
“war neurosis” in World War II and redefined ries, needs, and well-being. This new language has
as post-traumatic stress disorder (PTSD) follow- become part of the everyday, beyond the special-
ing the Vietnam War. Its inclusion as an anxiety ized knowledge of expert professionals. Embedded
disorder in the DSM-III was achieved primarily in everyday social interaction, it is voiced in maga-
through the efforts of Vietnam War veterans and zines, movies, reality television and social media,
psychiatrists and other professionals advocating and through the operations of the workplace.
on their behalf. Since then, the diagnosis of PTSD In recent decades, emotions have become
has been expanded to include traumatizing events increasingly evident as a frame of reference for
beyond the experiences of war, such as rape and understanding situations and shaping our actions
natural disasters. In the DSM-IV and DSM-5, in all sectors of social life, prompting some crit-
the framing of the traumatic event was again ics to claim that an “emotionalization of society”
expanded. No longer limited to the direct experi- has taken place. In the criminal justice system, for
ence of a trauma, it can include the witnessing of example, practices of restorative justice are provid-
a traumatic event or hearing about the event, for ing opportunities for victims of crime to confront
example, in the case of the violent death of a fam- their perpetrators over the impacts of their crimes,
ily member or close friend. thus delivering a form of emotional retribution.
In the education sector, “child-centered” teaching
Growth of the Mental Health Professions practices emphasize open dialogue and emotional
The growth of the mental health professions, ini- engagement between student and teacher, with a
tially through psychiatry and psychiatric nursing shift away from didactic approaches. Similarly, in
 Employment 269

the health sector, “patient-centered care” encour- Healing, Gillian Bendelow, Mick Carpenter,
ages health professionals to focus on patients’ Caroline Vautier, and Simon Williams, eds. New
needs, choices, and emotional well-being. In men- York: Routledge, 2002.
tal health, the establishment of peer support ser- Busfield, Joan. Mental Illness. Cambridge, UK: Polity,
vices and user-led services also demonstrates the 2011.
growing emphasis on service users’ emotional Greco, Monica and Paul Stenner, eds. Emotions: A
well-being. Social Science Reader. London: Routledge, 2008.
Furthermore, the far-reaching effects of second- Wright, Katie. “Theorizing Therapeutic Culture:
wave feminism, civil rights movements, height- Past Influences, Future Directions.” Journal of
ened individualism, and the contemporary focus Sociology, v.44/4 (2008).
on the human rights and social inclusion of disad-
vantaged or needy populations have contributed
more broadly to the growing focus on emotions
and emotional well-being in public life. Over the
decade leading up to 2013, these values and orien- Employment
tations have been expressed in policy agendas to
extend the “happiness” and “well-being” of the Three million Americans are suffering from seri-
general population in such countries as the United ous mental illness and 70 to 90 percent of those
Kingdom and in policy initiatives to cover the people are unemployed. People suffering from
wide-ranging spectrum of mental health, mental mental illness are very likely to also suffer from
health problems, and mental illness. These agen- the negative effects of unemployment. Addition-
das have been generated by advances in knowl- ally, people who become unemployed are four
edge of child and adolescent development and times as likely to be suffering from mental ill-
related efforts to extend early intervention and ness, compared to people who are still employed.
prevention, as well as underlying concerns that Considering that employment has been found to
poor mental health at the population level leads reduce the impact and likelihood of mental ill-
to economic inefficiencies. ness, employment issues are closely tied to treat-
All of these developments have helped expand ment and outcomes of mental illness.
the boundaries of mental disorder far beyond the According to the Centers for Disease Control
rudimentary and relatively narrow classifications and Prevention in 2011, mental illnesses are esti-
used in the early asylum system, which focused mated to affect approximately one in four Ameri-
almost exclusively on understanding mental disor- cans at any given point during the year. Employees
ders through the lens of reason or rationality. spend the majority of their waking hours at work
or commuting to their jobs. The daily demands
Anne-Maree Sawyer of this schedule and the work that is expected
La Trobe University can lead to stressful environments or the percep-
tion of unnecessary or burdensome stress. This
See Also: Anxiety, Chronic; Asylums; Depression; places significant burden on employers to provide
DSM-5; Gender; Medicalization, History of; safe and effective accommodations for workers
Mental Illness Defined: Historical Perspectives; affected by a mental illness.
Mental Illness Defined: Sociological Perspectives; Individuals suffering from mental illness have
Mind–Body Relationship; Post-Traumatic Stress significantly higher rates of unemployment, ter-
Disorder; Psychoanalysis, History and Sociology of; mination, and sporadic work lives compared to
Psychoanalysis and Popular Culture; Shell Shock; individuals not suffering from these conditions.
War.
Mental Illness as a Stigma in the Workplace
Further Readings Mental illness is still seen as a stigma, which can
Busfield, Joan. “The Archaeology of Psychiatric result in negative stereotypes and social shunning
Disorder: Gender and Disorders of Thought, of afflicted individuals. Influences that perpetuate
Emotion and Behavior.” In Gender, Health and the stigma of mental illness in employment include
270 Employment

the media, the mental health system, employ- managers often cite a lack of resources and under-
ment programs, and government policies. These standing across management and other employees
influences lead to assumptions about the com- as a reason for expecting that a person’s mental
petence, dangerousness, legitimacy of work, and illness should be fully under control before being
“work as charity” of those who are mentally ill. offered employment or being allowed to return to
The intensity of these assumptions can vary from employment. The primary concerns of employers
deeply held negative beliefs to simple ignorance regarding employee mental illness involve issues
regarding issues of mental health. The salience of absenteeism, performance issues, and required
of assumptions determines the degree to which a workplace accommodations.
mentally ill individual will be socially included or Smaller companies often report more concern
excluded in work contexts as well as the impact about absenteeism, performance, and accommo-
of these negative impressions on the mentally ill. dation issues compared to larger companies that
The consequences of stigmas of the mentally ill have resources already in place to support employ-
in employment include negative societal impacts ees with mental illnesses. Because of these factors,
such as labeling of the mentally ill and the sys- the mentally ill who do return to the workforce
tematic exclusion of mentally ill individuals from often do so in a controlled and limited fashion,
employment. Additionally, steady employment is often utilizing supported employment programs.
a strong predictor of positive outcomes in employ- Such programs report high success rates and
ees battling mental illness. That being said, not all employers report being generally satisfied with the
individuals with a severe mental health issue may programs. In spite of the protections of the Ameri-
find improvement simply by gaining employment, cans with Disabilities Act (ADA), which includes
not to mention the effect that the individual may those suffering mental illness as a protected class
have on coworkers and employers needing to deal of workers, many individuals are still reluctant to
with persistent symptoms; however, for many reveal their disability or ask for work allowances.
individuals with treated illnesses, employment
can have a positive impact. Accommodation for Employees
Employees who have experienced serious men- With Mental Illness
tal illness while working report experiencing both The ADA was signed into effect in 1990, with
discrete and blatant prejudice and discrimination an amendment in 2008. The ADA is intended to
at work. Reactions tend to include negative and address and mitigate discrimination against per-
biased evaluations of their work performance and sons with disabilities. The ADA protects individu-
problematic interactions with their managers and als with disabilities who, with or without accom-
coworkers. Subjectivity is a challenge to begin modation, can successfully perform the tasks of a
with in workplace evaluations, and stereotypes job compared to similarly qualified and similarly
of mental health issues can worsen the problem. educated individuals without disabilities.
The expectation of prejudice and discrimination Not all medical conditions constitute a dis-
in a person suffering with the mental illness can ability. The ADA defines disability as a physical
be just as damaging as actual discrimination. Dis- or mental condition that substantially limits one
crimination and the expectation of being discrim- or more major life activities, a record of such an
inated against result in greater stress and psycho- impairment, or is regarded as having such an
logical strain on the individual, further impeding impairment. Thus, not all mental illnesses may
their performance and increasing the likelihood be covered and protected by the legislation. For
of further mental illness. instance, an employee with severe depression
being treated with therapy and medication may
Impact on Colleagues and the Workplace still be able to accomplish major life activities,
Additionally, the individual with a mental health including work tasks, without accommodations.
issue may have a reciprocal impact on their col- The ADA requires that employers make reason-
leagues in both a positive and negative way. able accommodations to employees with known
Employers often express concerns about hiring disabilities in order to improve their working con-
individuals with mental illnesses. Employing ditions. For example, an individual working in a
 Employment 271

grocery store checkout lane with a major medical stamina, and handling multiple pressures and
issue with his or her back may be given a chair to addressing time-sensitive tasks. Establishing a
sit on rather than being asked to stand during his mentor system, preparing employees for upcom-
or her shift. This accommodation has little effect ing changes, allowing employees to wear head-
on the employer and can be considered reasonable. phones or creating a more private environment
Similar accommodations can be made for those for them to work, assisting in breaking projects
who suffer from mental illness. Such accommoda- into smaller task lists, and meeting regularly to
tions can include flex-time scheduling, time off for prioritize tasks can help in combating many of
mental health counseling, job sharing, reduction of these activities that a person may find challenging.
distractions, clearly delineated job tasks, and more
frequent feedback and mentoring sessions. Conclusion
Individuals with a mental illness may report In general, mental health issues are interconnected
or experience behaviors such as feeling listless or to employment issues. Employment, as a function
apathetic, show a decreased interest in their work of financial and social support, provides positive
processes or outcomes, have difficulty meeting benefits that mitigate mental illness; however, for
work schedules such as project deadlines or arriv- most people suffering from serious mental ill-
ing on time, problems concentrating, difficulty ness, unemployment is the norm. Under the ADA,
interacting with others, and decreased productiv- U.S. workers with a mental illness are eligible for
ity. When these behaviors occur as symptoms of a reasonable accommodations or simple structural
mental illness, they are persistent, often long term, changes to their jobs that can make employment
and can significantly interfere with an employee’s a feasible option. Employers under U.S. law are
ability to do his or her job. These behaviors can required to accommodate both physical and men-
also occur without the presence of a mental ill- tal impairments, but for many, stigma and the
ness, such as the result of a major life change, fear of discrimination keep employees from seek-
divorce, or loss of a close family member. ing such accommodations. Continued advocacy
Common ADA-suggested accommodations, and education for both employees and employers
supported by case law, for those suffering from concerning mental illness and disability accom-
mental illness include improving interactions with modations is still necessary.
others, learning the job, maintaining the expected
pace or standards of work output, and coping Joel T. Nadler
with daily and long-term job stressors. Supervi- Southern Illinois University, Edwardsville
sors, managers, or employers can provide a num- Meghan R. Lowery
ber of accommodations, many through improve- Psychological Associates
ments in communication with employees.
For example, establishing regular meetings—an See Also: Business and Workplace Issues; Law and
influential way to positively affect any employee— Mental Illness; Stereotypes; Stigma: Patient’s View;
can provide a structured environment for an Work–Family Balance.
employee with a mental illness to hear, receive, and
respond to feedback, mentoring, and coaching in a Further Readings
predictable way. If an employee does not seem to Biggs, D., N. Hovey, P. Tyson, and S. MacDonald.
understand or resists interpreting negative feedback “Employer and Employment Agency Attitudes
about their decreased performance, the supervisor Towards Employing Individuals With Mental
can offer to have the employee meet with a coach Health Needs.” Journal of Mental Health, v.19
or the human resources department, or find a more (2010).
suitable way to conduct the feedback meeting that Mancuso, L. L. “Reasonable Accommodations
enables the employee to take appropriate action. for Workers With Psychiatric Disabilities.”
Other activities that a person with a mental ill- Psychosocial Rehabilitation Journal, v.14 (1990).
ness may have trouble doing include interacting U.S. Congress. Americans With Disabilities Act of
with others, responding to change, screening out 1990. Public Law No. 101-336, § 2, 104 Stat.
stimuli, sustaining concentration, maintaining 328 (1991).
272 Environmental Causes

Zlantka, R., et al. “Workplace Prejudice and and living environments are presented below.
Discrimination Toward Individuals With Mental There is significant individual variation in resil-
Illnesses.” Journal of Vocational Rehabilitation, iency levels, however, and trends should not be
v.35 (2011). interpreted as determinative. An environment
that is stressful to one person may be perceived
as restorative for another.
Chronic problems in an individual’s environ-
ment (such as ongoing bullying in school or dif-
Environmental Causes ficulty with a boss) have a greater impact on over-
all mental well-being than discrete events (such as
When discussing environmental causes of mental a divorce). Thus, it is the sustained accumulation
health and mental illness, scholars consider all of environmental stressors that increass risk.
factors external to the individual, including the An important caveat to the discussion of envi-
importance of both the built and social environ- ronmental causes of mental illness is that corre-
ment in which an individual is embedded. lation does not necessarily beget cause. Connec-
An ecological approach analyzes the context of tions appear to exist, and the strength of those
a human’s engagement with their environments. connections is still under debate. The etiology of
Navigating these environments has implications most major mental disorders is limited and uncer-
for both the maintenance of and the degradation tain. One cannot necessarily infer that living in
of mental well-being. Environmental stressors crowded, substandard housing caused depression
are clearly associated with the development of in a person, for instance, when perhaps depression
mental disorders. Stressful environments, no mat- caused the person to live in such conditions. Tem-
ter the locale or context, put people at risk for porality is a key concern, as are feedback loops
mental illness symptoms. Researchers have con- between the individual and the environment.
sistently found that these risk factors have a ten-
dency to cause internalization of stress symptoms, The School Environment
most often expressed as depression and anxiety. This section provides a brief overview of both
Depression in particular is highly associated with school-based bullying and violence and the effects
stressful environments, while anxiety disorders of teacher-student interactions.
are associated with socially toxic environments. Bullying includes verbal abuse, threats, teasing,
There is a complex interplay of environmen- rumor spreading, social excluding, sexual harass-
tal factors and genetic predisposition. Research- ment, physical harm, and assault. Reports of
ers have noted the implications of the combined harassment and bullying in schools range upward
effects of genetic and environmental factors in to 50 percent of children, although prevalence
mental illness. The notion of nature versus nurture varies from study to study.
is outdated and is being reconsidered as nature Children who are bullied often have lower
with nurture. Through the science of epigenetics, grades and do not want to go to school. Com-
researchers are discovering that environmental pared to children who do not experience bullying,
factors can change neurobiological processes and they are more likely to experience depression and
influence gene expression. poorer overall physical health. They experience
By understanding environmental effects, higher levels of anxiety, depression, and loneli-
people may be able to mitigate negative conse- ness. They may also have psychosomatic/psycho-
quences. This is an important consideration for logical problems such as bed-wetting, frequent
clinical practice. No clear formula exists for the headaches, sleep disturbances, stomachaches,
combination of environmental factors best suited tension, and fatigue. Bullying is correlated with
for mental health. The interaction of too many suicidal ideation and suicide.
derivations and variables makes such a task There is gender variation in both the form and
impossible. However, notable trends are found outcome of bullying. Males are most often the
in the literature on the environment and mental perpetrators and females are most often the vic-
health. General trends in school, the workplace, tims. Among girls, bullying tends to take the form
 Environmental Causes 273

of relational victimization, while among boys, achievement. In addition, social acceptance or

bullying tends toward physical violence. Bullying rejection by one’s peers impacts identity forma-
disproportionately impacts girls, and girls are at tion and can have implications into adulthood.
higher risk of sexual harassment. Girls who are Teacher-student interaction is also a key facet
victimized in midadolescence are more likely to of the school environment. Higher-quality teach-
suffer negative mental health effects than boys, ers create better social environments for students,
and they are more likely than boys to experience as does student perception that the school rules
more serious symptoms. are fair and that the school is supportive of indi-
Minority and immigrant children often experi- vidual needs. Positive teacher-student interaction
ence higher rates of bullying, and they are more increases student performance and well-being.
vulnerable to bullying than children in majority Students in supportive environments are more
groups. Racism manifesting along with bullying likely to seek help when needed and typically are
is particularly harmful. In addition, gay, lesbian, less likely to experience depression. This may be
bisexual, and transgendered (GLBT) children (or of particular importance for girls. Teachers who
children who are negatively identified as GLBT) bully or harass students constitute a unique viola-
have higher rates of victimization in school. tion of student trust. This is accentuated for immi-
This type of bullying results in traumatic stress grant children who come from regions with high
symptoms and violence. GLBT children who are levels of respect and honor for teacher scholars.
harassed in school are at increased risk of suicide
and often have multiple suicide attempts. Home and Family Life
Children have a range of coping mechanisms Families are the primary socialization agent,
at their disposal to deal with bullying. Generally teaching members how to participate in society.
speaking, children with stronger social networks, Because families also typically provide the basic
at school or outside the school setting, have bet- human needs of their members, significant stress
ter mental health outcomes in response to bul- may result when the family is unable to meet this
lying. Close friendships can mitigate negative responsibility. Food and housing insecurity leads
effects of bullying and other problems. Friend- to anxiety and depression.
ships increase protection and create a stronger Family is the most important environmental
community. Children without close friendships influence on children’s development. Families
can be more vulnerable to the effects of bullying teach their members coping mechanisms (both
and harassment. positive and negative). Higher levels of social
School personnel can do much to mitigate bul- support, attachment, and approval lead to bet-
lying. Research has demonstrated that perception ter mental health outcomes. Parents can be a
of school environment can explain up to 18 per- significant form of social support for children. A
cent of emotional distress among teens. Schools father’s involvement has been shown to be of par-
with clear antibullying policies that support dif- ticular help to bullied boys. A well-functioning
ference, honor diversity, and honor same-sex family can mediate outside stressors and provide
relationships have much lower rates of bullying a safe haven for the emotional development of
than schools that do not place such emphasis all of its members. A poorly functioning family,
on mitigating school-based violence. Children however, can put members at significant risk for
attending cohesive schools have better mental mental health complications. Harsh discipline at
health outcomes than students attending dys- home has been shown to lead to internalization
functional schools. of stress symptoms. Dysfunctional family life is a
Aside from bullying, school-based friendships serious risk factor for mental illness and can cre-
and social networks impact mental well-being. ate a legacy of disorganization generationally.
Children who are accepted by their peers are less Marriage is protective for both men and
vulnerable than children who experience rejec- women, although it is less so for women. Unmar-
tion. Children with lowered peer acceptance are ried women are at higher risk for mental illness
more vulnerable to isolation, social avoidance, than their married counterparts. Marital instabil-
conduct problems, depression, and poor academic ity leads to depression, especially among women.
274 Environmental Causes

Violence in the home is often predictive of communication skills or engage in positive disci-
mental health. Intimate partner violence and pline. Parents with mental illness tend to have less
child abuse are particularly harmful to mental social support and lower family cohesion.
well-being. Even when children are not physically There has been much debate about televi-
or emotionally abused, witnessing violence in the sion and computer time and mental health, and
home is harmful. Children who witness abuse while this is outside the scope of this article, it is
are more likely to be aggressive themselves. Vic- important to note that media can both increase
tims of family violence experience higher levels family cohesion (such as through playing games
of depression and suicidal ideation, and children together) and interrupt it (such as when one or
are more likely to have behavioral problems. Sub- more members use media as an avoidance tool).
stance abuse in the home is detrimental to family
members’ mental health. The Work Environment
Mental illness in one family member can put One of the most important factors in assessing
significant stress on the family in entirety, as can the relationship between the work environment
chronic illness and addiction. Parental mental and mental health is the amount of control an
illness, particularly depression in mothers, con- individual has within that environment. Employ-
tributes to mental health problems in children, ees with more control over their work environ-
as these parents are less likely to practice good ments are happier and more productive than

A homeless woman sits idle at Howard and 6th Streets, a decrepit neighborhood in San Francisco, California, July 2006. Many homeless
individuals have diagnosable disorders such as bipolar disorder and may also have substance abuse problems. In addition, people living in
socially disorganized neighborhoods, like this one, experience psychological distress from the lack of control over their environment.
 Environmental Causes 275

those with less control. Working in uncontrol- decreased worker productivity. Open office floor
lable environments leads to fatigue, irritation, plans increase ambient noise and distractions,
and distress. decreasing productivity due to difficulty in focus-
Job strain results from high employee workload ing. When several workers share one space, they
coupled with low decision-making ability and tend to report lower job satisfaction, lower moti-
control. Chronic work stress increases vulnerabil- vation, and distress over lack of privacy. Workers
ity to mental illness. People with job strain report who are allowed to personalize their workspace
depression, exhaustion (physical and emotional), are more productive than those with less control
and poorer overall health status. Job strain also over their physical work environment.
leads to burnout and lowered job satisfaction, Ambient noise can be distracting and create
and employees with higher levels of job strain are feelings of annoyance and agitation. Increased
more likely to quit work. An unfulfilling work life volume is associated with fatigue, hearing loss,
can lead to a downward spiral for an employee. and psychological distress. Natural lighting has
People who are depressed have lower workplace been shown to have a positive impact on mood,
productivity. They are more likely to miss work and access to windows improves employee ability
and to be less ambitious. to focus on tasks. Lighting is of particular interest
Generally speaking, employees in higher-qual- when circadian rhythms are disrupted, which can
ity jobs experience higher social status and better not only disrupt sleep patterns but can also create
working conditions. These are both protective for physical health problems.
mental health. Unemployment and low-skill-level Conflicting demands between work and home
employment are associated with higher risks for life can also create high levels of stress. Women
mental illness. Long-term unemployment is par- are disproportionately impacted by issues of
ticularly problematic and can lead to feelings of work–life balance.
worthlessness and hopelessness.
Physically hazardous working conditions, espe- Neighborhood
cially those coupled with uncertainty and high Both the social and built environments are per-
responsibility such as experienced by police offi- haps most salient when examining the neighbor-
cers, firefighters, and emergency room health care hood contextual impact on individual mental
workers, can lead to stress-induced mental illness, health outcomes. People living in socially disor-
particularly when employees do not have an outlet ganized neighborhoods experience psychological
to debrief or work in environments that discourage distress as a result. They have less control over
the discussion of emotion. Soldiers are also at high their environment and perceive disorganization as
risk, and numerous mental health issues are asso- physically dangerous. Social capital can mediate
ciated with combat. Persons in these occupations some of the effects. Again, these perceptions are
are at high risk for post-traumatic stress disorder, subjective, with variation among individuals.
marital difficulties, family violence, and suicide. Neighborhood cohesion is associated with pos-
Middle managers experience the unique strain itive mental health outcomes and increased social
of conflicting demands, having to respond to capital. Higher neighborhood cohesion is also
those both below and above them, and they tend associated with lower rates of depression.
to report chronic job stress. Ineffective leaders Social integration is measured by how attached
create stressful environments for their employees. an individual is in society (such as with friends,
Employees of incompetent leaders demonstrate family, and community) and is protective for
poorer work performance and significant dissat- mental health. Integrated individuals have greater
isfaction at work. access to social support and other resources
In the last two decades, many workplaces through extended social networks and are more
have opted for open floor plans, with or with- engaged in the community. Individuals who vol-
out cubicles or partitions. Research has consis- unteer in their communities tend to have better
tently refuted the usefulness of this tactic. While overall health and better psychological well-being
perhaps a cost-saving measure, over the long due to increased social interaction as well as the
term, companies may experience loss through intrinsic rewards associated with helping others.
276 Environmental Causes

Social isolation is a risk for mental illness. Iso- risky both through violence and/or exposure to
lation is best explored as a matter of personal per- pollution. Exposure to physical risks is involun-
ception, through examination of how connected tary, uncontrollable, and potentially catastrophic,
an individual believes he or she is to others. Mea- which increases feelings of anxiety and dread.
sures of perception of connectedness are likely Persons living in deteriorated and substan-
better indicators than simple counts of social dard housing have a tendency toward social
encounters. withdrawal. They are less likely to invite people,
Men tend to view their neighborhoods in terms arrange social gatherings, or set up play dates for
of physical layout, whereas women tend to focus their children. Reluctance to have people over to
more on the social and relational aspects. Women one’s home limits social opportunities. Substan-
are more likely than men to be socially invested in dard housing includes structural problems such as
their neighborhoods. Women have higher levels dampness and lack of adequate plumbing. Exces-
of social interaction with their neighbors and tend sive clutter and hoarding also put people at risk
to rely more on their neighbors for social support. for physiological distress and are associated with
Crowding decreases control over interper- depression, anxiety, and psychological distress.
sonal interaction and can expose people to too Residents who are relocated to better-quality
much unwanted social interaction. High popu- housing show improvements in mental well-being,
lation density can be overstimulating and cause as do residents whose homes are renovated.
anxiety. In crowded environments, people lack Homelessness is a significant risk for mental ill-
privacy and alone time. Women tend to be more ness. Many homeless individuals have diagnosable
negatively impacted than men, likely because of disorders, including schizophrenia and bipolar
gender stratification and divisions of power and disorder, and/or may have substance abuse prob-
social roles, particularly domestic responsibilities lems, although temporality is a factor. Homeless
and home emotional work. High-density living children have high rates of internalizing symp-
may be overwhelming without opportunity to toms, even compared to poor children, and are
withdraw. Men can become more aggressive as a more inclined to engage in risk-taking behaviors.
coping mechanism to this overstimulation. Some Ambient stressors are factors in the environ-
studies have found that children in high-rise, ment that are chronic, persistent, and the individ-
multiple-dwelling complexes have higher rates of ual has no control over, including pollution, noise,
behavioral problems compared to those living in crowding, traffic congestion, and noxious odor.
single-family homes or smaller complexes. Odor, particles, and smoke are danger cues and
In cases of interior residential density, stress increase overall distress. When the stimulation is
increases over time. Research in prisons has found outside the range of a person’s coping capacity,
a strong correlation between prison population stress increases. This leads to lowered life satis-
size and psychological distress among inmates. faction, heightened arousal, and changes in emo-
Living in chronically crowded conditions may tional states, and impacts cognitive functioning.
also increase the likelihood of externalized stress Prolonged or repeated exposure causes mood
symptoms, leading to violence. disturbances, social withdrawal, and sleep distur-
People living in poverty have higher levels of bances. Aircraft and traffic noise have been linked
depression, although this can be mitigated with to anxiety and depression. One study showed that
high levels of social support. Poverty is associated these noises can also be associated with increased
with higher incidence of emotional and behavior hyperactivity among children.
disorders and with substance abuse. Children liv- Perceiving that one resides in a chemically toxic
ing in poverty have more emotional and behav- environment can lead to high levels of anxiety
ioral problems than other children. The negative and uncertainty. Women are more likely to frame
mental health impact is long lasting. industrial activity as a local environmental issue
Litter, graffiti, abandoned cars, poorly main- involving health and safety risks and thereby
tained property, lack of green space, and other experience higher levels of stress as a result. Resid-
signs of decay signify social disorganization. ing in an industrial area increases stress, even
These neighborhoods are perceived as physically when controlling for other demographic factors
 Environmental Causes 277

such as income and gender. Typically, people with The Urban Environment
lower income and who are members of racial/eth- There is an extreme burden of traumatic stressors
nic minority groups are more likely to live near in the inner cities. These areas are characterized
industrialized activities and pollution. Research by higher levels of violence, and residents report
has demonstrated low psychological health in higher levels of physical assault (including rape)
areas classified as industrial compared to those and assault with a deadly weapon. Residents are
classified as nonindustrial. more likely to experience the unexpected death
of someone they care about. Cumulative expo-
The Rural Environment sure to violence leads to poorer mental health
While pastoral life is culturally framed as miti- outcomes. Persons experiencing chronic violence
gating mental health complaints, rural living as a victim or witness have higher levels of major
presents unique challenges to mental well-being. depression, post-traumatic stress disorder, and
Rural residents often have low income. They tend suicide attempt/completion. They are also more
to hold a strong attachment to place. Farmers and likely to resort to violence themselves, and wit-
ranchers in particular have a strong attachment nessing community violence increases overall
to the land, and the mental health of farm fami- aggression.
lies is influenced by their emotional connection to Researchers have accumulated significant evi-
the land. They are particularly vulnerable to the dence that consistent social stress leads to higher
impact of weather-related events, which can cause risk of psychiatric disorder. Disadvantaged
emotional distress to the entire family. Because of minority groups experience the highest levels of
the correlation between weather and financial social stress. Inner-city disadvantaged minority
considerations, weather events can lead to uncer- groups, particularly African Americans, experi-
tainty and create issues associated with self-iden- ence recurring trauma. Despite these trends, how-
tity. Children and adolescents show higher levels ever, there is a serious lack of access to mental
of distress due to this uncertainty and may have health resources for these residents.
behavioral problems as a result.
Rural unemployment leads to high levels of psy- The Natural Environment
chological distress, particularly when presented Exploration into the impact of the natural environ-
with significant limitations for job opportunities. ment is increasingly receiving attention for its pro-
There is a significant shortage of trained mental tective qualities. The natural environment includes
health care workers in rural areas. Rural residents wooded areas and greenbelts, parks, mountains,
with mental health challenges typically have few, and other areas with little human modification.
poorly coordinated social services. Mental health Spending time in natural, or “green” spaces, is
providers often do not understand the unique associated with decreased risk of mental illness.
needs of rural residents and try to apply what There seems to be an immediate effect on mood
works in the urban areas, with less success. There from spending time in nature, with as little as five
are often long waiting lists for limited providers, minutes having a positive impact, particularly on
that is, if the region even has a provider. Seeking adults and on people who are mentally ill. Research-
mental health services presents additional barri- ers have identified improved mental health status
ers of stigma and loss of anonymity and confi- in persons looking out a window at nature, being
dentiality because of low population density. For- in nature, and exercising in nature. Exercising in
tunately, rural communities tend to be close-knit green spaces improves both mood and self-esteem.
with an elevated sense of belonging and strong Experiments in which research subjects were
community support, which is protective for men- exposed to public green spaces and natural parks
tal health. There also tends to be a higher percep- consistently show improved mood and concentra-
tion of physical safety. Because of the cohesive- tion as well as self-reported quality of life. Newer
ness of the community, residents experience low studies are finding that data also support expo-
levels of privacy. Rural residents are more reliant sure to “blue” spaces, such as natural coastal
upon family, and family functioning can mediate areas, rivers, and lakes, all of which appear to
or exacerbate mental health impacts. augment mental health. Data support the notion
278 Epidemiology

that natural spaces are psychologically restorative. groups may suggest more about the diagnoses of
This is a burgeoning area for research that holds mental and behavioral health than actual occur-
much promise. rence. This is particularly the case for racial eth-
nic minorities who may seek mental health and
Jessica Smartt Gullion behavioral health treatment less than their white
Texas Woman’s University counterparts.

See Also: Business and Workplace Issues; Children; Core Epidemiological Concepts
Dangerousness; Employment; Family Support; Several core concepts are discussed in the study
Homelessness; Neighborhood Quality; Social of disease epidemiology, including mortality, mor-
Isolation; Violence; Work–Family Balance. bidity or comorbidity, prevalence, and incidence.
Mortality refers to death from a specific disease.
Further Readings Mortality rates, or death rates, are measured in
Barton, Jo and Jules Pretty. “What Is the Best Dose of different ways such as by age (age-adjusted or
Nature and Green Exercise for Improving Mental age-specific mortality rate), disease type (cause-
Health: A Multi-Study Analysis.” Environmental specific mortality rates), or by population group
Science and Technology, v.44 (2010). (such as infant, neonatal, and postneonatal mor-
Freeman, Hugh and Stephen Stansfeld. The Impact of tality rates). Morbidity refers to disability from a
the Environment on Psychiatric Disorder. London: disease or condition.
Routledge, 2008. The World Health Organization (WHO) has
Valentin, Jorge and Lucila Gamez. Environmental used the concept of disability-adjusted life year
Psychology: New Developments. New York: Nova (DALY) to describe either morbidity or mortality
Science Publishers, 2010. based on a year of life lost due to death or dis-
ability from a condition. Comorbidities acknowl-
edge the occurrence of one or more diseases at the
same time, while prevalence refers to the propor-
tion of cases or a condition in a population group.
Epidemiology The prevalence rate is the percentage of a people
in a population group experiencing a particular
Epidemiology is the area of public health con- outcome at a given point in time. Incidence refers
cerned with patterns of disease or epidemics in to the rate at which a new case of an illness or
population groups. The study of epidemiology condition occurs in a population over time. Social
is useful to track and monitor population trends epidemiology is the area of public health that con-
and rates of disease or health concerns in a pop- siders the social conditions that help produce or
ulation in order to compare incidence (one-time aggravate health outcomes, including behaviors,
occurrences) or prevalence (routinely occur- access to social resources (such as education), or
ring) rates of diseases to determine the health chronic poverty.
and well-being of groups as well as to compare
the importance of certain diseases in population Mental Health Prevalence Rates in
groups. Prevalence and incidence rates are often the United States
compared across groups to describe overall rele- There are a range of mental health disorders in
vance and create awareness for service provision. the United States, including anxiety, mood, bipo-
Gender, race, ethnicity, and region are often used lar, major depressive, and personality disorders
to describe disease outcomes across population and schizophrenia. Mental illness accounts for
groups. more disability than any other disease or condi-
The epidemiology of mental health disor- tion in the developed world, including heart dis-
ders describes a range of mental and behavioral ease. Disability from mental illness is significant.
health concerns and the variability in prevalence According to the official criteria of the American
rates by race, ethnicity, gender, and class. The Psychiatric Association, roughly 25 percent of the
comparison of rate information across various U.S. population suffer from some form of mental
 Epidemiology 279

A World Health Organization (WHO) official distributes treats to Indonesian children as he conducts a survey about the condition
of local inhabitants in Gunung Meunasah and surrounding villages on the island of Sumatra, Indonesia, January 17, 2005. Social
epidemiology is the area of public health that considers the social conditions that help produce or aggravate health outcomes,
including behaviors, access to social resources, or chronic poverty.

illness. Although mental illness is common in the such as agoraphobia and specific phobias (such as
general population, a smaller percentage of the fear of heights).
population suffers from severe and debilitating Anxiety disorder prevalence varies across age,
forms of mental illness. Certain mental illnesses gender, and race. According to the National
such as depression are also important risk factors Institute of Minority Health, nearly 18 percent
for other health outcomes, such as cardiovascular of the U.S. adult population and 25 percent of
disease and obesity, or may coexist with pre-exist- youth ages 13 to 18 experience anxiety disorders.
ing health conditions. In many cases, those living Women are 60 percent more likely to experience
with severe mental illness die 25 years earlier than anxiety than men. Non-Hispanic blacks, His-
the general population. panics, and Asians are less likely to experience
anxiety than whites. Furthermore, whites are
Epidemiology of Anxiety and more likely to be diagnosed across a spectrum
Mood Disorders of anxiety disorders, including social anxiety
Anxiety disorders are the most common form of disorder, generalized anxiety disorder, and panic
mental illness, affecting close to 40 million Amer- disorder. African Americans are more frequently
icans. Anxiety disorders are often stress related diagnosed with post-traumatic stress disorder
and characterized by excessive and uncontrollable than white Americans, Hispanic Americans, and
thoughts or behaviors. A wide class of behaviors Asian Americans. Asian Americans are also less
and thoughts are classified as anxiety disorders, likely to be diagnosed with generalized anxiety
including obsessive-compulsive disorder, post- disorder, social anxiety disorder, or post-trau-
traumatic stress disorder, generalized anxiety dis- matic stress disorder than Hispanic Americans,
order, panic disorder, and other social phobias African Americans, or whites.
280 Epidemiology

Bipolar (manic-depressive) disorder is a brain Mental Health Comorbidities

disorder that affects mood and the overall ability Comorbidity refers to one or more conditions
to carry out normal daily functioning. The hall- co-occurring in the individual at the same time.
mark of bipolar disorder is episodes of mania and Often persons suffering from mental and behav-
depression that fluctuate over time. Over 5 mil- ioral health concerns may suffer from additional
lion Americans are living with bipolar disorder. health conditions. The fourth edition of the
Prevalence rates for mood disorders are 9.5 Diagnostic and Statistical Manual of Mental Dis-
percent of the adult population with 14 percent orders describes Axis III disorders as pre-existing
prevalence rates in youth. Mood disorders are medical conditions that trigger behavioral and
50 percent more prevalent in women than men. mental health disorders. Studies have shown
Blacks are 40 percent less likely and Hispanics 20 the association between behavioral health and
percent less likely to experience mood disorders. mental disorders such as depression and cardio-
According to the Centers for Disease Control and vascular disease or substance abuse and bipolar
Prevention, the prevalence rates for bipolar disor- mood disorder.
der are 4 percent. Bipolar disorder occurs more
frequently in women than in men. More than Minorities: Mental Illness, Social
other patients with mental health or behavioral Epidemiology, and Care
health diagnoses, patients with bipolar disorder Although racial ethnic minorities and whites
are hospitalized at a greater rate. may experience mental illness to the same extent,
minorities are diagnosed with mental illness less
Epidemiology of Depression, Dysthymic often than whites. The difference in mental health
Disorder, and Schizophrenia diagnoses has been attributed to minorities not
The WHO declared depression as the third most having access (because of employment and pov-
important cause of disease around the world. erty) to the same range of health services as whites
Major depressive disorder, a disabling condi- and because of the social and cultural stigma of
tion that affects nearly 15 million Americans, is mental illness in minority communities that may
characterized by symptoms that interrupt normal rely more heavily on spiritual and religious heal-
activities such as work and the ability to sleep, ing (such as attending church) rather than use of
to eat, or to partake in activities that were once mental health services for care and treatment.
enjoyable. Dysthymic disorder is a type of chronic Prevalence rates for behavioral and mental
depression (lasting at least two years) but at a health reflect diagnosed disease and therefore do
lower level. Dysthymic disorder affects approxi- not necessarily capture the actual occurrence of
mately 1.5 percent of the adult population in the mental disorder in community samples. Accord-
United States. ing to the U.S. Department of Health and Human
Depression is more prevalent in higher-income Services Office of Minority Health, although Afri-
countries than in lower-income countries. Annu- can Americans are less likely to seek treatment,
ally, 6.7 percent of U.S. adults experience major African Americans/blacks are more likely to expe-
depression. Major depression occurs more fre- rience mental disorders than their white counter-
quently in women than in men. On average, 6.5 parts. Overall, the rate of mental illness among
percent of whites, 4.5 percent of blacks, and 5.1 Hispanics is similar to that of whites. However,
percent of Hispanics experience depression. among Hispanic women, depression rates are
Schizophrenia is a severe mental illness charac- higher than average.
terized by hallucinations such as hearing voices or Asian Americans are also less likely than
paranoia that others are controlling their thoughts whites to receive a mental health diagnosis. Asian
or reading their mind. Nearly 2.4 million Ameri- Americans are the least likely of any racial or eth-
cans have been diagnosed with schizophrenia. nic group to seek mental health care and treat-
Worldwide, the prevalence rate for schizophrenia ment. Asian Americans are 50 percent as likely
is approximately 1 percent. Persons with schizo- as African Americans or Hispanics to seek outpa-
phrenia present a higher risk than the general tient care for mental health concerns. American
population for suicide. Indians and Alaska Natives are more frequently
 Epidemiology 281

represented in inpatient mental health services. Race; Race and Ethnic Groups, American; Racial
The prevalence of depression and substance abuse Categorization.
among American Indians and Alaska Natives is
disproportionately greater than for other racial Further Readings
ethnic groups. Adler, N. E., T. Boyce, M. A. Chesney, S. Cohen,
Although racial ethnic minorities are thought S. Folkman, R. L. Kahn, and S. L. Syme.
to experience mental illness less often than major- “Socioeconomic Status and Health: The Challenge
ity white populations, the diagnoses of mental ill- of the Gradient.” American Psychologist, v.49
ness among minorities occurs less often because (1994).
of less access to mental health services as well Asnaani, A., J. A. Richey, R. Dimaite, D. Hinton,
as the cultural stigma associated with receiving and S. Hofmann. “A Cross-Ethnic Comparison of
these services. There is extensive literature that Lifetime Prevalence Rates of Anxiety Disorders.”
documents the chronic stress—including post- Journal of Nervous and Mental Disease, v.198/8
traumatic stress—that minorities suffer due to (August 2010).
poverty, exposure to violence, and racism and Baker, F. M. and C. C. Bell. “Issues in the Psychiatric
discrimination. Social conditions experienced by Treatment of African Americans.” Psychiatric
minority populations include higher unemploy- Services, v.50/3 (March 1, 1999).
ment, a greater likelihood of living below the Bell, C. C. and H. Mehta. “The Misdiagnosis of Black
federal poverty level, lifelong exposure to chronic Patients With Manic Depressive Illness.” Journal of
poverty, and the greater likelihood of growing up the National Medical Association, v.72/2 (February
in a single-parent household. Further, minorities 1980).
are more likely to receive a less adequate educa- Berry, J. W., U. Kim, T. Minde, and D. Mok.
tion than their white counterparts, are more likely “Comparative Studies of Acculturative Stress.”
to face arrest, are more likely to be targeted by International Migration Review, v.21 (1987).
police, and face greater exposure to violence and Center for Mental Health Services (CMHS),
crime than white populations. Substance Abuse and Mental Health Services
Mental health care and treatment of minori- Administration, U.S. Dept. of Health and Human
ties should be culturally competent. In addition to Services. Cultural Competence Standards in
considering the social exposure of certain clients, Managed Care Mental Health Services: Four
it is important that clinicians do not wrongly diag- Underserved/Underrepresented Racial/Ethnic
nose strong cultural practices and beliefs such as Groups. Rockville, MD: HHS, 2000.
“listening to God” or “talking to the ancestors” Centers for Disease Control and Prevention, Office
as aberrant. Ethnic minorities may not seek men- of Minority Health and Health Disparities.
tal health services due to stigma and the use of “Eliminating Racial and Ethnic Health Disparities.”
alternative ways to cope, such as prayer, religion, http://www.cdc.gov/omhd/about/disparities.htm
or social supports. Further, cultural practices and (Accessed January 2013).
language may present a barrier for the client in Clark, R., N. B. Anderson, V. R. Clark, and D.
speaking to a professional about emotional or R. Williams. “Racism as a Stressor for African
mental health challenges. Lack of cultural compe- Americans: A Biopsychosocial Model.” American
tence, coupled with mistrust, may prevent racial/ Psychologist, v.54 (1999).
ethnic clients from utilizing mental health services Dwight-Johnson, M., C. D. Sherbourne, D. Liao,
and receiving adequate diagnoses and appropri- and K. B. Wells. “Treatment Preferences Among
ate treatment. Primary Care Patients.” Journal of General
Internal Medicine, v.15 (2000).
Raja Staggers-Hakim Falicov, C. J. Latino Families in Therapy: A Guide to
Eastern Connecticut State University Multicultural Practice. New York: Guilford Press,
1998.
See Also: Age; Cross-National Prevalence Estimates; Gorman-Smith, D. and P. Tolan. “The Role
Cultural Prevalence; Geography of Madness; of Exposure to Community Violence and
Incidence and Prevalence; Measuring Mental Health; Developmental Problems Among Inner-City
282 Ethical Issues

Youth.” Development and Psychopathology, Whaley, A. L. “Issues of Validity in Empirical Tests of

v.10 (1998). Stereotype Threat Theory.” American Psychologist,
Hogue, C., M. Hargraves, and K. Scott-Collins, eds. v.5 (1998).
Minority Health in America. Baltimore, MD: Johns Williams, D. R. and R. Williams-Morris. “Racism
Hopkins University Press, 2000. and Mental Health: The African American
Lopez, S. R., K. A. Nelson, J. A. Polo, J. Jenkins, M. Experience.” Ethnicity and Health, v.5 (2000).
Karno, and K. Snyder. “Family Warmth and the Williams, J. W., Jr., K. Rost, A. J. Dietrich, M. C.
Course of Schizophrenia of Mexican Americans Ciotti, S. J. Zyzanski, and J. Cornell. “Primary
and Anglo Americans.” Paper presented at the Care Physicians’ Approach to Depressive
International Congress of Applied Psychology, San Disorders: Effects of Physician Specialty and
Francisco, August 1998. Practice Structure.” Archives of Family Medicine,
Neighbors, H. W., M. A. Musick, and D. R. Williams. v.8 (1999).
“The African American Minister as a Source of World Health Organization (WHO). “Report of
Help for Serious Personal Crises: Bridge or Barrier the International Pilot Study on Schizophrenia.”
to Mental Health Care?” Health Education and Geneva: WHO, 1973.
Behavior, v.25 (1998). Yehuda, R. “The Biology of Post-Traumatic Stress
Ng, C. H. “The Stigma of Mental Illness in Asian Disorder.” Journal of Clinical Psychiatry, v.61
Cultures: Australia and New Zealand.” Journal of (2000).
Psychiatry, v.31 (1997). Yen, I. H. and S. L. Syme. “The Social Environment
Noh, S., M. Beiser, V. Kaspar, F. Hou, and J. and Health: A Discussion of the Epidemiologic
Rummens. “Perceived Racial Discrimination, Literature.” Annual Review of Public Health, v.20
Depression and Coping: A Study of Southeast Asian (1999).
Refugees in Canada.” Journal of Health and Social Yinger, J. Closed Doors, Opportunities Lost: The
Behavior, v.40 (1999). Continuing Costs of Housing Discrimination. New
Ojeda, V. D. and T. G. McGuire. “Gender and Racial/ York: Russell Sage Foundation, 1995.
Ethnic Difference in Use of Outpatient Mental Young, A. S., R. Klap, C. D. Shebourne, and K. B.
Health and Substance Use Services by Depressed Wells. “The Quality of Care for Depressive and
Adults.” Psychiatric Quarterly, v.77 (2006). Anxiety Disorders in the United States.” Archives
Peterson, J. L., S. Folkman, and R. Bakeman. “Stress, of General Psychiatry, v.58 (2001).
Coping, HIV Status, Psychosocial Resources, Zhang, A. Y., L. R. Snowden, and S. Sue. “Differences
and Depressive Mood in African American Gay, Between Asian and White Americans’ Help-Seeking
Bisexual, and Heterosexual Men.” American and Utilization Patterns in the Los Angeles Area.”
Journal of Community Psychology, v.24 (1996). Journal of Community Psychology, v.26 (1998).
Sansone, R. A. and L. A. Sansone. “A Nation-Based
Perspective on Prevalence.” Innovations in Clinical
Neuroscience, v.8/4 (2011).
Schraufnagel, T., A. Wagner, and J. Miranda, et al.
“Treating Minority Patients With Depression Ethical Issues
and Anxiety: What Does the Evidence Tell Us?”
General Hospital Psychiatry, v.28 (2006). The central role of ethics in a meaningful cultural
Sclar, D. A., L. M. Robison, T. L. Skaer, and R. sociology of mental health and mental illness calls
S. Galin. “Ethnicity and the Prescribing of for both respect for cultural variations and broad
Antidepressant Pharmacotherapy: 1992–1995.” recognition of human rights and general ethical
Harvard Review of Psychiatry, v.7 (1999). principles that are not culture bound. The inher-
Weisz, J. R., C. A. McCarty, K. L. Eastman, W. ently ethical dimensions of cultural and social
Chaiyasit, and S. Suwanlert. In Developmental practices that contribute to the health and well-
Psychopathology: Perspectives on Adjustment, being of individuals and populations demand at
Risk, and Disorder, S. S. Luthar, J. A. Burack, the outset that critical stakeholders—individual
D. Cicchetti, and J. R. Weisz, eds. Cambridge: persons, mental health professionals, and com-
Cambridge University Press, 1997. munities—are identified and aims and methods
 Ethical Issues 283

are made explicit in seeking to deepen under- (1) relationship or interpersonal ethics, (2) pro-
standing of ethical encounters, agency, obligation, fessional ethics, (3) practice ethics, (4) environ-
and decision making. mental ethics, (5) research ethics, and (6) care
First and foremost, the relationship between a ethics. Carl Rogers (1902–87), who is viewed as
person and a person’s mental health professional, one of the founders of humanistic psychology,
as well as the person’s place in an ethical com- has provided a clear description of professional
munity of relational others, need to be recog- roles and ethical responsibilities for mental health
nized and ethically accounted for. In addition, it professionals and explained how such roles and
is important to turn attention more globally to responsibilities center on the interpersonal rela-
the place of ethics in mental health policy, prac- tionship between the person and professional.
tice, and research. It is at this intersection that Rogers’s framing of the therapeutic relationship,
a turn may be made to public health ethics and which has been widely adopted across many of
a broader concern for the health of populations the professions, sheds light on the fundamentally
and the policies that will best support the goals human aspects of the person–mental health pro-
of population health and well-being. The perspec- fessional relationship that lead unavoidably to
tive of public health ethics is also attuned to the questions of philosophical ethics and how such
underlying social determinants of health and the inquiries may inform professional, practice, and
social structures that may influence and impact research ethics.
mental health. At the practice level, Rogers’s framework is
An interdisciplinary framework can help driving a major transformation in mental health
explore the ethical dimensions of social problems services that is broadly called the recovery move-
that span a continuum of ecological, interper- ment. The emphasis in this movement is on build-
sonal, and personal challenges, especially as such ing personal strengths, removing barriers to self-
challenges are understood in light of the devel- actualization, and identifying appropriate goals
opment of human values and, more specifically, of care rather than focusing on personal deficits.
moral values. Contemporary global issues con- While it is important to define the boundaries of
cerning violence, cultural conflict and pluralism, each of the domains addressed below, in many
dehumanization, gender expression, disabilities instances there is significant overlap among them.
and health disparities, social injustice, and racial,
ethnic, and religious identity merit examination Relationship or Interpersonal Ethics
from inter- and transdisciplinary perspectives There continues to be much debate in sociol-
drawing upon disciplines such as sociology, psy- ogy, psychology, and other mental health profes-
chology, philosophy, theology, history, anthropol- sions today about the meaning of the therapeu-
ogy, social work, and the helping professions. An tic relationship for the person and the person’s
interdisciplinary perspective helps illuminate the healing and recovery. A positivistic, evidence-
nature and depth of moral experience for persons based approach defines the clinical encounter
living through mental illness and the values they in terms of measurable goals and outcomes and
attach to such experience, and raises awareness causality. Rogers defines the therapeutic rela-
of ethics as deeply embedded in essential person- tionship with the person in treatment much
centered care. more broadly, based on the following three key
In this article, the word person is used to refer- dimensions: unconditional positive regard, con-
ence the individual in a treatment relationship with gruence or genuineness, and empathic care. In
a mental health professional. This places appro- this context, the ethical encounter with the per-
priate emphasis on “person-centeredness” and son and the professional’s ethical obligation to
avoids the medicalizing of the person as patient. such person extends beyond a strictly scientific
evidence base to encountering the person in their
Domains of Ethics essentially human dimensions. The relationship
It is helpful to conceptualize ethical responsibil- is therefore seen as the ground of ethics from a
ity and accountability in mental health as belong- deeply humanistic perspective: the ongoing ethi-
ing to one or more of the following domains: cal inquiry into what it means to be human. Both
284 Ethical Issues

these perspectives contribute to an understand- involving nonconceptual forms of social inter-

ing of the place of ethics in mental health. course and communication as well as communica-
The role of philosophy in informing ethics and tion through language. In this paradigmatic shift,
this humanistic perspective has been recognized questions of autonomy may be reconceptualized
for many decades. The place of ethics at the inter- more broadly in terms of relational autonomy
section of philosophy and the helping professions and social responsibility.
has long been recognized, as well as the impor- Within this framework of interpersonal or rela-
tance of fundamental questions in philosophy tionship ethics, how is the professional guided in
and even theology about existence and reality making ethical decisions? Ethical theories that
that sociologists, psychologists, psychiatrists, and are drawn upon include deontology, virtue ethics,
social workers must grapple with in dealing with and utilitarianism. Social ecology offers another
the concrete problems of human beings in the fruitful ground for decision making. An ecologi-
social world. Humanistic psychology has contin- cal assessment of the person-in-environment may
ued to expand the commitment and fidelity of the yield rich information about the person that is
human sciences to the lived experiences of human helpful in guiding ethical decision making in the
beings as subjects and moral agents, especially in treatment relationship.
the creative expression of human freedom.
The work of phenomenologists Maurice Mer- Professional Ethics
leau-Ponty and Gabriel Marcel has deepened Professional ethics and ethical decision making
understanding of the fundamentally social and are governed formally today by applicable pro-
relational nature of human relationships. This fessional codes. For example, psychologists have
foundational corpus of work in phenomenologi- a code of ethics, as do psychiatrists and social
cal science establishes that human persons are workers. While there may be significant variation
body-subjects living in a social world with others across professions in specific provisions of ethical
and, as subjects, are not reducible to thoughts or codes, there is also much commonality. There are
consciousness. The phenomenological perspec- essential features of professional ethics that are
tive as explained by these scholars ruptures the universal for all the professions. Some of those
concept of a purely subject-object or intrasubjec- features include safeguarding the integrity of the
tive reality that from the very beginning makes patient and the profession, professional educa-
it impossible to access things and others outside tion and socialization, protecting the public trust
oneself and one’s self-consciousness. Instead, as in the profession, and enforcement of standards
Marcel clarifies, the subject is present in being for the profession. Both the American Psycho-
from the very beginning. logical Association (APA) Code of Ethics and the
According to Marcel, the human person and National Association of Social Workers (NASW)
the suffering condition of the human person defy Code of Ethics incorporate these key features.
definition in terms of a problematic. Suffering is While no code of ethics can guarantee or assure
not located outside oneself and is not personal, but ethical conduct, development of ethics codes is
is inherently a part of living through experience in frequently based upon practice situations, or
the world. Building upon the work of Merleau, what J. C. Flanagan called “critical incidents” in
Ponty and Marcel, sociologist Alfred Schutz and 1954. Flanagan’s critical incident technique was
other scholars have helped reframe the meaning used in the development of the APA Code. Under
of suffering in its fully developmental and social this method, data are collected from descriptions
origins and as deeply rooted in the human condi- of concrete ethical dilemmas or situations that
tion from birth to death. In making this essential professionals have dealt with in assessment and
move to a subject who is always in the world and treatment. From these descriptions, provisions of
intimately related to others, in what Schutz calls the code are written to be most directly applicable
in Making Music Together (1951) “the mutual and useful to mental health professional practice.
tuning-in relationship,” the possibility is opened This method is still quite commonly used.
up for a radical redefinition of mental disorders Ethics codes usually begin with an aspirational
and mental illness as fundamentally social and section that focuses on the core values of the
 Ethical Issues 285

particular profession. For example, the National It is important for the professional in such situa-
Association of Social Workers (NASW) Code of tion to clarify, to the extent possible, any limita-
Ethics identifies its primary mission in its pre- tions on professional roles and attempt to resolve
amble and enumerates six core values: service, potential conflicts in advance or as early as pos-
social justice, dignity and worth of the person, sible through informal resolution mechanisms. In
importance of human relationships, integrity, and most situations, the mental health professional
competence. The NASW code also has ethical should avoid entering into professional relation-
principles and standards but states explicitly that ships where there is any possibility that profes-
none of its provisions is prescriptive; they are only sional judgment will be compromised or harm
a guide for decision making. The individual prac- may result to a person with whom they have a
titioner must use her/his professional judgment in professional relationship.
making ethical decisions in light of all givens. In all cases, mental health professionals must
Similarly, the APA code identifies principles assure the safety and protect the integrity and
of beneficence and nonmalfeasance, fidelity and welfare of the person with whom they have a
responsibility, integrity, justice, and respect for relationship of trust. Fidelity to such persons is
persons’ dignity. It also enunciates enforceable most assured by the professional competence
ethical standards. of the practitioner. Provisions of the ethics code
One of the most common issues that may arise make clear that mental health professionals must
for a professional under a code of ethics is a con- be careful never to exceed the boundaries of their
flict of interest. In this situation, the professional professional competence based on their educa-
should turn to the code of ethics for guidance, tion, training, study, consultation, or professional
which may or may not provide guidance, as codes experience.
are not exhaustive. There are numerous types of
conflicts of interest. For example, a mental health Practice Ethics
professional might have a conflict of interest with There have been major changes in practice eth-
a policy of the agency or employer for whom she/ ics in the mental health profession in this millen-
he works. In some cases, the policy in question nium. Those changes relate mainly to a paradigm
might conflict directly with the code of ethics. In shift in the way in which mental illness is viewed
other cases, the conflict may be with the profes- and delivered. A purely medical model of care has
sional’s own ethical judgment and values. This is given way to person-centered care models. This
the most difficult and ethically demanding situa- is unfolding perhaps most dramatically through
tion for a professional, as it may involve trade­ the recovery movement, which is transforming
offs that have unpleasant consequences, such as a mental health policy and practice and placing
threat to one’s job security. more power in the hands of the self-determining
The APA provides explicit guidance in each patient. From writing personal goals of care to
of these situations: the psychologist must sort assuming more direct responsibility for determin-
out the nature of the conflict, make known her/ ing one’s own recovery from illness, the person
his commitment to the principles and standards in mental health treatment today is assimilating
spelled out in the code of ethics, and try to resolve a person-centered focus supported and guided by
the conflict. The APA ethics code has an addi- recovery-oriented mental health professionals.
tional provision barring reliance on provisions of The aims of recovery are to improve one’s func-
the ethics code for the purpose of any violation of tioning, secure stable housing and employment,
human rights. and transition fully into one’s community.
A second type of conflict of interest that may The recovery-oriented approach stands in con-
arise in professional ethics is the result of dual trast to the medical diagnostic approach reflected
or multiple relationships. For example, a school- prominently in the fifth edition of the Diagnos-
based mental health professional may have mul- tic and Statistical Manual of Mental Disorders
tiple roles and responsibilities, not all of which (DSM) and the increasingly intensive psychiatric
are congruent. The school-based counselor may and pharmacological environment. Issues of con-
have duties to the school as well as to the student. cern have been raised related to the DSM-5 in
286 Ethical Issues

light of changes to many of the diagnostic cat- such illnesses as trauma. It remains unclear, based
egories. In an open letter to the DSM-5 task force upon current research, to what extent there is
and the American Psychiatric Association, Divi- fidelity to such protocols and, even given fidelity,
sion 32 of the American Psychiatric Association if adherence produces better outcomes for persons
cites the following scholarly concerns about the in treatment. Debate about exercise of practitio-
DSM-5: (1) the lack of scientific basis for certain ner discretion has been a major source of concern
new DSM-5 diagnoses, (2) the lowering of diag- in this area.
nostic thresholds in several categories (includ- Results from studies of the effectiveness of
ing in the category of cognitive disorders), and manualized-based treatment protocol suggest
(3) the introduction of new disorder categories there may be certain essential dimensions to these
that may result in harm, especially to vulnerable protocols. Bruce Chorpita, Eric L. Daleide, and
populations. John R. Weisz have proposed synthesizing the
Because of the rapidly changing environment treatment intervention literature. As a result of
in the delivery of mental health services, mental the work of Richard Barth, Chorpita, and other
health professionals today must be well trained leading researchers, an emerging consensus is
in knowledge management. The evidence-based forming that supports a new direction in seek-
movement has resulted in the development of ing to identify common elements and factors
multiple manual-based practice protocols for in evidence-based protocols for the purpose of

In this 1876 painting by Tony Robert-Fleury, French psychiatrist Philippe Pinel (1745–1826) releases lunatics from their chains at the
Salpêtrière asylum in Paris in 1795. In 1793, Pinel’s new program of mental care, “moral therapy,” introduced more humane and ethical
methods to the treatment of the mentally ill. The Rogerian humanistic tradition of the 20th century involves a similarly ethical approach,
which is to always provide nurturing and relational empathic care to support a patient’s development, healing, and full recovery.
 Ethical Issues 287

matching synthesized evidence with persons in Environmental Ethics

treatment. Initial studies in trauma point to com- An ecological assessment of a person experi-
mon elements in the domains of safety, attach- encing distress is essential to understanding the
ment/strengthening relationships, and attention nature of a person’s illness. Such an assessment
to the social context. These domains all converge should take account of the systems in which a
around the person-in-environment. person is embedded and the relationship of the
One of the biggest challenges for mental health person to each system and across systems, as well
professionals today in faithfully serving persons as to other persons with whom they stand in ethi-
with mental illness is complying with the con- cal relation.
fidentiality requirements of applicable federal, In examining principles of environmental eth-
state, and local laws and regulations. In general, ics in the context of mental health, the question
the law has sought to protect the patient-therapist that must be asked is whether the human person
relationship under a broad public policy goal of is viewed as the center of the universe, which is
preserving the integrity of the therapeutic rela- the dominant homocentric view in ethics. The
tionship and not discouraging help seeking among opposing view would be that human beings do
those who need mental health services. However, not have supremacy over nonhuman forms of
the therapeutic relationship is under attack, espe- life such as animals and plants. This nonanthro-
cially in the wake of the perception of mount- pocentric view calls for humility in the presence
ing violence in society and movements to enact of other sentient life and the world, both known
stricter gun control laws. Some states are mov- and unknown. Scholar Paul Waldau writes that
ing to enact legislation that would impose much as humans, it is incumbent upon us to recognize
broader requirements on therapists to report to our own animality as the ground of fully human
governmental authorities information about meaning-making activity.
patients who may potentially threaten the safety
and security of others pursuant to much lower Research Ethics
thresholds of risk and evidence. Ethical issues in research in mental health and
The therapist is always faced with a profes- in the domains of ethics related to mental health
sional ethical responsibility to both the patient continue to be critically important. Persons with
and society that transcends the explicit boundar- mental illness who have the capacity to render
ies of laws and demands continual reassessment an informed consent should be fully consented
and balancing of the patient’s health needs, the before participating in a research study. Unless
patient’s safety, and the public safety in the con- there is an adjudication of incompetence, there is
text of a rapidly changing society. External man- a presumption of capacity. However, the need for
dates cannot take the place of the mental health a clinical assessment of capacity may be indicated
professional’s own exercise of professional judg- under certain circumstances. For example, if a
ment in evaluating and deciding what is the right person demonstrates evidence of clinical depres-
thing to do under the unique circumstances pre- sion, an evaluation should be conducted. Atten-
sented by a patient in relationship with a thera- tion should be paid to human subject protections
pist. In this respect, the therapist in practice today in conducting research investigations with such
accepts an increasingly serious and sometimes populations as older adults, prisoners, pregnant
onerous responsibility in caring for patients with women, persons with cognitive impairments, and
mental illness. other vulnerable populations. Recruitment of per-
Mental health professionals in practice also sons to clinical trials is also an area fraught with
have a responsibility of self-care to assure that ethical difficulty, especially in light of the check-
they are not putting themselves at risk in the ther- ered history of research such as the 1932 to 1972
apeutic process, either physically or emotionally. Tuskegee syphilis experiment.
Maintaining appropriate boundaries and being The qualitative research movement affords
attentive to one’s own health and well-being lays new opportunities for vulnerable persons to par-
a strong foundation for an effective, protective ticipate in studies and make meaningful contribu-
therapeutic relationship. tions to knowledge building. One very promising
288 Ethiopia

research method is participatory action research, See Also: Commitment Laws; Competency and
in which individuals with mental illness or dis- Credibility; Eugenics; Euthanasia; Human Rights;
abilities can take an active role and be given a Inequality; Labeling; Patient Accounts of Illness;
voice in research projects. Patient Rights.
There also needs to be heightened awareness
among mental health researchers that they stand Further Readings
in an ethical relation to their research subjects. American Psychological Association. “Ethical
Humanistic psychologist Fredrick J. Wertz, draw- Principles of Psychologists and Code of Conduct”
ing upon the work of French phenomenologist (2010). http://apa.org/ethics/code/index.aspx
and ethicist Emmanuel Levinas, has written elo- (Accessed September 2012).
quently about the inherently ethical obligation Chorpita, Bruce F., E. L. Daleiden, and J. R. Weisz.
of the researcher to the participants in a research “Identifying and Selecting the Common Elements
study. In his 2011 book, Five Ways of Doing of Evidence-Based Interventions: A Distillation
Qualitative Analysis, Wertz has described this and Matching Model.” Mental Health Services
relationship as one of love. Research, v.7/1 (2005).
Davidson, L., E. Flanagan, D. Roe, and T. Styron.
Conclusion: Care Ethics and Palliative “Leading a Horse to Water: An Action Perspective
Approaches to Mental Health Care on Mental Health Policy.” Journal of Clinical
While it is not possible in this article to provide Psychology, v.62/9 (September 2006).
an exhaustive description and discussion of ethi- Fisher, Celia B. Decoding the Ethics Code: A Practical
cal issues in mental health, the areas addressed Guide for Psychologists. 3rd ed. Thousand Oaks,
lay a strong foundation for ethical decision mak- CA: Sage, 2012.
ing in a culturally diverse world. Ethical deci- Flanagan, J. C. “The Critical Incident Technique.’’
sion making in mental health care is essentially Psychological Bulletin, v.51/4 (1954).
palliative in nature because its primary aim is to Kleinman, A. “From Illness as Culture to Caregiving
relieve the pain and suffering of the person who as Moral Experience.” New England Journal of
is experiencing distress and seeks the help of a Medicine, v.368/15 (2013).
professional. The unit of care in palliative care is Maslow, Abraham H. Motivation and Personality.
the person as well as the person’s family. Attune­ 3rd ed. New York: HarperCollins, 1954.
ment to the person’s social ecology, cultural and National Association of Social Workers (NASW).
family life, and cultural practices is therefore NASW Code of Ethics: Guide to the Everyday
paramount. Professional Conduct of Social Workers.
The role and orientation of the mental health Washington, DC: NASW, 2008.
professional, in the Rogerian humanistic tradi- Rogers, Carl. On Becoming a Person. Boston:
tion, is always to hold the person seeking help in Houghton Mifflin, 1961.
a loving maternal embrace, nurturing and pro- Schutz, Alfred. “Making Music Together.” Social
viding relational empathic care to support their Research, v.18/1 (1951).
development, healing, and full recovery. This duty
to the person, or turning to the person in an ethic
of care, may be described as a commitment of
nonabandonment; it is the primary obligation to
the person seeking help in a trusting relationship. Ethiopia
Although cultural and social practices surround-
ing mental health and mental illness may vary, Ethiopia is an east African country with an area
the ethical commitment of nonabandonment is of 426,373 square miles (1.1 million square kilo-
invariant in the structure of this relationship of meters) and a 2012 population of 93.8 million.
profound trust. As is typical in developing countries, the popu-
lation is predominantly young, with 50 percent
Mary Beth Morrissey younger than 18 and 3 percent older than 65.
Fordham Graduate School of Social Service As of July 2012, Ethiopia had the fifth-highest
 Ethiopia 289

population growth rate in the world at 3.2 per- As of 2011, Ethiopia had 57 mental health
cent and the seventh-highest total fertility rate at outpatient facilities at a rate of 0.07 per 100,000
six children per woman. Life expectancy at birth people, three day-treatment facilities (0.004 per
is 59 years for females and 56 years for males. 100,000), 32 psychiatric beds in general hospitals
Ethiopia is classified by the World Bank as a (0.04 per 100,000), one community residential
low-income country, with a 2011 per capita gross mental health facility (0.001 per 100,000) with
domestic product (GDP) of $1,110. It was also 168 beds (168 per 100,000), and one mental hos-
ranked low on the United Nations (UN) Human pital (0.001 per 100,000) with 300 beds (0.35
Development Programme’s Human Development per 100,000). The rate of admissions to mental
Index, with a score of 0.363 (where 1 indicates hospitals was 2.02 per 100,000, of which 32 per-
high development and 0 indicates low develop- cent were female and 5 percent were under age
ment). According to the World Economic Forum’s 18. Most (98 percent) of people treated in mental
Global Gender Gap Index, Ethiopia also ranks hospitals stayed less than one year, with 1 percent
low on gender equality, with a rank of 116 out staying from one to five years and 1 percent longer
of 135 countries in 2011 (a lower rank means than five years. The rate of treatment in mental
less equality). The country also ranks relatively health outpatient facilities was 114.8 per 100,000;
high on government corruption, with a score of 20 percent of those treated were female and 1 per-
2.7 out of 10 on the 2011 Corruption Perceptions cent were under age 18. The rate of treatment in
Index (a lower score means more corruption) by mental health day-treatment facilities was 0.91
Transparency International, which ranks 183 per 100,000, of which 49 percent were female.
countries. In 2010, the UN High Commissioner Most people in Ethiopia use traditional meth-
for Refugees estimated that there were 154,295 ods, including herbal remedies, prayer rituals,
refugees and people in refugee-like situations in the wearing of amulets, and sprinkling with holy
Ethiopia. waters to treat mental disorders. If they receive
medical treatment, this usually occurs only after
Current Mental Health Services traditional means have been exhausted. Many
Total Ethiopian government expenditures on are treated against their will, and patients who
health were estimated at $16 per capita in 2006, become aggressive are often kept restrained by
representing 4.3 percent of GDP. Ethiopia does shackles or ropes. Because Ethiopia is a relatively
not have a national mental health policy, although poor country with a largely rural population (83
mental health is mentioned in the national health percent), providing and delivering adequate men-
policy. In 2005, the average incidence of mental tal health treatment is a challenge. In 1986, the
health disorders was estimated at 18 percent for World Health Organization began a program to
adults and 15 percent for children. In 2008, neu- train nurses to identify and treat common psychi-
ropsychiatric disorders were estimated to repre- atric disorders, and 26 regional and district hospi-
sent 5.8 percent of Ethiopia’s total burden of dis- tals have psychiatric units operated by nurses who
ease. Most (over 85 percent) of Ethiopia’s mental can refer difficult cases to psychiatric care in Addis
health budget is spent on mental hospitals, and Ababa. However, the country’s mental health care
mental health care is primarily available in the workforce remains inadequate: In 2011, Ethiopia
national capital of Addis Ababa. had 0.04 psychiatrists per 100,000 population,
Primary care physicians are allowed to pre- 0.59 nurses working in the mental health sector
scribe and continue prescriptions for psycho- per 100,000, 0.02 psychologists per 100,000,
therapeutic medications; however, most have 0.004 social workers in the mental health sector
not received in-service training in mental health per 100,000, and 0.03 other health workers in the
care within the past five years. Expenditures for mental health sector per 100,000.
medicines to treat bipolar disorders were $148 The primary location for advanced men-
per 100,000 population in 2011; for psychotic tal health care is Amanuel Mental Hospital in
disorders, $399 per 100,000; for general anxi- Addis Ababa, which is chronically overpopu-
ety, $1,092 per 100,000; and for mood disorders, lated and short of staff and medications. Many
$174 per 100,000. are psychotic and/or violent and are brought to
290 Ethnicity

the hospital by their families, often against their Ethnicity

will. However, because Ethiopia does not have
social support services, patients depend on their Ethnicity is a complex, multifaceted, and conten-
families if they are to avoid becoming vagrants, tious concept that is used to classify individuals or
and staff are therefore likely to value the fam- populations and mark difference. It can be under-
ily’s description of the patient’s needs over the stood in terms of the social construction of differ-
desires of the patient. After admittance, the hos- ence. Ethnicity may be used to describe oneself or
pital does not provide recreational or therapeu- a set of people to which you belong as members
tic activities, so often patients spend their days of a distinct social group or to characterize others
in a nonstimulating environment. Although this as belonging to a separate group. For example, a
description sounds highly critical of the Ethio- person or group may be identified by an ethnic
pian mental health care system, it is not atypi- label such as Asian, British, Irish, black Carib-
cal of that in many African countries and, given bean, or Hispanic. Categorizing according to eth-
the poverty and many competing needs that the nicity is associated with both harms and benefits.
Ethiopian government must try to serve, there is For example, ethnic diversity may be celebrated
no easy solution to the problems of Ethiopia’s as people pursue experience of different cultures
mental health care system. through music, food, and travel. However, eth-
nicity may be used to position people in negative
Sarah Boslaugh ways, through the association of particular eth-
Kennesaw State University nic groups with higher levels of illness or crime.
The meaning of ethnicity is therefore highly con-
See Also: Asylums; Congo, Democratic Republic text dependent.
of the; Human Rights; International Comparisons; Ethnicity as a concept overlaps with race; how-
Kenya; Nigeria; Patient Rights; South Africa; Sudan; ever, whereas race is defined in relation to pur-
Tanzania; Uganda. ported biological factors, particularly physical
characteristics such as skin color, definitions of
Further Readings ethnicity are based on social and cultural char-
Alem, A. “Human Rights and Psychiatric Care in acteristics of individuals or groups. The term
Africa With Particular Reference to the Ethiopian ethnicity derives from the ancient Greek word
Situation.” Acta Psychiatrica Scandinavica, v.101 ethnos, which means “people” or “nation.” It
(2000). was initially used to denote the difference of non-
Maes, Kenneth C., Craig Hadley, Fikru Tesfaye, and Greek peoples, rather than as a means of self-
Selamwit Shifferaw. “Food Insecurity and Mental identification. Elements of this use of ethnicity
Health: Surprising Trends Among Community to mark otherness, and the possible applications
Volunteers in Addis Ababa, Ethiopia, During the that this allows, remain in the way that ethnic-
2008 Food Crisis.” Social Science and Medicine, ity is used today. Related concepts are national-
v.70 (2010). ity, country of birth, immigration status, culture,
Sathiyasusuman, Appuni. “Mental Health Services in and ancestry. Definitions of ethnicity emphasize
Ethiopia: Emerging Public Health Issues.” Public shared social and cultural history. Ethnicity can
Health, v.125 (2011). be defined as membership in a population group
World Health Organization. “Mental Health Atlas that has shared long-standing social origins and
2011. Country Profiles: Ethiopia.” http://www.who cultural traditions that are maintained between
.int/mental_health/evidence/atlas/profiles/en/index generations and contribute to the sense of ethnic
.html (Accessed April 2013). identity of the group. It often also implies a com-
World Health Organization Regional Office for mon language or religion.
Africa. “Mental Health, Violence and Injuries
(MVI): Country Profile for Ethiopia.” http://www Social Construct
.afro.who.int/index.php?option=com_docman& Ethnicity is a social construct, with identities and
task=doc_download&gid=3069 (Accessed April categories that change depending upon context
2013). and time. It is a way in which people socially
 Ethnicity 291

organize and understand themselves as individu- ethnic majority) groups has expanded. Immigra-
als and communities. People use ethnicity in order tion patterns change over time, as do the ways
to construct individual and collective identities in that people settle in new countries. Some local
relation to concepts about who they are and how communities may have large settlements of one
the world works. Collective ethnic identity is both minority ethnic community, or communities may
a form of social action and a basis for it, impos- be ethnically diverse, which is the trend in many
ing boundaries in terms of group membership and large cities. This is exemplified in the number of
access. Identification with an ethnic group there- languages now spoken in cities such as New York
fore implies membership, which in turn may be (over 200) and London (over 300). Another fac-
linked to rights, duties, and reputation. tor adding to ethnic diversification is the growing
Ethnic groups may directly or indirectly posi- number of people with mixed ethnic backgrounds.
tion themselves in society in order to promote or In the UK 2001 census, the fastest-growing ethnic
protect the interests of their membership. Viewed minority group was “mixed.”
from this perspective, ethnicity can be consid- The fluid and context-specific nature of ethnic-
ered in terms of social structure and relation- ity can be seen in differences in the official record-
ships of power within and between societies. This ing of ethnicity. The ethnic makeup of many
involves the way in which social positioning is countries around the world is officially recorded
configured along ethnic lines so that other ethnic through a national census program. Ethnicity was
groups, usually ethnic minorities, will be in less first included in the national census in the UK in
powerful positions. 1991, whereas in the United States, detailed infor-
The use of ethnicity as a concept and classifi- mation has been collected about race and ethnic-
cation system varies among countries. In many ity since the 18th century. Current best practice
countries, interest in identifying and understand- in recording ethnicity involves asking people to
ing ethnicity is mainly concerned with ethnic self-assign their ethnicity based on a number
minorities. Although there has been increasing of predefined categories. This is not a clear-cut
interest in describing and exploring the nature of task for governments, as is reflected in the ever-
ethnicity in majority populations, such as white changing range of ethnic categories used in census
Britishness in the United Kingdom (UK), most questionnaires. Personal decisions by individuals
academic work, research, and policy development about which ethnic group one belongs to may
that refers to ethnicity focuses on ethnic minorities also change over time, with significant numbers
and their social position through a more powerful of people assigning themselves to different ethnic
ethnic majority population. Interest in ethnicity categories on different occasions.
is nested in principles of human and civil rights, The need to formally assess ethnicity is con-
and the social justice imperative to promote tentious. For many from ethnic minority groups,
equity between social groups. This is supported it is viewed as unnecessarily labeling people as
through the identification and monitoring of eth- “other,” and there is understandable distrust as to
nic inequality. In part, the emphasis in promoting how such information will be used. On the other
equity is related to the way that the world order hand, it is considered necessary in order to high-
is constructed along ethnic lines, with ethnic iden- light inequality and to investigate the relation-
tity used throughout history to justify inequality ship between ethnicity and markers of societal
and exploitation of particular populations. This quality such as health, education, and income.
can be seen in stories of ethnic cleansing that are When investigating and reporting on ethnicity, it
regularly reported in the media. is important to consider the interplay with other
variables such as socioeconomic status, gender,
Globalization age, immigration status, and generation. The way
Migration has always been a feature of human in which data on ethnicity are presented is selec-
life, however, the late 20th century saw particu- tive and often misleading, implying a causal rela-
larly rapid levels of migration between countries. tionship that may be mediated by many other fac-
For example, in many large cities, the proportion tors, in particular, social class. Ethnicity should
of people from ethnic minority (as opposed to therefore not be applied as a single variable in
292 Ethnopsychiatry

efforts to explain likely complex relationships impact of living in ethnically diverse communities
with things like levels of illness or educational on mental health.
achievement.
Ethnicity can be conceptualized in cultural Moira J. Kelly
terms as a set of behaviors, perspectives, and Queen Mary University of London
social practices. Social research has shown how
ethnic groups may differ culturally in their expe- See Also: Diagnosis; Diagnosis in Cross-National
riences, views, and responses to different types Context; Ethnopsychiatry; Globalization;
of illness. Such research is of value in informing International Comparisons; Migration.
understandings of the causes and experiences of
mental illness, but care needs to be taken not to Further Readings
essentialize culture and use it as a way of explain- Bhophal, R. S. Ethnicity, Race, and Health in
ing mental illness. This is the basis of cultural Multicultural Societies. Oxford: Oxford University
stereotyping, which leads to skewed and partial Press, 2007.
understandings of complex issues such as mental Care Quality Commission. “Count Me in 2010:
health, and contributes to stigma and discrimina- Results of the 2010 National Census of In-Patients
tion. Ethnicity needs to be understood critically, and Patients on Supervised Community Treatment
in terms of its construction, meaning, and use in in Mental Health and Learning Disabilities Services
different social contexts. This includes careful in England and Wales.” London: Care Quality
and reflexive consideration of the sociocultural Commission, 2011.
conditions in which mental illness occurs and the Cornell, S. and D. Hartmann. Ethnicity and Race:
processes through which ethnicity may influence Making Identities in a Changing World. 2nd ed.
mental illness. Thousand Oaks, CA: Pine Forge Press, 2007.
The need to consider ethnicity critically can be
seen in relation to the over-representation of eth-
nic minorities in mental health care in countries
such as the UK and United States. For example, a
recent UK survey of inpatient admissions to men- Ethnopsychiatry
tal health hospital services found that admission
rates to hospitals were at least two times higher Ethnopsychiatry is sometimes referred to as
than average for people from black Caribbean, “transcultural psychiatry” or “cross-cultural psy-
black African, and mixed white/black groups. chiatry.” Contrary to its name, ethnopsychiatry is
This could be taken to indicate that people from a subfield of anthropology, rather than psychiatry.
black ethnic groups are more susceptible to men- “Ethno” is in reference to cross-cultural groups.
tal illness. However, social research has shown Ethnopsychiatry is primarily focused on study-
that when social factors such as socioeconomic ing mental health and illnesses, as well as normal
status and institutional racism are taken into and/or abnormal states, in different cultures in
account, the role that ethnicity plays in suscepti- order to understand the cultures’ perspectives of
bility to mental illness is much reduced. mental health and illness. The ethnopsychiatry
Policy makers need to consider how ethnicity is perspective emphasizes understanding cultures’
socially constructed in a globalized world that is expressions of mental health and illness. They
constantly transforming in order to promote and maintain that in other cultures, Western models
defend social and political goals. This will involve of diagnosis and treatment for mental illnesses are
developing theoretical, and therefore critically inadequate, and this results in misunderstandings
informed, approaches to understanding ethnic- and inappropriate mental health care.
ity in terms of social and cultural practices, social Ethnopsychiatry is a subfield of psychologi-
structure, and power. Significant challenges lie in cal anthropology and focuses on many of the
studying ethnic differences in mental health, with- same topics as psychological anthropology but
out creating stigma or inequity. Future conceptual from a slightly different perspective. There are
and research work is also likely to attend to the many subfields (or schools) of psychological
 Ethnopsychiatry 293

anthropology, such as psychoanalytic, configu- Mohave. Devereux was using the term ethnopsy-
rationalist, and cognitive anthropology. Each of chiatry to understand mental illness in cultural
these subfields seeks to explain the concept of groups from a psychoanalytical analysis of the cul-
culture within the context of mental health and tural groups. Differing from Mars and Devereux,
illness but from a different methodological and/ E. Ackernecht rejected the psychoanalytical
or research perspective. Ethnopsychiatry is one approach in favor of a straight-up cross-cultural
of these subfields. comparison, which focused on comparing vari-
Ethnopsychiatry and psychological anthropol- ous cultures’ mental health and illness conditions.
ogy are similar in the topic areas they study. For R. Bastide, a colleague of Devereux, conceptual-
example, both ethnopsychiatry and psychologi- ized ethnopsychiatry as the study of indigenous or
cal anthropology study the interaction between local conceptualizations of mental illness.
cultural and mental processes, with a particular
emphasis on how the respective cultures shape Ethnopsychiatry Research
and socialize mental health, emotions and moti- Ethnopsychiatry research is focused on the causes
vation, and cognition and perception. Much of of mental illness across different cultures, such
the focus is on cross-cultural comparison. They as spirit possession and/or the supernatural. The
also both study how members of a culture under- culture’s conception, definition, and classification
stand, interpret, and evaluate emotions, motiva- of particular mental conditions are a common
tions, cognitions, and perceptions as related to research focus in ethnopsychiatry. A prominent
mental health. Ethnopsychiatry and psychologi- focus of ethnopsychiatry investigations is the
cal anthropology, however, differ in methodolo- cross-cultural treatment of mental health condi-
gies and specific research topics. tions, which includes the study of local healers,
Prior to ethnopsychiatry as a field, researchers shamanism, witch doctors, and medicine men.
conducted personality studies using psychoana- This research pays particular attention to the
lytical measures to investigate basic differences indigenous or local group’s explanations for the
across cultures and societies. At the time, West- causes of mental illness and to the cultural or
ern researchers thought that severe mental ill- folk beliefs connected to the conditions. Beyond
ness was a universal experience directly related the attempts to understand mental health and/
to a person’s ethnicity, gender, class, and religious or illness from a particular culture’s perspective,
beliefs. The common explanation for the differ- ethnopsychiatry research also examines ways for
ences was attributed to the childrearing prac- possible collaborations between local healers and
tices of the group under study. The researchers Western mental health professionals.
assumed that the childrearing practices of other There are several research questions that eth-
cultures were inferior to Western models of chil- nopsychiatrists investigate. A principal ques-
drearing. Another common explanation was that tion of inquiry is what constitutes mental health
the groups were primitive and lower on the evo- across different cultures. Mental health varies sig-
lutionary scale. These researchers assumed that nificantly across cultures around the world, with
the variation in mental illness was the result of ethnopsychiatrists noting that what is mentally
the group being less evolved. These theories were normal in one culture may not be considered nor-
commonly held beliefs for many years in anthro- mal in another culture. For example, if a person
pology. The childrearing practices and evolution- displays too much emotion in one culture, they
ary scale theories were later proven wrong, a may be considered abnormal or having a mental
systematic bias of Western research not based on illness, while in a different culture the same dis-
scientific evidence. play of emotion would be considered normal or
Lois Mars, a Haitian psychiatrist, is credited mentally healthy. Another example is how people
with coining the term ethnopsychiatry in 1946. of a particular culture handle daily stress, which
Mars noted the term after attempting to define requires learning and understanding cultural cues
a local psychiatric illness. However, Georges as well as the parameters of appropriate behavior
Devereux popularized and clarified the term in of certain situations, which can vary significantly
the 1950s with his psychoanalytical study of the from one culture to another.
294 Eugenics

Globally, the variation in what is normal or negative eugenics, or prevention of those deter-
abnormal, or what is mental health or illness, is mined to be genetically inferior from reproducing.
so diverse that attempts to define mental health Galton’s initial concern was to preserve people of
are problematic. Some common theories define high intelligence, but the concept has also been used
mental health as the absence of a mental disorder, to promote “purification” through elimination of
having an accepted perception of reality, or being mental illness, alcoholism, and other “defects,”
adequately adjusted to the local culture and/or and even, in the Nazi movement, to extermination
environment. of non-Aryan ethnic groups. Eugenics has been
Ethnopsychiatry provides a unique perspective applied differently in different countries, as can be
on cross-cultural mental health and illness. By dif- illuminated by comparing the movement in Gal-
ferentiating the normal and/or abnormal states in ton’s country, Great Britain, to its manifestations
different cultures, a better understanding of other in the United States and Germany.
cultures’ social worlds is achieved. The ethnopsy- Galton saw positive eugenics as the most suc-
chiatry perspective also provides a space to exam- cessful way to enhance the human condition. In
ine how Western society views and treats people his 1901 paper, Galton recommended that societ-
with mental illness. ies encourage marriage between women and men
of high quality, and provide nutritious food and
Andrew Hund good housing for their children. His paper was
Umea University well received in some circles, and in 1908 Galton
established the Eugenics Society of Great Britain.
See Also: Ethnicity; International Classification of In 1909, he founded the journal Eugenics Review,
Diseases; International Comparisons. which was published until 1968. Galton was an
enthusiastic, influential champion of eugenics
Further Readings until his death in 1911.
Casey, C. and R. Edgerton. A Companion to Before World War I, eugenics was exported to
Psychological Anthropology: Modernity and other countries. The First International Congress
Psychocultural Change. Hoboken, NJ: Wiley- of Eugenics was held in London in 1912. One
Blackwell, 2005. of Charles Darwin’s sons, Leonard Darwin, was
Kleinman, Arthur. Rethinking Psychiatry: From president of the congress. Papers were presented
Cultural Category to Personal Experience. New by individuals from a number of different coun-
York: Free Press, 1988. tries over several days. Both positive and negative
LeVine, R. Psychological Anthropology: A Reader eugenics were discussed. An American discus-
on Self in Culture. Hoboken, NJ: Wiley-Blackwell, sant argued for compulsory sterilization of some
2010. citizens as a means to achieve a superior human
genetic stock.
In Great Britain, eugenics received little financial
support from the government. Sterilization was
not legalized, although discrimination in educa-
Eugenics tion and employment based upon social class was
common. In the United States, more aggressive
In the early 1900s, British polymath Francis Gal- actions were taken. In 1914, a group of American
ton founded modern eugenics, a movement that academics and other prominent citizens, members
spread throughout much of the world. In 1901, of the Committee for the Heredity of the Feeble-
in an article published in the journal Nature, Gal- Minded, recommended that “defective classes”
ton coined the term eugenics based on the Greek of people be sterilized. These “defective classes”
word eugenes, which means “well born.” Soon included the mentally retarded, insane, epileptics,
after the introduction of the eugenics concept, two congenitally handicapped, criminals, and the poor.
main branches developed: positive eugenics, or By 1930, 21 states had passed laws that permit-
encouragement of selective breeding among those ted sterilizations of some or all of these catego-
presumed to have a superior genetic makeup, and ries of individuals. The total number of sterilized
 Eugenics 295

Americans is often reported as 60,000 to 64,000.

A number of states also passed laws that restricted
marriage based upon eugenic criteria. For instance,
some states illegalized marriage for an individual
who was mentally retarded, mentally ill, or epilep-
tic. Some states, such as Virginia in 1924, passed
antimiscegenation laws, prohibiting interracial
marriage. At the federal level, the Immigration
Act of 1924 greatly restricted immigration. South-
ern and eastern Europeans were more negatively
affected by this legislation than prospective immi-
grants from northern and western Europe.

Eugenics in Germany
In Germany, the Kaiser Wilhelm Institute for
Anthropology, Human Heredity, and Eugenics
was created in 1927. Germany passed a steriliza-
tion law in 1933, and within a few years, hundreds
of thousands of individuals who were viewed as
mentally or physically unfit were sterilized. Sub-
sequently, under the T-4 program, the mentally
ill were systematically killed, with the active
cooperation of many German psychiatrists. They
were the first group to be gassed en masse, and
the techniques that the Nazis used on the men-
tally ill were subsequently used to exterminate
other groups they regarded as undesirable. The
Nazis took the eugenics doctrine and infamously The Human Betterment Foundation in Pasadena, California,
applied it to racial and ethnic background, view- distributed this broadside in about 1937 to promote the benefits
ing the Aryan race as superior to all others. of sterilization for mental patients. On the list is the prevention
In January 1942, 15 high-ranking members of of “the birth of children who would have a bad heredity.”
the Nazi regime met in Wannsee, Germany, to dis-
cuss policies relating to Jews. Under the direction
of Adolf Eichmann and Reinhard Heydrich, the
group discussed plans to deport European Jews Haldane implored geneticists to do society a service
(even those living outside Germany) to German- by explaining how little is known about genetics.
occupied eastern Europe, where the physically Consistent with Haldane’s statement, a number of
fit would perform manual labor, presuming that arguments against eugenics, some made by genet-
most would die during the work. According to icists, have emerged. For instance, it is not clear
plan, those who survived the camps would be that increasing the reproduction of people with
killed after the completion of the labor projects. desirable traits and decreasing the reproduction of
The Nazi extermination of Jews and others accel- people with undesirable traits would achieve the
erated. Between 1942 and 1945, six million peo- desired effects. Human genetics are complex, and
ple died in Nazi concentration camps. many examples of mental or physical disability
A number of experts in genetics or eugen- may occur through a single mutation, rather than
ics responded to the atrocities committed by the as the result of genetic information that is inherited
Nazis. J. B. S. Haldane, one of Britain’s leading from one or both parents. Additionally, unintended
geneticists of the first half of the 20th century and consequences may arise when selective breeding is
a former eugenicist, wrote a warning in a paper implemented for humans, such as possible negative
in 1964 that was published soon after his death. effects of decreasing genetic diversity.
296 Euthanasia

Despite the cautionary words of people like mental health professionals in the United States
Haldane, eugenics continues to survive in some and worldwide. Such interest is rooted in the
form in many countries. In 1994, China passed well-established patients’ rights movement as
legislation restricting marriages and mandating well as in a growing societal awareness of the
sterilizations or agreement to long-term contra- need to integrate pain management and palliative
ception for some individuals in order to prevent care into mainstream health care. Various forms
the continuation of certain (presumably) genetic of hastening death are now legal, regulated prac-
diseases. The law is no longer federally enforced tices worldwide.
but is in effect in some provinces. Changes in Assisted dying is legal in the U.S. states of Ore-
genetic, genomic, and reproductive technologies gon, Washington, and Montana, and euthanasia
at the end of the 20th century have led to resur- is legal in the European countries of Belgium,
gence in discussions about eugenics. For exam- Luxembourg, and the Netherlands. In Switzer-
ple, in 2002, in his book Redesigning Humans: land, assisted suicide is permitted under the law,
Our Inevitable Genetic Future, American bio- but active euthanasia is prohibited. However, has-
physicist Gregory Stock recommended genetic tening death at the end of life is still not a widely
modifications to eggs, sperm, and embryos for accepted legal or social practice in the United
eugenic purposes. States; it remains a conceptual swamp of multiple
With the rapid development of genetic tech- perspectives crossing the disciplinary boundaries
nologies and contemporary conversations about of health, public health, law, policy, human rights,
eugenics, the mentally ill may again become tar- psychology, cultural sociology, and ethics. Con-
gets of eugenics measures. cerns center on issues of patient safety, includ-
ing risks of discrimination and abuse, especially
Gretchen M. Reevy among vulnerable populations of older adults or
California State University, East Bay persons with disabilities; availability and access
to pain management and palliative care; opposi-
See Also: Ethical Issues; Genetics; Nazi tion from physicians and the larger health care
Extermination Policies; Sterilization. community; and the diverse social and cultural
understandings of the spiritual meanings of life
Further Readings and hope, even at the end of life. These concerns
Carlson, Elof Axel. The Unfit: A History of a Bad are heightened when issues such as lack of capac-
Idea. Cold Spring Harbor, NY: Cold Spring ity or mental illness enter the picture, with debates
Harbor Laboratory Press, 2001. over the risks of the clinically depressed opting
Engs, Ruth Clifford. The Eugenics Movement: An for assisted dying.
Encyclopedia. Westport, CT: Greenwood Press,
2005. Euthanasia Types and Practices
Gillham, Nicholas W. A Life of Sir Francis Galton: It is in this uncertain environment that it becomes
From African Exploration to the Birth of Eugenics. even more important to identify general types of
New York: Oxford University Press, 2001. hastening death as legal or social practices and to
Stock, Gregory. Redesigning Humans: Our acknowledge widely accepted language describ-
Inevitable Genetic Future. Boston: Houghton ing such practices, such as the term euthanasia.
Mifflin, 2002. There are several types of euthanasia. Voluntary
active euthanasia may be described broadly as the
intentional, active termination of a human life at
the explicit request of a patient through means of
administration of a lethal dose of medication to
Euthanasia the patient by a physician. Involuntary euthanasia
occurs in the absence of an explicit patient request
Hastening death is a subject that continues to or written consent, and nonvoluntary euthanasia
generate debate today among policy makers, occurs when the patient is not capable of mak-
patients, families, caregivers, and health and ing a request or rendering an informed consent.
 Euthanasia 297

Other types of hastening death activity are known Mental Illness and Euthanasia
as physician-assisted suicide, physician aid in The availability and use of hastening death prac-
dying, or assisted dying, and are distinguished tices in any society as a matter of public policy
from euthanasia on the basis that the patient self- and practice necessarily implicate understand-
administers the lethal dose of medication himself ings of mental health and mental illness and their
or herself. In the execution of these procedures, cultural contexts. It is important to understand
there continues to be some blurring of boundaries lived experiences at the end of life in all their cul-
among the forms of hastening death practices that tural social complexities and in relationship to
vary more specifically by state. the nature and temporality of embodied human
Hastening death practices are sometimes con- illness, including serious mental illness, illness
fused with other types of end-of-life decision pro- trajectories, and their meanings for the patient.
cesses such as forgoing life-sustaining treatment Health and mental health are integrally related
and therefore choosing not to receive treatments generally as well as for the purpose of making
that artificially support and prolong life. How- decisions in serious illness and at the end of life,
ever, there is a fairly broad and well-established especially in light of the understanding that the
legal and ethical consensus that hastening death human person is an experiencing, lived body. A
is legally and ethically distinct from forgoing life- patient’s request to end her/his life because of ill-
sustaining treatment and dying a natural death. ness and the burden of suffering obligates health
Variation exists in the prevalence of hastening professionals to investigate the patient’s capacity
death practices, both in and outside the United and freedom from depression, mental disorder, or
States, as well as significant demographic varia- other types of decision-making interference such
tion. For example, data reported for the period as coercion.
from 1990 to 2010 show variations in utiliza- Increasingly, a transformation in mental health
tion rates of euthanasia in the Netherlands, with services is moving away from Cartesian mind-
a 2.8 percent rate in 2010 compared to 1.7 per- body dualisms and biomedical models of care
cent in 2005. The state of Oregon reported that based solely on objective measurement of symp-
for 2012, 115 people received prescriptions for toms, disease diagnosis, and polypharmacy. The
lethal medications under Oregon’s 1997 Death recovery movement in mental health is instead
With Dignity Act (DWDA) compared to 114 in focused on person-centered care and integrating
2011, 97 in 2010, and 95 in 2009. The rate of nonpharmacologic approaches to care manage-
DWDA deaths in Oregon is approximately 23.5 ment into planning goals of care for individuals
per 10,000 deaths as reported by the Oregon Pub- suffering with mental illness, including palliative
lic Health Division. approaches to symptom management. Person-
Oregon’s epidemiologic data, while limited for centered approaches to care are also attuned to
the purposes of an in-depth analysis of the phe- patients’ diverse social ecologies and cultural
nomenon of seeking and hastening death at the meanings. Understanding the patient’s life-world
end of life in the context of illness burden, pres- situation and intentionalities; cultural attitudes
ent strong evidence of utilization of DWDA legal toward illness, suffering burden, and death; and
procedures by adults who are predominantly communication and decision-making styles are
white and better educated, suggesting a certain essential to multidimensional assessment and
demographic pattern that may have implications treatment and providing critically necessary ser-
for equitable access to care. The data also suggest vices to the patient.
that the presence and anticipation of pain and The request to end one’s life by turning to the
suffering, previously thought not to be among the hastening of death is a radical decision that calls
most salient factors influencing patients’ decisions into question one’s health, mental health, and
to hasten death, are emerging as issues of signifi- well-being, and creates conflicts that need to be
cance in understanding these decisions. The most sorted out based on accepted ethical guidelines.
recent 2012 data from Oregon show an increase From a rights perspective, the decision to end
in inadequate control of pain (29.9 percent in one’s life on account of illness puts the right to
2012 versus 22.6 percent in prior years). health and the concomitant right to care in direct
298 Euthanasia

conflict with other rights of significance, such as and therefore lacks the requisite capacity to be
the right to exercise personal autonomy and the self-determining, the patient would usually be
right to self-determination—rights that are not referred for appropriate screening and treatment.
absolute. In a rights-based scheme of evaluating Beyond a rights schema, however, hastening
one’s decision options, the right to be autono- death policy and practice raise other ethical issues
mous is widely viewed as taking priority over for policy makers as well as for practitioners who
other rights. As opposed to a purely rights-based provide care to seriously ill patients who are suf-
focus, an ethics of care would give primacy to the fering. These issues center on deeply humanis-
care needs of the patient in ethical encounter with tic cultural and sociological concerns about the
others while also respecting patient rights. patient themselves, the patient’s own meanings
of living through serious illness and dying, and
Human Rights and Beyond accessing the patient’s meanings in the context
The health and mental health of human persons of her/his full personhood and human develop-
are inextricably tied to human rights as well; ment over the life course. These meanings have
that is, the rights persons have because they are implications for the social and relational nature
embodied human beings and not rights that arise of the patient’s lived experiences at the end of life,
as a matter of law. It is widely accepted and under- including desires for empathic care from formal
stood that human rights are universal and inviola- and informal caregivers and the significance of
ble and not legislated by or subject to laws or reg- such experiences as a person-in-environment situ-
ulations made by governments. However, some ated in a cultural, social life-world.
would argue that human rights are culture bound On a more global scale, more attention needs
and must be interpreted within cultural contexts. to be paid to social structural determinants of
There are many governments and societies that health, mental health, and well-being such as
do not recognize human rights or international income, education and housing, and forms of
human rights covenants and principles. Mental structural discrimination that perpetuate inequi-
health, the right to mental health care, and the ties in access to health care, hospice, and pallia-
right to palliative care in serious illness and at the tive care that may influence patient experiences
end of life are constituents of the right to health and outcomes at the end of life.
and the concomitant goals of attaining the high-
est levels of health and well-being. Thus, human Conclusion
rights have normative content for the conduct of Striving to eliminate inequities in the attainment
societies even though such rights may need to be of health care justice for all persons is an impor-
understood with reference and sensitivity to cul- tant public policy goal relevant to serious public
tural contexts. discourse and public deliberation about hasten-
For example, freedom from torture and other ing death practices. In light of this goal as well
forms of coercion are universal human rights that as the dearth of empirical evidence about the
are not culture bound. Therefore, decisions to personal, social, and cultural meanings of deci-
end one’s life on the grounds of terminal or life- sions to hasten one’s death, the question of what
threatening illness ought never be permitted on hastening death means for human development,
grounds of coercion or involuntariness but only human agency, and human freedom at the end of
as voluntary decisions. Before permitting a per- life remains one that calls for deep reflection and
son to receive a prescription for a medication to well-designed research studies.
end their life, most states require that a patient be
examined by a physician, usually with a concur- Mary Beth Morrissey
rence by an independent physician to determine Fordham Graduate School of Social Service
that the patient has capacity to make decisions
and render an informed consent to a life-termi- See Also: Ethical Issues; Human Rights; Merleau-
nating procedure. If there is evidence that the Ponty, Maurice; Nazi Extermination Policies; Patient
patient may be suffering from clinical depression Accounts of Illness; Patient Rights; Right to Refuse
or some other psychological or mental disorder Treatment.
 Exclusion 299

Further Readings group engagement by the individual. The ubiq-

Foley, Kathleen and Herbert Hendin. “The Oregon uity of exclusion makes the experience pervasive
Report: Don’t Ask, Don’t Tell.” Hastings Center across human cultures and even among certain
Report, v.29/3 (1999). animal species. There is variance, however, in the
Ganzini, L., E. R. Goy, and S. K. Dobscha. Archives type of social behavior that triggers a sentiment of
of Internal Medicine, v.169/5 (2009). exclusion (source) as well as the quality and ratio
Hendin, Herbert and Kathleen Foley. “Physician- of responses deployed by the object of exclusion
Assisted Suicide in Oregon: A Medical (target).
Perspective.” Michigan Law Review, v.106 (2008). While the multiplicity of behaviors and level
Julian, J. Z., B. A. Prokopetz, and L. S. Lehmann. of responses by sources and targets in the exclu-
“Redefining Physicians’ Role in Assisted Dying.” sion experience is beyond measure, making the
New England Journal of Medicine, v.367 (2012). identification of singular causes for exclusion-
Lindsay, R. A. “Oregon’s Experience: Evaluating the ary reactions improbable, a common feature of
Record.” American Journal of Bioethics, v.9/3 exclusion is readily observable: it engenders a
(2009). latent effect in the physical, mental, and social
Loggers, E. T., H. Starks, M. Shannon-Dudley, well-being of the person. In the sociological and
A. L. Back, F. R. Appelbaum, and M. Stewart. psychological literature, other concepts have been
“Implementing a Death With Dignity Program at a used interchangeably to refer to the experience of
Comprehensive Center.” New England Journal of exclusion, including ostracism, rejection, margin-
Medicine, v.368/15 (April 11, 2013). alization, and alienation. Though referring to the
Oregon Public Health Division. “Oregon’s Death same experience, there are nonetheless conceptual
With Dignity Act: Thirteen Years.” CD Summary, nuances to be considered, since ostracism implies
v.60/6 (March 15, 2011). exclusion voided of a particular explanation or
Oregon Public Health Division. “Oregon’s Death rationale, whereas rejection implies an overt and
With Dignity Act—2012.” http://public.health expressive form of exclusion. Emotional responses
.oregon.gov/ProviderPartnerResources/Evaluation to exclusion depend mainly on whether a clear
Research/DeathWithDignityAct/Documents/year reason or case can be determined by the target.
15.pdf (Accessed August 2012). In turn, marginalization and alienation are
Pearlman, R. A., C. Hsu, and H. Starks, et al. experiences impinging on a greater number of indi-
“Motivations for Physician-Assisted Suicide.” viduals who share common traits (such as ethnic-
Journal of General Internal Medicine, v.20/3 (2005). ity, race, socioeconomic status, and even clinical
Steinbrook, Robert. “Physician-Assisted Death— conditions) and who encounter limited admission
From Oregon to Washington State.” New England to larger groups where power, access, and influ-
Journal of Medicine, v.359 (2008). ence are concentrated. As collective equivalencies
to individualized experiences of ostracism and
rejection, marginalization results from cultural
forces that are in motion within a sociopolitical
system that excludes without inherent judgment,
Exclusion while alienation—as the word itself conveys—
displays noticeably the reason of exclusion in the
Social recognition, in order to foster a sense of allusion to the target’s “otherness.” In the same
belonging and manifested in the process of incor- manner that ostracism and rejection affect the
porating individuals to circumscribed groups mental stability of the individual, marginalization
such as family kinships, communities, institu- and alienation threaten the psychological state of
tions, organizations, political bodies, and national groups, leading to prevalent mental health prob-
states, constitutes a basic need of the person in lems within particular sociocultural groups.
every place and culture. Exclusion is experienced
when such a need is not satisfied properly either Experiencing Exclusion
by the group to which one attempts to belong or As with any external stimuli affecting the per-
by the conscious or unconscious detachment from son’s sense of well-being, the individual who is
300 Exclusion

experiencing exclusion will go through stages of homicidal tendencies. In lieu of the pervasive-
recognition, interpretation, and response. Psycho- ness of exclusionary experiences, this is why it is
logical studies on the experience of exclusion have important to identify and develop strategies that
shown that regardless of the motives for exclu- can reduce the initial state of distress that usually
sion and the consistency or frequency of the expe- follows the recognition of exclusion.
rience, all individuals respond in a prereflective
mode to the initial recognition of group rejection. Cultural Considerations
This phase of recognition is characterized by a Whereas culture may not be considered a deter-
reflexive discomfort before the situation of exclu- minant variable in evaluating the impact of exclu-
sion. Studies of neural responses, where a group sion at the reflexive stage of recognition, it plays
of subjects were submitted to exclusion manipu- an important part in the reflective stage where
lation experiments, have demonstrated immedi- the interpretive models of exclusion (the why of
ate activation of the brain at the anterior cingu- the exclusion) and the adequacy of behavioral
late cortex, the same region that manifests neural responses (the “what” to do as a result of the ini-
activity when the individual experiences physical tial affective impact) are considered. Both cogni-
pain or agony. Individuals who are excluded from tive interpretive models and behaviors are cultur-
social groupings and interactions have an initial ally biased and will inform the adaptive strategies
reaction that elicits feelings of hurt and distress. deployed in the context of exclusion. Generally,
In order to cope with these feelings, the indi- each singular culture will have its own nonreductive
vidual attempts to interpret the motivations understanding of acceptable norms of social inclu-
for exclusion, forming the basis for develop- sion. A comparative study of cultural responses to
ing responses to reduce the negative emotional exclusion and the ensuing impact on mental well-
impact of the situation or to gain inclusion into being is almost impossible to achieve if one were to
the group or relationship. These responses usu- consider the complex relations of gender, genera-
ally translate into prosocial or antisocial behav- tional sectioning, ethnicity, race, nationality, and
ior, depending on the interpretive judgment of other signifiers of difference in the construction of
the target. If the target interprets the causes of cultural identity. Nonetheless, there are some gen-
exclusion and understands that he or she is able eral categories of cultural differentiation that can
to control the situation and adapt accordingly, provide an analysis of variance and correlation in
the individual can attempt to gain group accep- the adaptive responses to exclusion.
tance by either increasing socialization with mem- One of these categories is provided by social
bers of the group, becoming more mimetic of the anthropologists and refers to the “power dis-
groups norms and behaviors, substituting that tance” that characterizes each particular culture.
group for a more congenial one, or engaging in In cultures that foster “low power-distance” rela-
socially productive activities among other proso- tions, members of organizations and institutions
cial responses. Adaptive responses do not erase accept the social distribution of power, presuming
the primal sense of hurt, but they can help indi- that access is readily available to those who want
viduals ameliorate the adverse effects of exclusion inclusion into groups that exercise some of this
in their mental and physical well-being. power. Race, social class, and ethnic background
Conversely, if the target cannot identify a clear may play a vital role in increasing the possibil-
cause for exclusion, or if he or she interprets the ity of exclusion in low power-distance cultures
exclusion as a the result of one’s negative projec- but, in principle, inclusion is assumed under the
tion toward the group, the target will invest psy- presumption that such a culture is informed by
chological energies in a thought process that can a consultative and democratic outlook. Because
lead to negative responses, from anger and bad low-power cultures promote social inclusion,
temper at the low range of antisocial behavior to overt or acute experiences of exclusion seem to be
depression, social anxiety, hostility, and aggres- unpredicted and infrequent.
sion at the higher range. In more critical cases, In contrast, “high power-distance” cultures
maladaptive responses to exclusion can result in assume the normalcy of hierarchical social rela-
self-destructive behaviors, including suicide or tions and, consequently, the restrictions of
 Exclusion 301

mobility across social lines and the subsequent the experience of exclusion as a defense mecha-
inexorability of exclusion. In high power-distance nism and, in the long term, can constitute a form
cultures, the exclusion is experienced as a recur- of cultural psychopathology. On the other hand,
rent experience or permanent condition by mem- the frequency and permanence of the exclusion-
bers at the bottom of the social hierarchy. The ary experience can help members of high power-
cultural dimension of power distance is impor- distance cultures develop and activate a variety of
tant in understanding the psychological effect of strategies to cope with exclusion in daily life.
exclusion in individuals and collectivities, as one In contrast, the individual who belongs to a
of the needs thwarted by exclusion is the inherent low power-distance culture will assume his or her
urge to control one’s environment and relation- capacity to control and the initial distress caused
ships. Diminished access to social power reduces by exclusion can move from negative emotional
the capacity to satisfy this urge for control and reaction to adaptive intentions. However, since
externalizes that control in the hands of those exclusion is seen as an atypical expectation within
who are the source of exclusion. low power-distance cultures, coping mechanisms
The effect of social exclusion in high power- can be underdeveloped and will take consider-
distance cultures may combine both maladaptive able psychological investment from the target to
and adaptive behaviors. At one side, it can evolve understand and address the implications of the
into undesirable levels of self-esteem and the oblit- exclusion. When unresolved (the need for belong-
eration of meaningful existence. Unconditional ing and control is not fully restituted), anxiety
acceptance of the person’s lack of control over ensues and antisocial behavior is potentially
power dynamics within social interactions can enhanced. In high power cultures, intragroup
lead the emotional system to shut down before prosocial behavior is favored as a response to

A mentally ill man rests on the street in Varanasi Benares, India, in 2005. In high power-distance cultures such as India, with its caste
system, there are restrictions of mobility across social lines, which subsequently lead to exclusion. As the inherent urge to control
one’s environment and relationships is thwarted by exclusion, there are psychological effects when it is experienced. The effect of
social exclusion in high power-distance cultures may include both maladaptive and adaptive behaviors.
302 Exclusion

extragroup exclusion because antisocial behavior American counterparts will. For Asian American
is highly restricted by external controls (punitive adolescents, aggression appears to be a responsive
law and enforcement). behavior tightly related to victimization because
Another dimension of culture implicated in it challenges the person’s assumed belonging
a comparative analysis of exclusion is the well- to a community where withdrawal is not an
known distinction between collective and indi- option (collectivist view). This type of peer rejec-
vidualistic approaches to social relations. Since tion, interpreted as victimization, may adversely
exclusion is predicated by the degree to which affect the emotional well-being of Asian Ameri-
individuals are integrated into social groups, it can students because aggression deviates sig-
is expected that the exclusionary experience will nificantly from cultural values and expectations
have a different effect on individuals who value instilled within their family systems and ethnic
personal initiative in group participation and those communities.
who value the cohesive agency of a community or Conversely, Asian American adolescents con-
group in determining the rules for social integra- sider shyness to have a loose association with
tion. In cross-cultural studies there is a tendency peer rejection, while European American adoles-
to define this distinction within the spectrum of cents interpret shyness as a sign and motive for
Western and non-Western cultures. Whereas West- social exclusion because one of the main purposes
ern cultures are seen as individualistic in nature, of group participation is the promotion of self-
non-Western cultures are seen as collectivist. enhancement (individualist view).
The principal motive for studying exclusion in Even with these visible differences in place,
individualist and collectivist cultures is to ascer- given the various levels of assimilation achieved
tain how members of each culture seek to fulfill by Asian American adolescents within an indi-
their need for belonging. Although the need for vidualistic culture and the degree to which they
group belonging is universal, belonging is enacted have experienced prejudice and marginalization
differently by individualist and collective cultures. in the context of American ethnic relations, these
Theories show this by contrasting Western and studies cannot render a conclusive and longitu-
Eastern views on group participation. Cultural self- dinal hypothesis on the effect of collectivism and
theory finds Eastern emphasis in interdependence individualism in interpreting and coping with
to be manifested in relational arrangements for exclusion. Yet, they convey the importance of
the sake of achieving harmony. Western emphasis considering cultural variants in relating exclusion
in independence is manifested in group participa- to behavioral responses in particular and to psy-
tion for the sake of self-enhancement and personal chological effects on mental health in general.
autonomy. In turn, basic trust theory implies that
Eastern cultures promote deliberate caution in Studying the Effects of Exclusion
seeking integration into established social groups Across Cultures
because the goal of inclusion is to establish depth A limitation in studying the effects of exclusion
and duration in social relations. In contrast, West- comparatively across cultures is the recognition
erners integrate themselves to groups with a basic that studies focusing on one singular culture are
level of trust, which allows ample exploration of in fact inconclusive, displaying a variety of con-
belonging to various groups at different times. testing theories about the causes and effects of
For this reason, it is expected that the effect of exclusion as well as partial explanations based
exclusion on the mental well-being and adaptive on the limited scope of research questions applied
behavior of individuals will vary, depending on to control groups exposed to exclusion manipu-
the affiliation of individuals to cultures within the lation. In addition, each culture is comprised of
individualist-collectivist spectrum. subgroups that may alter a generalized conceptu-
In a study of Asian American and European alization of psychological effects and behavioral
American adolescents, for example, it was found responses associated with exclusion within that
that Asian American adolescents will consider culture. In each cultural group there are indi-
peer rejection to be a form of victimization rather viduals who show some propensity toward social
than a form of exclusion, as their European anxiety or phobias and, when confronted with
 Exclusion 303

exclusion, will probably deviate from cultural Further Readings

norms by exuding uncharacteristic hypervigi- Bukowski, W. M. and B. Laursen, eds. Handbook of
lance to cues of rejection and/or opting for rela- Peer Interactions, Relationships, and Groups. New
tional evasion. York: Guilford Press, 2009.
Furthermore, each culture will host individu- Menzer, M. M., W. Oh, K. L. McDonald, K. H.
als with clinical issues where difficulties in social Rubin, and E. Dashiell-Aje. “Behavioral
interactions are a core feature, such as schizo- Correlates of Peer Exclusion and Victimization
phrenia, clinical depression, and post-traumatic of East Asian American and European American
stress disorders. These individuals are especially Young Adolescents.” Asian American Journal of
affected by ostracism and may manifest abnormal Psychology, v.1/4 (December 2010).
neural responses to exclusion, leading to unpre- Sebastian, C. L., G. C. Tan, J. P. Roiser, E. Viding,
dictable social behavior. Yet, despite all levels of and I. Dumontheil, et al. “Developmental
variegation in the analysis of the relationship of Influences on the Neural Bases of Responses
exclusion to mental health, cultural difference to Social Rejection: Implications of Social
remains a pivotal variable in enhancing theoreti- Neuroscience for Education.” Neuroimage, v.57/3
cal conceptualizations of this relation. (August 2011).
van de Vijver, F. J. R., D. A. van Hemert, and Y. H.
José R. Irizarry Poortinga, eds. Multilevel Analysis of Individuals
Cambridge College and Cultures. New York: Taylor & Francis/LEA-
Psychology Press, 2008.
See Also: Cultural Prevalence; Depression; Williams, K. D., J. P. Forgas, and W. von Hippel, eds.
Family Support; Post-Traumatic Stress Disorder; The Social Outcast: Ostracism, Social Exclusion,
Schizophrenia; Social Causation; Social Class; Social Rejection, and Bullying. New York: Psychology
Control; Social Isolation; Social Support. Press, 2005.
 F
Family Support is unparalleled by other forms of treatment, care,
and support for mental health disorders. A fam-
Patients’ relatives and loved ones often bear the ily’s likelihood of experiencing cases of mental
burden of mental illness, not from a first-person illness in one or more of its members occurs far
clinical viewpoint of the disorder itself, but rather beyond the expectation of chance, with at least
from the perspective of social, economic, and one member in any given family experiencing a
public-policy consequences of providing ongo- psychiatric abnormality.
ing support and care to family members who live Most patients who receive formal treatment
with a variety of disorders. In their attempt to will see an improvement in their prognosis, but a
assist with stabilizing, managing, and advocating significant number will still require consistent sup-
for the mental health of their loved ones, fami- port from family members and loved ones around
lies often face obstacles and challenges to the goal them. The ones who do not receive formal treat-
of keeping their situations manageable. When ment and support via the health care industry will
implemented effectively, however, family support become dependent upon informal means of sup-
models can be quite beneficial and advantageous port from their social networks, which most fre-
for patients seeking improvement and recovery. quently include the family unit. Families are faced
Beyond mental health professionals and medi- with an array of social, economic, and emotional
cal personnel, patients receive most of their men- challenges, which are collectively known as the
tal health care and support informally from the family burden of mental illness.
people closest to them in social networks. Much
of this emerges from family members with whom Historical Perspectives on Family Support
they live. This informal care is fraught with chal- Family support as it is known today springs
lenges posed by imperfect health care systems, directly from the roots of the deinstitutionaliza-
shortages of resources, and a general lack of avail- tion movement. In the early 20th century and
ability for wrap-around community care. into its early decades, treatment models for men-
Despite those daunting implications, family tal illness suggested a movement toward patient-
support models are increasingly helpful to patients centered management and a focus on the incor-
inasmuch as they afford supportive opportunities poration of social and community resources for
for social inclusion, adaptive independence, treat- optimum patient experiences. During the last
ment adherence, and overall life satisfaction that several decades, the number of American patients

305
306 Family Support

housed in government-sponsored psychiatric associated with family support become intensi-

facilities substantially diminished from 559,000 fied. An estimated 21 to 23 percent of children
to 57,000 by the mid-1990s. Because of resource live in households with at least one parent suffer-
constraints and deficiencies in levels of state sup- ing from a diagnosed mental illness. Related to
port, communities have not been able to respond this trend, children report having a parent who is
to the high demand for mental health services in hospitalized for mental health concerns or experi-
outpatient community-driven settings. encing acute phases of mental illness as being sub-
These historical trends of the deinstitutional- stantially stressful to developmental outcomes.
ization and community-based treatment move- When parents struggle to cope with mental ill-
ments have contributed a great deal to the cur- ness, children frequently develop maladaptive
rent need for increased family support in mental behaviors such as withdrawing, avoiding, and
health. Without adequate resources to support the distancing, leading to greater risks of emotional
integration of people with mental disorders into disturbance and attachment issues. Parents with
the global community while adequately address- mental illnesses are substantially less likely than
ing their mental health care needs, patients face their healthy peers to provide emotionally avail-
potentially detrimental outcomes. Family support able and stable parenting responses to childhood
can and often does allow for patient-centered behaviors and social needs. Parents with mental
support while ensuring connectedness and mem- illness have been reported to be more successful in
bership within the community at-large. With sup- retaining custody of their children when familial
portive family units, up to 70 percent of patients support was offered within their illness-manage-
with mental illnesses are found to avoid multiple ment and recovery processes.
hospitalizations, maintain adherence to medica- Economic support is critical in assisting people
tion regimens, and experience fewer episodes of with mental illness to maintain independence.
social trauma and personal crisis related to their Increasingly, people with mental illness frequently
diagnosis of record. are in need of familial assistance and support for
meeting their needs. Approximately 13 percent of
Problems Associated With Family Support people with mental illnesses rely solely on finan-
Social support is a primary variable for success. cial support from their families. Up to 70 per-
Most often, adult members of a family are those cent of patients who earn their own living have
who find themselves in caretaking and support an annual income of $20,000 or less; of that 70
roles to meet the needs of individuals with men- percent, one in five lives on less than $5,000 per
tal illness wherein challenges arise with regard year. This limitation in income causes significant
to family dynamics, socialization opportunities, numbers of patients to experience difficulties with
and stress coping. Family environments become finding suitable and affordable housing, access to
important contexts for understanding mental continuous supplies of medication, and availabil-
health issues, in that family characteristics either ity of quality services for counseling. The unem-
manifest or protect against vulnerabilities in psy- ployment rate for adults living with mental illness
chosocial functioning. There is a strong positive is three to five times higher than for those without
correlation between healthy family relationship mental illness. Those who do hold jobs are under-
dynamics and the recovery rate from mental ill- employed, often earning less than $10 per hour.
ness. Similar effects are observed between gen- The cost of medical and psychological care
eral family resiliency from social and ecological and treatment also impacts family support. The
risks and the mental health status of its members. current estimate of out-of-pocket expenditures
Because the likelihood of family discord and for mental health care is 26 percent, suggest-
expressed negative emotion are higher in families ing that despite the dismal prospect for mental
who cope with mental illness, however, this ben- health patients’ financial independence, there is
efit is more difficult to come by within the family a substantial expectation for the care to be paid
dynamic process. for individually. Family economic situations are
When parents and caretakers suffer from implicated within this venue. Families who live
mental illness as well, however, the problems at or below the 30th percentile of annual income
 Family Support 307

some degree on the assistance programs and sup-

port opportunities provided by advocacy organi-
zations and other privatized sources.

Benefit to Patients
Despite the problems associated with family sup-
port, having a strong and viable social family net-
work is a key element of the recovery from and
management of mental illnesses. Over 65 percent
of patients who are released from mental health
hospitals and facilities are discharged into the
care of family members. Because this occurs at
such a high rate, support from those caring fami-
lies becomes ultimately important. Social support
is known to vitally impact patients with mental
illness by alleviating stress, strengthening compli-
ance with medical recommendations, increasing
confidence and self-esteem, and diminishing feel-
ings of isolation and stigmatization. Research pro-
Mental patients receive most of their mental health care and vides evidence that particular types of treatment
support informally from the people closest to them in social for mental health concerns are not as important as
networks, most often from family members with whom they live. a family’s participation in their loved one’s treat-
ment process, when examining rates of outcome
success. Patients who live with and receive social
support from their families are three to four times
report substantially less success and stability with more likely than their peers who are unsupported
their loved ones’ mental health treatment pro- by their families to experience freedom from
grams. Cost of treatment and management can relapse following a major mental illness episode.
have a crippling effect on families who are sup-
porting loved ones with mental health concerns. Russell Vaden
Given the issues of social and economic impli- University of Wisconsin, La Crosse
cation, a lack of public policy and direction for Steven Arenz
family support is a rising concern among fami- Winona State University
lies who support loved ones with mental illnesses.
Nearly three-quarters of American states do not See Also: Economics; Employment; Help-Seeking
have a policy for the types of services delivered Behavior; Legislation; National Alliance on
to families supporting patients. Typically, sup- Mental Illness; Patient Activism; Social Support;
portive services and advocacy for families arise Work–Family Balance.
from national organizations such as the National
Alliance for the Mentally Ill rather than from Further Readings
public entities and governmental sources. How- Karp, D. A. The Burden of Sympathy: How Families
ever, managed-care agencies have dominated the Cope With Mental Illness. New York: Oxford
health care industry via their focus on policies University Press, 2001.
that guide recovery protocols, leaving little choice Marsh, D. T. Serious Mental Illness and the Family:
for patients and their families when treatment The Practitioner’s Guide. Hoboken, NJ: John
and management are necessary from a medical Wiley & Sons, 1998.
vantage point. This has caused advocacy groups Morey, B. and K. Mueser. The Family Intervention
to heighten their concern for family support net- Guide to Mental Illness: Recognizing Symptoms
works in patient recovery and maintenance. Like and Getting Treatment. Oakland, CA: New
the patients themselves, caring families depend to Harbinger, 2007.
308 Fiction

Fiction For Euripides (ca. 480–406 b.c.e.), divinely

imposed madness is often the scourge of mortals
Mental illness—or madness—has been prominent who violate logos in the sense of proportion or bal-
in Western literature since the classical Greek era, ance. In Euripides’s The Bacchae, Pentheus angers
when madness usually arose from divine action, the god Dionysius by banning his rites, which
a pattern that originates in Greek myth. In medi- involve drunken revelry and ecstatic behavior. Pen-
eval and Renaissance literature, madness was theus’s mother, Agave, also dishonors Dionysius by
informed by Claudius Galen’s theory of humors denying his divinity. Dionysius punishes them both
in the 2nd century. As modern literature evolved, through madness. Pentheus dresses as a woman to
it favored psychological and then biomedical observe the rites; his mother, while participating,
interpretations. Today, portrayals of mental ill- kills Pentheus, believing him to be a beast.
ness still appear frequently in literature and film Euripides’s Medea, betrayed by her husband
but are primarily literal in nature rather than as Jason when he plans to marry another woman,
allegory for social disruption. murders her own children as well as the other
woman in vengeance. The play has been variously
Madness in Classical Antiquity read as misogynistic or protofeminist.
The Greeks understood madness in contrast to The “madness” of classical Greek comedy
logos, a concept central to their intellectual cul- is manifest in immoderation or social deviance.
ture, roughly corresponding to rationality and Aristophanes’s (ca. 448–380 b.c.e.) The Wasps
intimately connected to language, measurement, depicts a man locked up by his son for becom-
proportion, and moderation. ing obsessed with serving as a juror in the Athe-
Madness plays little role in the Homeric epics. nian law court, a popular activity in that litigious
The theme of madness flourished in Greek trag- society. Unlike in tragedy, Aristophanes’s “mad”
edy, beginning with Aeschylus (ca. 525–456 characters are usually triumphant.
b.c.e.), whose Orestes, having murdered his In Plato’s dialogue Pheadra, Socrates celebrates
mother, is haunted by supernatural Furies that some types of madness as a gift from the gods
only he can see. Sophocles (ca. 496–406 b.c.e.) that facilitates poetry and love. Elsewhere, in The
provides the first literary portrayal of a character Republic and Timaeus, Plato has Socrates argue
who recognizes madness impinging on his will: that deliberate evil is impossible and that all evil
Ajax, enraged by losing a dispute over inherit- conduct can be traced to either mania (madness)
ing the arms of Achilles, slaughters animals he or amathia (stupidity).
believes are Greeks. His hallucinations are caused Madness is explained in terms of the theory
by Athena, goddess of wisdom, whom he has of humors proposed by Hippocrates; however,
insulted and whose help he has rejected, signaling Socrates attributes the humoral imbalances to
his break with reason (or logos). excessive pleasures and pains. In contrast, the
Sophocles’ Oedipus is driven mad to the point Roman Stoics, especially Cicero, moralized mad-
of tearing out his own eyes when he becomes ness, placing the blame on the individual who
convinced that he has unwittingly killed his failed to regulate their passions.
father and married his mother. The critic Freder-
ick Ahl proposes that Oedipus deceives himself Madness in Medieval and
in believing he has fulfilled the prophecy—that Renaissance Literature
Oedipus concludes without real evidence that he The understanding of madness in medieval and
has killed his father and married his mother. This Renaissance literature was informed by Galen’s
would make Oedipus’s belief itself an aspect of (ca. 120–200 c.e.) theory of humors, which elabo-
his madness. Oedipus became the namesake of rated on Hippocrates’s teachings and dominated
the Oedipus complex, a psychological condi- Western medical thought from approximately 200
tion proposed by Sigmund Freud wherein young c.e. to 1700 c.e. However, Galenic theory was
boys pass through a phase of desiring to kill their subordinate to Christian doctrine, which held that
fathers and have a sexual relationship with their madness could be the product of demonic posses-
mothers. sion or moral failing rather than of bodily causes.
 Fiction 309

Moreover, in the Christian view, God might Wertham’s competing psychoanalytic reading,
directly cause madness through humoral imbal- Hamlet is more enraged by his mother’s infidel-
ance as a punishment for wickedness or as a test ity than by his father’s murder; therefore, Hamlet
of faith. In poetry based on his own experience of is dominated by matricidal impulses. However,
mental illness, Thomas Hoccleve (ca. 1370–1450) experts have come to view much of Hamlet’s
exemplifies this hybrid view of madness as both indecision and fluctuations of mood as normal
a scourge of God and bodily ailment; this is the responses to his situation.
earliest extant account of such an experience by a Lear is Shakespeare’s other great mad charac-
European. ter; the playwright subtly portrays Lear’s symp-
However, medieval Christian thought also toms of early dementia and his gradual decline
included a rationalist strain that allowed for no into psychosis. Critics have pointed to a minor
impingement of the will by external forces— detail from the play as revealing the author’s pre-
either natural or supernatural—leaving mad- science: a physician’s prescription for Lear is rest,
ness to be explained only by sin. This strain is aided by soporific drugs—a far more humane
represented most prominently in philosophy by treatment than those prevailing at the time, which
Thomas Aquinas and in poetry by Dante, whose included scourging and bleeding.
Divine Comedy relegates madness to the inferno. Miguel de Cervantes’s novel Don Quixote—
Allegory was prevalent in Renaissance litera- the most influential literary work on the theme of
ture, and Catholic writers often used madness as madness—depicts a gentleman landowner who,
an allegory for the threats they saw confronting from reading too many chivalric novels, develops
European society, especially the social and politi- the delusion that he is the greatest knight errant
cal forces of the Reformation and the menace of in history, a belief that draws him into numerous
Turkish invasion. Torquato Tasso’s (1542–95) misadventures. The people Quixote encounters
epic poem Jerusalem Delivered was an influen- variously mock him, exploit his madness, or try
tial vehicle for Counter-Reformation zealotry, to help or cure him. Quixote recovers his sanity
but Tasso also wrote from his own experience following a ruse in which he agrees to lay down
of mental illness, for which he was confined for his arms for a year.
seven years. Madness played a prominent role in culture
William Shakespeare’s plays provide the most and everyday life in Cervantes’s Spain. Most of
psychologically nuanced representations of mad- the locos (mad) were not confined, but those who
ness up to his time; thus his plays lend themselves were remained in public consciousness: a select
to interpretation through the lens of modern clini- number paraded daily through the city streets to
cal concepts more readily than does earlier litera- collect contributions for their care. The mad were
ture. Lady Macbeth’s hallucination of blood that objects of mockery but also sympathy, seen as
could not be washed off her hand may be read blameless for their ill behavior. Locura (madness)
as a depiction of post-traumatic stress disorder had religious significance, being considered espe-
(PTSD); Ophelia’s suicide may be viewed in a cially worthy of charity. During the Holy Week
similar light. festivities, 12 men were selected from the asylum
Hamlet’s madness has been extensively dis- population to play the role of the 12 apostles;
cussed by critics as well as psychiatrists and psy- their feet were washed by the hospital adminis-
choanalysts. Debates focus on whether Hamlet’s trators. Madness was also a defense—often suc-
madness is real, feigned, or some combination of cessful—in secular courts and in the Inquisition.
the two; the cause of Hamlet’s madness, if it is But the label of locura could also limit one’s rights
real; and why Hamlet delays taking vengeance and result in stigma.
on his father’s killer, Claudius. The Freud-Jones
interpretation holds that Hamlet’s indecision Modern Portrayals of Mental Illness
arises from the Oedipus complex: he delays tak- In modernity, literature has deemphasized the sym-
ing vengeance on Claudius because he, Hamlet, bolic and religious interpretations of mental illness
had subconsciously wished to kill his father and in favor of psychological—and later, to a lesser
therefore identifies with Claudius. In Frederic extent, biomedical—interpretations. Sir Walter
310 Fiction

Scott’s The Bride of Lammermoor (1819), one does not deal with the exploitation of Bromden’s
of the earliest historical novels, portrays a young tribe, nor is “the Combine” mentioned. Thus,
woman maneuvered into an unwanted marriage; the film is more narrowly focused on the literal
she stabs her husband and then descends into portrayal of the psychiatric hospital; the broader
madness. Nikolai Gogol’s short story Diary of a social critique is sharply compromised, though
Madman (1835) depicts a bureaucrat who goes the critique of emasculation is retained. Cuck-
mad with love; he imagines two dogs are engaged oo’s Nest (primarily the film) likely had a greater
in a love affair and that he has discovered letters impact on public perceptions of psychiatric hospi-
exchanged by them. F. Scott Fitzgerald’s novel talization than any other cultural work in history,
Tender is the Night (1932), portrays a psychoana- doing much to establish the view of psychiatric
lyst who marries one of his clients whose mental hospitals as abusive and authoritarian, a view
illness is brought on by her father’s sexual abuse. that contributed to the deinstitutionalization of
Ken Kesey’s One Flew Over the Cuckoo’s Nest the mentally ill in the United States in the 1960s
(1962) portrays several men residing in a psychi- and 1970s.
atric hospital in the 1950s—the peak of the insti-
tutionalization of the mentally ill in the United The Contemporary Context
States. The plot focuses on the struggle between Mental illness continues to be portrayed frequently
McMurphy, a criminal feigning mental illness to in novels, films, television, and other media. Mad-
avoid a prison sentence, and Mildred Ratched, ness as metaphor or allegory for social disruption
the hospital’s head nurse who uses psychologi- lacks the currency it had in earlier periods, espe-
cal humiliation to control her patients. McMur- cially the Renaissance. Portrayals of mental ill-
phy leads the other patients in various rebellious ness are now predominantly literal and focused
actions and eventually injures Nurse Ratched by on the nuances of individual psychology, a tradi-
strangling her. Nurse Ratched finally quashes him tion that began with Shakespeare. The supernatu-
by having him lobotomized. ral explanations of madness that predominated in
The narrator is “Chief” Bromden, a Native classical antiquity and persisted in the medieval
American who relates his tribe’s exploitation by and Renaissance periods are now largely confined
the U.S. government as well as the events in the to the horror genre, where possession by demons
hospital. Bromden believes that society is domi- or spirits is still a prevalent theme.
nated by “the Combine”—elites who use invisible The moralizing attitude of the Roman stoics,
wires to control people. The book may be read while still commonly applied to substance abuse,
as a critique of institutional psychiatry and as an is essentially disconnected from portrayals of
allegory for the pressure toward conformity that mental illness, as characters considered morally
Kesey saw in midcentury American culture. The responsible for their actions are simply not cat-
psychiatric hospital is both an instrument of and egorized as mentally ill. Psychological explana-
a symbol for social control. Thus, Kesey inverts tions of mental illness, observed since classical
the Renaissance device of madness as metaphor antiquity, flourished with Shakespeare and have
for social disruption. been prevalent since.
With the exception of certain clearly medical The greatest difference between the contempo-
disorders, Cuckoo’s Nest portrays mental ill- rary context and earlier eras is the growing focus
ness as having psychological origins, especially on medical explanations of mental illness. Mental
in the emasculation of men, as depicted in Nurse illness is now more likely to be seen as an illness
Ratched’s manipulations, the domination of like any other, treatable with medications. Over
certain patients by their mothers or wives, and the last few decades, fictional portrayals have
McMurphy’s complaints about women who are become increasingly likely to take this attitude,
“ball cutters.” Bromden is emasculated because for example, by showing individuals improving
he is deprived of his traditional culture; moreover, with treatment or decompensating when they stop
his mother emasculated his father. taking their medication. However, purely medi-
The novel was made into a 1975 film directed cal explanations of mental illness are unlikely to
by Milos Forman. The film has no narrator and dominate fictional portrayals simply because
 Food and Drug Administration, U.S. 311

psychological explanations are more intrinsically transfusions, medical devices, and electromag-
amenable to dramatization. netic drugs. The FDA also enforces other laws,
some of which are not directly related to food or
Joseph Daniel Anson drugs, such as sanitation requirements on inter-
Florida State University state travel and control of disease on products for
pets. The commissioner of food and drugs heads
See Also: Asylums; Deinstitutionalization; Internet the FDA and reports to the secretary of HHS.
and Social Media; Mass Media; Mental Institutions, While perhaps the best known and most impor-
History of; Movies and Madness; Psychoanalysis tant aspects of the FDA for mental health con-
and Literary Theory; Religion; Television; Theater; cerns are its regulation of drugs and approval of
Therapeutics, History of. new drugs, these responsibilities are only a small
part of the overall scope of the agency. The FDA
Further Readings regulates more than $1 trillion worth of consumer
Barglow, P. and T. Murphy. “An Early Greek goods, about 25 percent of consumer expendi-
Portrayal of a Mad Mind.” American Journal of tures in the United States, including food sales,
Psychiatry, v.168/9 (2011). drugs, cosmetics, and vitamin supplements. It is
Hershkowitz, Debra. The Madness of Epic: Reading also responsible for an array of goods imported
Insanity From Homer to Statius. Oxford, UK: into the country. In terms of its costs and gener-
Clarendon, 1998. ated revenues, it is a large agency with a budget of
Jones, A. “Literature and Medicine: Narratives of over $4 billion, about half of which is generated
Mental Illness.” The Lancet, v.350/9074 (1997). by user fees, most paid by pharmaceutical firms to
Saunders, Corinne J. and Jane Macnaughton. expedite drug reviews.
Madness and Creativity in Literature and Culture.
Houndmills, UK: Palgrave Macmillan, 2005. History and Activities
Thiher, Allen. Revels in Madness: Insanity in The history of the agency is important to under-
Medicine and Literature. Ann Arbor: University of standing its current roles. Its origins date back
Michigan, 1999. to the appointment of Lewis Caleb Beck around
1848 in the Patent Office, where he was given
a responsibility to carry out chemical analyses
of agricultural products. This was shifted to the
newly created Department of Agriculture in 1862
Food and Drug when chemist Charles L. Wetherill was appointed
to head the Chemical Division. What are now
Administration, U.S. considered among the most essential functions of
the FDA began with the passage of the 1906 Pure
The U.S. Food and Drug Administration (FDA), Food and Drugs Act, which prohibited interstate
an agency of the U.S. Department of Health and commerce in adulterated or misbranded food
Human Services (HHS), is the oldest comprehen- and drugs.
sive consumer protection agency in the country. It The agency responsible for the FDA has been
has been known as the FDA since 1930 but has modified a number of times, such as in 1940,
earlier origins. Because of the importance of drug when the agency was shifted to the newly cre-
therapy in the treatment of mental illness over ated Federal Security Agency. It was moved to the
the past 50 years, this agency is very important newly created Department of Health, Education,
in understanding issues linked to mental illness. and Welfare (HEW) in 1953, becoming part of
Major responsibilities include protecting and pro- the Public Health Service within HEW in 1968.
moting public health through the regulation and It was moved to the Department of Health and
supervision of a variety of types of food and drug Human Services in 1980 when the education
products. This includes tobacco products, dietary function was removed from HEW.
supplements, prescription and over-the-coun- Most federal laws concerning the FDA are part
ter drugs, vaccines, biopharmaceuticals, blood of the Food, Drug, and Cosmetic Act, first passed
312 Food and Drug Administration, U.S.

in 1938 and extensively amended since. This act production and warehousing facilities; investigate
improved the 1906 legislation by mandating that complaints, illnesses, or outbreaks; and review
all new drugs be proved safe before marketing, by documentation in the case of medical devices,
making therapeutic devices and cosmetics subject drugs, biological products, and other items where
to regulation, and by requiring that standards of it may be difficult to conduct a physical exami-
identity and quality be established for foods. The nation or take a physical sample of the product.
law also made explicit FDA’s ability to conduct The ORA is divided into five regions and 13 dis-
factory inspections. tricts. The OCI was established in 1991 to inves-
While most offices of the FDA are located tigate criminal cases such as fraudulent claims or
around Washington, D.C., and are part of the the knowing and willful shipping of adulterated
Headquarters Division, two important divi- goods in interstate commerce.
sions have field offices and a workforce spread Two of the best-known activities of the FDA
across the United States—the Office of Regula- are food and drug regulation. The Center for Food
tory Affairs (ORA) and the Office of Criminal Safety and Applied Nutrition handles most safety
Investigation (OCI). The ORA conducts most and labeling concerns for food products except
of the FDA’s work in the field. Consumer safety those with meat, which are handled by the Depart-
officers, commonly called investigators, inspect ment of Agriculture, and alcohol-related products,
which are also handled separately. The Dietary and
Supplement Health and Education Act of 1994 led
to the FDA regulating dietary supplements, but as
foods rather than as drugs. Thus, these products
are not subject to safety and efficacy testing. Action
can only occur against supplements if they are
unsafe. Manufacturers of dietary supplements are
permitted to make specific claims of health benefits
but they may not claim to treat, diagnose, cure, or
prevent disease and must include a disclaimer on
the label. With the growth of some supplements
with mental health related claims, these restrictions
on the regulation of supplements are of importance
in the mental health area. Bottled water is also reg-
ulated by the FDA.

Drug Regulation
For drug regulation, there are different require-
ments for each of three types of drugs: new drugs,
generic drugs, and over-the-counter drugs. A
“new” drug is a product made by a different man-
ufacturer using different inactive or other ingredi-
ents, with a different purpose than the older drug
being modified, or with any other substantial
change. The most rigorous requirements apply to
drugs that are not based on existing medications.
These new drugs receive extensive scrutiny before
FDA approval. Once approved, the sponsor
must review and report to the FDA every patient
An scientist with the U.S. Food and Drug Administration (FDA) adverse drug experience known for that drug. If
evaluates beads used for coating a controlled-release product, the drug event is unexpected, serious, or fatal, it
February 2013. Any adverse drug experience that is unexpected, must be reported within 15 days. Other events are
serious, or fatal must be reported to the FDA within 15 days. reported quarterly.
 Forensic Psychiatry 313

Generic drugs are chemical equivalents of Forensic Psychiatry

name-brand drugs with expired patents. They are
generally less expensive. Generic drug approval The scope of forensic psychiatry as a field is
requires scientific evidence that it is interchange- defined by the application of psychiatry to ques-
able with or therapeutically equivalent to the orig- tions of justice. Its mission is to study and evalu-
inally approved drug. Over-the-counter (OTC) ate the relationships between mental illness and
drugs do not require a doctor’s prescription. criminality and violence. In the narrow sense of
Often, they are previously approved prescription the term, it refers to the clinical evaluation of
drugs but are now considered safe for use without the mental state of defendants or victims in the
a physician’s supervision. context of criminal trials or civil lawsuits (e.g.,
In recent years there has been controversy for private insurance companies). In the wider
about the negative side effects of some drugs, sense, the term refers to questions of care and
especially the suicide-inducing side effects of evaluation within prisons, special hospitals, or
many antidepressants. One of these issues is ordinary contexts, although the meaning varies
linked to the regulation of drugs in the United according to country. The criminal justice system
States, which critics argue has more of a focus determines not only the psychiatrist’s function as
on the development of blockbuster drugs, lead- expert but also the nature of questions at stake:
ing to an overhyping of benefits and a lack of since the 1980s, the question of dangerous state
attention to real hazards. A well-known physi- has tended to replace that of exemption from
cian critic, David Healy, argues that too much of criminal responsibility. Social science studies of
the information about negative impacts of drugs the field are extremely limited and critical. They
is kept from the public and from physicians and tend to focus on forensic psychiatry in the nar-
believes that opening up patient adverse-event rowest sense.
reporting would be an improvement, a change The psychiatrist’s role varies under each of
not supported by the FDA. four main legal systems: Roman law (Europe,
Central and South America, and Francophone
Jennie Kronenfeld Africa), common law (United Kingdom, India,
Arizona State University Canada, and the United States), bijuridical law
(South Africa), and religious law. For example,
See Also: Amphetamines; Antidepressants; Clinical Roman law favors one “impartial” court psychia-
Trials; Clozapine; Department of Health and Human trist, whereas common law favors “the adversary
Services, U.S.; Diazepam; Drug Development; Law process,” which implies the use of two forensic
and Mental Illness; Lithium; Medicalization, History experts, one for the prosecution and one for the
of; Minor Tranquilizers; Pharmaceutical Industry; defense. In certain countries, forensic psychiatry
Policy: Federal Government; Policy: Medical; is a specialty close to criminology, which goes
Polypharmacy; Psychopharmacological Research; hand-in-hand with the use of personality tests,
Psychopharmacology; Reserpine; Ritalin; Serotonin whereas in others it can be carried out by any
Reuptake Inhibitors; Thorazine and First-Generation psychiatrist on the basis of a simple clinical inter-
Antipsychotics; Tricyclic Antidepressants. view. However, in all systems, if the defendant is
judged to be exempt from criminal responsibility
Further Readings at the time of the events, he or she falls under
Healy, David. Let Them Eat Prozac: The Unhealthy the province of psychiatric treatment, rather than
Relationship Between the Pharmaceutical Industry imprisonment.
and Depression. New York: New York University Since the 1980s, a rationalization of the evalua-
Press, 2004. tion procedure and the clinical interview has pro-
Healy, David. Pharmageddon. Berkeley: University of gressively been abandoned in favor of personality
California Press, 2012. tests and probabilistic actuarial methods (derived
Hilts, Philip J. Protecting America’s Health: The FDA, from tools used in insurance) aimed at identify-
Business, and One Hundred Years of Regulation. ing mental disorders or anticipating violent acts
New York: Alfred E. Knopf, 2003. on the basis of profiling the traits of personalities
314 Foucault, Michel

at risk. Recent attempts to apply neuroscience to See Also: Dangerousness; Insanity Defense; Prison
questions of justice (e.g., neurolaw) have extended Psychiatry; Social Control.
the evaluation of defendants not only to their
credibility or the neural traces of their cruelty but Further Readings
also to the severity or leniency of jury members Dumit, Joseph. Picturing Personhood: Brain Scans
and judges. and Biomedical Identity. Princeton, NJ: Princeton
The professional literature of legal experts and University Press, 2004.
psychiatrists has mainly developed around ethi- Fernandez, Fabrice, Samuel Lézé, and Hélène
cal or technical issues (battles between experts, Strauss. “How to Evaluate a Person? The
or high-profile miscarriages of justice), aiming Psychiatric Report and Its Moral Uses.” Cahiers
to rectify the controversial bias of psychiatric Internationaux de Sociologie, v.128–129 (2010).
practice within a legal rather than medical frame- Foucault, Michel. Abnormal: Lectures at the
work. Scientific studies, however, are highly criti- Collège de France 1974–1975. New York:
cal. They target the arbitrary nature of the evalu- Picador, 2003.
ation of deviance by showing the univocal impact McCallum, David. Personality and Dangerousness:
of expertise on criminal justice decisions. Genealogies of Antisocial Personality Disorder.
Following the philosopher Michel Foucault, Cambridge: Cambridge University Press, 2001.
studies in history have demonstrated the impor- Redding, R. E., M. Y. Floyd, and G. L. Hawk. “What
tance of the evaluation of murderous madness Judges and Lawyers Think About the Testimony
and homicidal monomania in the professional- of Mental Health Experts: A Survey of the Courts
ization of the 19th-century alienists. The expert and Bar.” Behavioral Sciences and the Law, v.19/4
became necessary in order to see an invisible mad- (2001).
ness—a state of insanity at the time of the act of Scheffer, T. “Knowing How to Sleep Walk: Placing
violence—and not a permanent state of fury. The Psychological Expert Evidence in an English Jury
genealogy of the category of dangerous individual Trial.” Science, Technology and Human Values,
and of dangerousness emphasizes the extension of v.35/5 (2010).
this category to sexuality and the development of
new tools to detect it.
The majority of sociological studies of devi-
ance denounce the substitution of judges by psy-
chiatrists, claiming that the psychiatrist now pro- Foucault, Michel
nounces a verdict in the judge’s place. According
to this view, this is because of the dominance of a Michel Foucault was born on October 15, 1926,
“therapeutic ethos,” or the determining and over- in Poiters, France. He was an unorthodox phi-
bearing role of the psychiatrist’s authority as a fig- losopher; social theorist; historian of medicine,
ure of social control. Paradoxically, there are few the social sciences, and ideas; and a campaigner
empirical studies or systematic comparisons avail- for prisoner’s rights. His influence has been wide-
able to substantiate the charges levied against the spread and profound throughout the social sciences
criminal justice system by sociology. The reverse and the humanities. In 1959, Foucault received his
social mechanism—the impact of the legal sys- doctorate under the supervision of Georges Can-
tem on forensic psychiatry—is almost completely gulheim. In 1969, he was elected to the Collège
ignored. However, research in the social sciences de France as professor of the history of systems of
has begun to develop on the practical rationales thought. He died from a human immunodeficiency
of the actors involved, both magistrates and psy- virus and acquired immune deficiency syndrome
chiatrists, with an emphasis that is perhaps still (HIV/AIDS)–related illness in Paris on June 25,
too strongly placed on the criminal rather than 1984. His theoretical approach emerges from the
the civil. structuralist and post-structuralist traditions and is
part of the postmodern strand of social theorizing.
Samuel Lézé Foucault’s main concerns were with the history
Ecole Normale Superieure de Lyon of ideas and the uses of power and knowledge in
 Foucault, Michel 315

regimes of social control. He pursued these themes flux, there is no rational order to the form of his-
in an analysis of the medicalization of madness/ torical change. The only order or truth found in
mental illness, of the penal system, and in a his- historical accounts is the order that the historian
tory of sexuality. The main articulating concept of gives it. This will reflect the interests and concerns
this theorizing of social control is that of discourse. of the historian and her social position and thus
This concept is not well defined in Foucault’s work cannot be an objective, true account. Written his-
but can be thought of as bodies of texts, ideas, tory is a narrative or discourse, a story reflecting
and artifacts that communicate and create mean- the arrangements and contingencies of power.
ing. These are combined in systems of signs, state- This elaboration of the genealogy of knowledge
ments, and practices that together make discursive represents a significant step toward an entirely
formations of thought and knowledge. new analysis of power. The nature of power is a
Discursive formations are the combined col- central concept in Foucault’s accounts of mad-
lections of statements in a culture that constitute ness, the development of the medical profession,
an ideological structure for the meanings of par- prison regimes, and sexuality. In this new analysis
ticular statements or artifacts. The meanings that of power, Foucault differs markedly from Marx-
these might hold, across multiple scientific disci- ist and liberal conceptions. For Foucault, power
plines and social institutions, are the function of is not a thing but a relation that is not merely
the wider culture in which they exist. Foucault repressive in function but is also productive of
develops this idea to suggest that all periods of and in all social relations. Power is present in all
history have a dominant discourse, articulated aspects of the social body, from the most macro to
through such terms as art, science, culture, or the most micro of social relations.
Islam, which provide the “truth conditions” for The development of disciplinary power becomes
a particular utterance’s or artifact’s meaning. Dis- a key aspect of the emergence of the modern. Over
cursive patterns and practices combine to create time, the power of the sovereign to extinguish life
individual subjectivities within those societies at will is gradually replaced by the power of pro-
or cultures; there is no a priori human nature. fessional disciplines. Medicine, the law, and the
Individual subjectivity is thus the product of the expertise and knowledge of scientific disciplines
power relations within a society’s or culture’s par- begin to form life by regulating its circumstances
ticular discursive formations. and definitions: architectural design organizes
Foucault characterized this tracing of the influ- space to create areas for particular behaviors and
ence of discursive formations in historical con- activities, timetables regulate bodies in time and
text—via the set of ideas that determined how those spaces, and technologies of posture and of
people thought and talked about madness/men- manners further regulate the body. All of this is
tal illness—as a process of an “archaeology of backed up by complex systems of surveillance,
knowledge.” Subsequent to this, he developed an directed at the social body and the self.
approach derived at least in part from an inter- In this way, reason and unreason were brought
est in the work of Friedrich Nietzsche, which into being as categories of biopolitics. The very
he called the “genealogy of knowledge.” This is close relationship between knowledge and power
explored in an essay from 1971 titled “Nietzsche, that Foucault maintained can be observed here.
Genealogy, History,” where Foucault criticizes Knowledge of what is normal provides the basis
what he considers a traditional view of history upon which to identify the abnormal. This in turn
as a diachronic, linear, and progressive develop- enables the bringing into existence of the social,
ment. In this view, history progresses through a discursive, bureaucratic, and physical appara-
series of rationally connected events, as parts of tus for their sequestration from normal, reason-
an unfolding story leading to a definite outcome; able life. The claims, and particularly the theses
for instance, a progressively humanizing attitude advanced in Foucault’s Madness and Civilization,
toward mental illness. A definite objective truth of have been both influential and controversial.
historical progress is thus available for the histo-
rian to uncover. Foucault rejects these principles, Jeffrey I. Goatcher
insisting that although the world is in constant Nottingham Trent University
316 France

See Also: Anthropology; Critical Theory; After liberation, the French désaliéniste move-
Deviance, Sociology of; Medicalization, History of; ment of deinstitutionalization sought to bring
Medicalization, Sociology of. both patient and treatment back into society. In
1952, at the Hôpital Sainte-Anne in Paris, Jean
Further Readings Delay and Pierre Deniker showed that chlor-
Foucault, Michel. “Nietzsche, Genealogy, History.” In promazine (Largacril or Thorazine) was efficient
Cultural Theory: An Anthology, Imre Szeman and in schizophrenic patients. This therapeutic revo-
Timothy Kaposy, eds. Chichester, UK: John Wiley lution of international scale launched the psy-
& Sons, 2010. chopharmacology of neuroleptics (1955) and
Foucault, Michel. Richard Howard, trans. Madness provided support for the deinstitutionalization
and Civilization? A History of Insanity in the Age movement. The French mental health care system
of Reason. London: Routledge, 2001. progressively became structured around the prin-
Foucault, Michel. The Order of Things: An ciple of secteurs (sectors), an official policy of the
Archaeology of the Human Sciences. London: administrative organization of French psychiatry.
Routledge, 2001. A sector is a tool for administration and health
Foucault, Michel. A. M. Sheridan Smith, trans. management, focusing on a delimited geographi-
The Birth of the Clinic. London: Routledge, 2003. cal zone of approximately 70,000 inhabitants. In
Still, Arthur and Irving Velody. Rewriting the History 2003, there were 817 general psychiatry sectors
of Madness. London: Taylor & Francis, 2012. and 321 infant-juvenile sectors. The central ser-
vice is the Centre Médico-Psychologique (CMP,
Community Mental Health Center) where a mul-
tidisciplinary team provides prevention, early
diagnosis, continuity of care between inpatient
France and outpatient treatment, and follow-up care.
In 50 years, the number of hospital beds has
France is a unitary semipresidential republic and been cut in half. Yet, the sector remains an antenna
a member of the European Union. On January 1, of the hospital. There is great disparity across the
2012, the country had a population of 65.3 mil- country in terms of the distribution of sectors and
lion. In 2010, it had a very high Human Devel- the means allocated to each one. In 1968, psy-
opment Index (HDI) of 0.872. This figure takes chiatry became a separate discipline from neurol-
into account French life expectancy, which is one ogy. Thanks to Jacques Lacan, psychoanalysis
of the longest in the world. Created in 1945, the rose substantially and became permanently estab-
sécurité sociale is a cornerstone of the French lished within psychiatry, despite episodes of the
social protection system. The institution’s mis- Freud Wars between 2003 and 2010. In 2005,
sion is to provide financial assistance to its ben- France had the highest density of psychiatrists in
eficiaries when they encounter costly life events. the world (13,600). It is the most frequent medi-
The health care arm (which includes pregnancy, cal specialization (13 percent). However, the pro-
disability, and death) is thus a model of univer- fession is aging, and there is great geographical
sal health care and funds a substantial portion disparity between the north and the south of the
of the health care system, with the rest falling country—Paris offers an exception, with three
to private insurance, often through nonprofit times as many privately practicing psychiatrists as
mutual insurers. the national average.
The number of doctors per 1,000 inhabitants Mental disorders are the second most fre-
(3.22 in 2008) is one of the highest in the world. In quently attributed diagnostic category in France.
2010, the WHO concluded its global evaluation Ranging from distress to psychiatric patholo-
of health care systems by underlining that France gies, mental disorders are estimated to affect 10
provided “close to best overall health care” in the million people. In 2005, they represented 10.6
world. The French mental health care system is percent of health care expenditure (11.4 billion
organized within this framework, as are the main euros). France is one of the countries in Europe
social sciences studies focusing on its dynamics. with the greatest incidence of depressive disorders
 Freud, Sigmund 317

and has a very high suicide rate (17 in 100,000). founded the Centre de Recherche Psychotropes,
However, only a minority of people suffering from Santé Mentale, Société (Research Center on Psy-
depression use the services available and receive chotrops, Mental Health, and Society), considered
adequate treatment. Yet, France is the greatest addiction and depression; and in 2009, Didier
consumer of antidepressants in Europe and the Fassin and Richard Rechtman tackled trauma
second-greatest consumer of alcohol. Tobacco and victimhood. This period also saw many doc-
and cannabis are also very prevalent among 18- toral theses in the social sciences advocating an
to 25-year-olds. ethnographic approach.
Social studies of mental health care in France
remain relatively rare in comparison with the Samuel Lézé
United Kingdom or the United States. There are Ecole Normale Superieure de Lyon
the major works by sociologist Émile Durkheim on
suicide (1897) and philosopher Michel Foucault See Also: Durkheim, Émile; Foucault, Michel; Lacan,
on the history of madness (1961); however, they Jacques.
have not given rise to the development of a specific
field. It is nonetheless possible to distinguish three Further Readings
main periods between 1959 and 2007 in research Bromet, Evelyn et al. “Cross-National Epidemiology
devoted to the mental health care system. of DSM-IV Major Depressive Episode.” BMC
Between 1959 and 1968, sociologist Roger Bas- Medicine, v.9/90 (2011).
tide (1898–1974) studied social correlations of Ehrenberg, Alain. The Weariness of the Self:
mental illnesses. The dominant method was sta- Diagnosing the History of Depression in the
tistics and the research object—mental illness— Contemporary Age. Montreal: McGill-Queen’s
was provided by psychiatry without any critical University Press, 2010.
discussion. In 1959, along with psychiatrist Henri Fassin, Didier and Richard Rechtman. The Empire
Baruk, Bastide founded the Centre de Psychiatrie of Trauma: An Inquiry Into the Condition of
Sociale (Center for Social Psychiatry) at the École Victimhood. Princeton, NJ: Princeton University
Pratique des Hautes Études (EPHE), but ethno- Press, 2009.
psychoanalysis, around Georges Devereux’s Lézé, Samuel. L’Autorité des Psychanalystes. Paris:
work, gained relative visibility. Literature reviews Puf, 2008.
of Anglo-Saxon research began to appear, and
ethnographic studies were carried out on the
fringes of mainstream research by psychologists.
Between 1968 and 1989, psychiatric institu-
tions met with criticism. Erving Goffman’s Asy- Freud, Sigmund
lums was translated in 1968 and was published
with a preface by Robert Castel, who used a Sigmund Freud’s theory of psychoanalysis, a
genealogical method inspired by Michel Foucault broad theory of human nature that propounds
to examine the transformation and expansion of ideas about personality, motivation, child devel-
psychiatric social control, particularly in his book opment, mental illness, and the purpose and pro-
The Regulation of Madness. The 1980s saw the cess of psychotherapy, has had an important influ-
development, still on the fringes, of ethnographic ence on psychiatry and Western culture. Freud’s
studies of psychiatric work, psychoanalysis, and personal life experiences and the cultural context
psychotherapists. in which he lived greatly influenced the develop-
Between 1990 and 2010, there was a renewal ment of psychoanalysis.
of research in the field. Questions now focused Sigismund (Sigmund) Freud was born in 1856
on the social stakes of mental health: in 2000, in Freiberg, Moravia, now part of the Czech
Pierre Bourdieu looked at the social production Republic. Sigmund was the first-born child of
of suffering; Ian Hacking, appointed to the Col- Jakob, a wool merchant, and Amalie. The Freuds
lège de France in 2000, focused on the history of had eight children and the family was Jew-
psychiatric classifications; Alain Ehrenberg, who ish. When Freud was a child, his father lost his
318 Freud, Sigmund

business and the family moved, eventually settling

in a low-income, Jewish neighborhood in Vienna,
Austria. Freud was an outstanding scholar; before
he entered higher education, he was proficient in
six languages. Freud entered medical school at the
University of Vienna in 1874 and completed his
M.D. in 1881. Though initially trained in neurol-
ogy and hoping for an academic career, follow-
ing further training under the French neurologist
Charcot in Paris, Freud entered private practice
and began to specialize in the treatment of some
forms of mental illness.

The “Talking Cure”

Freud met Josef Breuer, a Viennese doctor who
was treating patients suffering from psychoso-
matic symptoms. Breuer made use of hypnosis
but had also begun to develop a new and revo-
lutionary “talking cure,” which relied upon the
claim that tracing and talking about the origin
of one’s psychological symptoms would lead to
alleviation of the symptoms. The talking cure was
to become the foundation for all psychotherapy.
Freud soon opened a private practice in his home,
specializing in neurological and brain disorders,
receiving referrals from Breuer and utilizing and Sigmund Freud (1856–1939) is a central figure in the disciplines
developing the new talking cure. of psychiatry and psychology. His theory of psychoanalysis was
The psychological conditions that his patients founded in part on Josef Breuer’s “talking cure.”
exhibited intrigued Freud, and he devoted long
hours trying to understand them. In 1895, he
and Breuer published Studies in Hysteria, a book
that described six case studies and presented early technique, and the causes of many mental dis-
foundations for the theory of psychoanalysis. In orders (e.g., depression, schizophrenia, hysteria,
this early work, Freud and Breuer emphasized the and obsessional neuroses). He had close profes-
unconscious mind as the source of psychological sional relationships with many psychiatrists and
suffering and provided an introduction to some psychologists of his era, such as Carl Jung, Alfred
psychotherapy techniques. Adler, and Erik Erikson. Some of these relation-
In the early 1880s, Freud met Martha Bernays, ships were intimate friendships, and several ended
of Hamburg, Germany, and they married in 1886. bitterly. By the early 1900s, Freud was becom-
The Freuds had six children. Their youngest, ing famous throughout Europe. In 1909, he was
Anna, became famous through further develop- invited to speak at Clark University in Massachu-
ing her father’s theory of psychoanalysis. setts. Eventually, particularly after World War II,
From the late 1800s through the 1930s, Freud Freud’s theory became influential throughout the
treated scores of patients. During this period, United States.
he published extensively on topics such as the Freud smoked cigars for most of his adult life,
unconscious mind, the nature of personality, up to 20 per day. In 1923, at age 67, he was diag-
human motivation, human sexuality, the pur- nosed with jaw cancer. He had several surgeries
pose of dreams, the development of personality over many years, eventually resulting in the fit-
(which Freud said was rooted in childhood rela- ting of a prosthetic jaw. In 1933, the Nazis took
tionships, largely with parents), psychotherapy control of Germany; and in 1938, they annexed
 Freud, Sigmund 319

Austria. Many in the international community facts were that Freud had described a male psy-
were concerned that Freud was in peril. Later that chology based primarily upon female patients, and
year, Freud and his family were safely escorted to that the theory of psychoanalysis may not apply to
London. Soon after emigrating, a recurrence of his those different from his patients. In 1970, psychia-
cancer was determined to be inoperable. In Sep- trist and psychoanalyst Harry Trosman responded
tember 1939, he died following injections of mor- to Brody’s critique in an essay, arguing that psy-
phine by his physician. Freud was 83 years old. choanalysis was not built entirely around Freud’s
Freud is considered one of the most influential experience with his patients, and that social class
Western thinkers of the 20th century. His gripping may matter little in regard to one’s psychology.
portrayal of the unconscious mind motivated oth- Psychoanalytic thinkers who followed Freud
ers to consider what role the unconscious might have attempted to produce theories that hold to
play in human psychology. He was one of the first many of Freud’s fundamental principles, such as
to discuss the function of psychotherapy and pre- importance of the unconscious mind and con-
sented practical suggestions about how therapy flict within the personality, which are also appli-
should proceed. He argued that childhood expe- cable to a larger segment of the population. For
riences give rise to adult personality traits. He instance, German psychoanalyst Karen Horney
proposed that the mind is inherently conflicted, developed a theory of feminine psychology, and
divided by contradictory drives of different com- German psychoanalyst Erik Erikson emphasized
ponents of the self. He examined sexuality and the influence that culture has on one’s personality
discussed its relation to psychological suffering. and development.
Freud’s theory of psychoanalysis has been criti-
cized on many grounds. One set of criticisms is Gretchen M. Reevy
directly related to the sociology of mental illness. California State University, East Bay
Freud’s patients, from whom his theory was pri-
marily derived, represent a narrow and limited See Also: Hysteria; Jung, Carl Gustav; Psychoanalysis,
sample of people. Freud’s patients hailed largely History and Sociology of; Psychoanalytic Treatment.
from Austria. In 1970, American psychologist and
psychoanalyst Benjamin Brody published a demo- Further Readings
graphic analysis of Freud’s published cases, a total Brody, Benjamin. “Freud’s Case Load.”
of 145. Brody described that two-thirds of Freud’s Psychotherapy: Theory, Research, and Practice,
cases were women, they were young to middle- v.7/1 (1970).
aged adults (90 percent were 20–44 years old), Gay, Peter. Freud: A Life for Our Time. New York:
and none represented the lower socioeconomic Norton, 1988.
class. They were also predominantly Jewish. The Gay, Peter, ed. The Freud Reader. New York: Norton,
criticisms that Brody leveled based upon these 1988.
 G
Gender symptoms. Men, compared to women, are twice
as likely to experience alcohol dependence, and
Gender is a term typically used to refer to the antisocial personality disorder is diagnosed three
social expression of one’s biological sex. Gender times as often in men than in women. The pres-
is a set of roles, behaviors, and activities that are ence of serious mental illness, such as schizophre-
defined as masculine, feminine, or androgynous. nia and bipolar disorder, does not seem to signifi-
One’s gender cannot be separated from the social- cantly differ by gender. Comorbidity often occurs
ization process. When examining the relationship with depression and anxiety, and because women
between gender and mental illness, some interest- experience these disorders more frequently than
ing patterns emerge. men, women are more likely to be diagnosed with
The World Health Organization (WHO) reports multiple disorders. The experience of multiple
that more than 450 million people worldwide suf- disorders places individuals at greater risk for
fer from mental illness. At any given time, about psychological disability
25 percent of the world’s population has a diag- According to the WHO, having a mental ill-
nosable mental illness. Women and men experience ness is a major risk factor for suicide for individu-
about the same rates of mental illness overall, with als who reside in North America and Europe. For
differences found in the patterns and symptoms of those individuals, suicidal behavior happens most
the disorder based on gender. The specific type of often during an episode of mental illness, and the
mental illness experienced by men and women dif- most common mental illness associated with sui-
fers based on gender. Women experience an anxi- cide is depression. Lifetime risk of suicide for indi-
ety or depressive disorder twice as often as men. viduals with mood disorders such as depression
The WHO suggests that gender-based dif- ranges from 6 to 15 percent. Women are more
ferences offer an explanation for the increased likely to experience depression than men, and this
prevalence of anxiety and depression among girls places them at greater risk for suicide attempts.
and women in comparison to boys and men. Substance abuse is another major risk factor for
In addition to depression and anxiety, somatic suicide, with men more likely to develop sub-
problems (somatoform disorders) are more fre- stance use disorders. Suicide ranks as one of the
quently found among women when compared top 10 causes of death in many countries. Suicide
to men. Somatization involves the experience of attempts occur 10 to 20 times more often than
psychological problems that result in physical completed suicide. Suicide attempts occur more

321
322 Gender

and intervene in the case of externalizing disor-

ders, whereas those with internalizing disorders
(perhaps because they are not causing significant
disruption in their environment) may not receive
the attention that is needed. This may leave girls
without early intervention and place them at risk
for ongoing problems.
The National Institute of Mental Health pub-
lished data supporting the notion that earlier in
childhood, girls and boys tend to have about the
same rates of depression, whereas during adoles-
cence, the rate of depression among girls becomes
higher than the rate among boys. It is thought
that a combination of biological, psychological,
and sociocultural factors interact to contribute to
the increased rate of depression among adolescent
girls. During adolescence, girls tend to experience
a drop in self-esteem and have more body image
concerns than boys. In adolescence, girls are more
Rape survivors gather at the USAID-sponsored Family Violence at risk for the development of body image prob-
and Sexual Abuse Trauma Center, Thohoyandou, South Africa, lems and eating disorders when compared to
in 2005. Interpersonal traumas increase one’s vulnerability to boys. Boys and men who identify as gay are also
post-traumatic stress disorder, depression, and anxiety disorders, at higher risk for the development of body image
of which women have higher rates of occurrence than men. problems and eating disorders when compared to
heterosexual boys and men.
Among children, boys are more likely than
girls to be diagnosed with oppositional defiant
frequently among women than men, whereas disorder (a pattern of defiance toward authority
completed suicide occurs more frequently among figures) and conduct disorder (an ongoing behav-
men than women. Overall, women are more likely ioral pattern of exhibiting disregard for rules and
to attempt suicide, and men are more likely to die authority and violating the rights of others). This
by suicide. Within groups of men and women, difference continues into adolescence, with con-
individuals (especially youth) who identify as les- duct disorder more frequent among adolescent
bian, bisexual, gay, or transgendered are at even boys; however, studies indicate that the gender
higher risk for suicide. difference found in childhood for oppositional
defiant disorder is no longer present during ado-
Childhood Disorders and Gender lescence. Conduct disorder during childhood is a
The prevalence of disorders among children and necessary criterion for the diagnosis of antisocial
adolescents also reveals interesting gender differ- personality disorder during adulthood. Since boys
ences. When discussing disorders of childhood, are experiencing conduct disorder at a higher rate
there may be a separation of problems that chil- than girls, it may make them more vulnerable
dren experience into categories of internalizing than girls to the development of antisocial per-
versus externalizing. Common mental disorders sonality disorder.
that have more internalizing features are depres-
sion and anxiety, while disorders with more exter- Explanations for Gender Differences in the
nalizing features include conduct disorder and Diagnosis and Treatment of Mental Illness
other disruptive behavior disorders. Girls tend to A combination of biological, psychological,
be diagnosed with more internalizing problems, social, cultural, and environmental factors may
and boys with more externalizing problems. Par- contribute to gender differences in the prevalence
ents and teachers may be more likely to notice and diagnosis of mental illness. Across the world
 Gender 323

women, when compared to men, are more likely be a man, or define the concept of masculinity,
to experience interpersonal violence such as a sex- individuals may offer adjectives such as strong,
ual assault, rape, and domestic violence. macho, dominant, assertive, provider, and tough.
According to data presented in a 2010 report Men may also be described as showing less emo-
on the status of women worldwide by the United tion and being less sensitive compared to women.
Nations (UN), women’s rates of experiencing Often, when asked what it means to be a woman,
physical violence at least once in their lifetime individuals may provide stereotypical responses
range from 12 percent in China to 59 percent such as passive, weak, emotional, submissive,
in Zambia. In the UN report, data indicate that caretaker, and nurturer. If one considers society’s
more than 10 percent of women in the Republic conceptions of masculinity and femininity and
of Moldova, Mozambique, the Czech Republic, the degree to which the society rewards or pun-
and Costa Rica reported experiencing physical ishes (sometimes explicitly, sometimes implicitly)
violence in the past 12 months. In the same report, individuals for deviance from expected and often
authors note that the rate of sexual violence expe- implicit gendered roles, one may find some sup-
rienced by women ranges from 4 percent in Azer- port for why certain disorders are more common
baijan to 44 percent in Mexico. According to among men than women.
information published by the Rape, Abuse, and In some cultures, men may be encouraged,
Incest National Network, about 17 percent of through gender-based expectations portrayed in
women and 3 percent of men in the United States the media and supported by peers, to engage in
experience sexual violence. The UN report sug- binge drinking behavior and in risk-taking behav-
gests that femicide and female genital mutilation/ ior that is often associated with disorders found
cutting are other forms of violence experienced by more commonly among men. If men are not sup-
women across the world. ported to express emotions, other than anger,
Experiences of interpersonal trauma increase engaging in substance abuse could be a way to
vulnerability to the development of mental ill- manage and/or suppress those emotions. In many
nesses such as post-traumatic stress disorder, cultures, women are placed in the role of provid-
depression, and anxiety disorders. The experience ing care for those who cannot care for themselves.
of these forms of violence against women may These gender-based expectations create tremen-
increase their likelihood of these disorders and dous role strain on women and are a source of
offer a possible explanation for some of the dif- stress that over time may increase vulnerability to
ferences in rates of occurrence of these disorders psychological problems.
when comparing men and women. Additionally, A study published in the Journal of Abnormal
multiple life stressors, over time, may contribute Psychology in 2012 suggests that gender differ-
to the risk of psychological problems. Women ences in mental illness may be accounted for by
are more likely than men to have lower income women’s tendency to internalize problems and
and socioeconomic status, be impoverished, and, men’s tendency to externalize problems. The
according to the WHO and other supporting authors state that men tend to engage in active
research, are more likely to be responsible for problem solving and avoid focusing on their neg-
providing care to those who are unable to care ative emotions, whereas women tend to ruminate,
for themselves. Women of color and sexual orien- leading to more exposure over time to negative
tation minorities experience even more stressors emotions. The authors argue that this difference
because of racism, discrimination, and oppres- in behavioral strategy, rather than the variable
sion. These life experiences may provide an expla- of gender, could account for gender differences
nation for some of the differences found among in mental illnesses such as depression, anxiety,
rates of mental illness, particularly depression substance dependence, and antisocial personality
and anxiety, in women and men. disorder. Behavioral strategies utilized by indi-
Gender-based messages received by men and viduals are also influenced by gender-based role
women may also play a role in the development expectations.
of problems by influencing certain behavioral pat- Another possible explanation for gender-based
terns. For example, when asked what it means to differences in mental illness involves the notion
324 Genetics

that the diagnostic criteria for some disorders Genetics

may be gender biased and that mental health pro-
fessionals may exhibit gender bias in the process The 20th century marked the era of the genome,
of diagnosing. For example, mental health profes- the uncovering of the entirety of an organism’s
sionals may exhibit bias in assessment, interpreta- genetic material. In order to appreciate genetics,
tion of data, and diagnosis. one must first understand the building blocks,
According to literature published by the WHO, namely, genes, DNA, and chromosomes. Genetic
women are more likely to have higher levels of abnormalities related to mental illness are the
distress when compared to men who have the focus of psychiatric genetics. Once a disorder
same symptoms and are more likely to perceive has been found heritable, investigators rely upon
these symptoms as a problem. Research studies twin and adoption studies to determine the rela-
find that women are more likely than men to seek tive contributions of genetic and environmental
treatment for mental illness. Men tend to seek factors. Other psychiatric genetic methods are
treatment when problems become more severe. used to answer questions regarding the mode
Also, being a woman is the single greatest pre- of genetic transmission and the location of the
dictor of whether an individual will be prescribed gene(s) implicated.
psychotropic medication. The goal of the Human Genome Project is to
The complex interaction between biological, locate and identify all the disease genes on the
psychological, and sociocultural factors offers the entire human genome. Huntington’s disease is one
most comprehensive explanation for these gender example of how difficult gene detection and gene
differences and similarities in the occurrence of discovery can be, even in a relatively straightfor-
mental illness across genders. ward case. In contrast, most psychiatric disor-
ders, such as schizophrenia, bipolar disorder, and
Tammy Hatfield autism, are characterized by complex inheritance.
Lindsey Wilson College The practical implications of complex inheritance
are that gene discovery will be even more difficult,
See Also: Children; Depression; Eating Disorders; and disease expression is less straightforward;
Sex Differences; Women. phenomena such as reduced penetrance and vari-
able expressivity can be seen. The advent of the
Further Readings era of the genome has also raised issues related to
American Psychiatric Association (APA). Diagnostic genetic counseling and genetic testing. Although
and Statistical Manual of Mental Disorders. 4th genetic testing is not available for all disorders,
ed. Arlington, VA: APA, 2000. there are several contexts in which such testing
Eaton, Nicholas, et al. “An Invariant Dimensional can occur, and ethical issues are relevant in each
Liability Model of Gender Differences in Mental of these contexts, with respective legal protections
Disorder Prevalence: Evidence From a National and ethical guidelines.
Sample.” Journal of Abnormal Psychology, v.121/1 Genetic information is carried in macromol-
(2012). ecules called DNA (deoxyribonucleic acid). DNA
National Institute of Mental Health. “Women and is organized into chromosomes. The structure of
Depression” (2009). http://www.nimh.nih.gov/ DNA is helical (i.e., like a helix). Francis James
health/publications/women-and-depression Crick and Watson discovered the double helix
-discovering-hope/depression-what-every-woman structure of DNA, the building blocks of genes,
-should-know.pdf (Accessed August 2012). in 1953. Typically, two DNA molecules are held
United Nations. “The World’s Women 2010: Trends together by hydrogen bonds between pairs of
and Statistics” (2010). http://unstats.un.org/unsd/ bases, either adenine–thymine (A–T), or cyto-
demographic/products/Worldswomen/WWfull% sine–guanine (C–G). The genetic code, consist-
20report_color.pdf (Accessed August 2012). ing of the four-letter alphabet, C-T-G-A, that
World Health Organization. “Gender and Mental permits nucleic acids to determine the order of
Health” (2002). http://whqlibdoc.who.int/gender amino acids in proteins, was discovered in 1966.
/2002/a85573.pdf (Accessed August 2012). In 1975, rapid DNA sequencing methods were
 Genetics 325

developed, which were used to identify the nucleic the phenotype, the overt expression of the char-
acids that form DNA. Genes are sequences of acteristic or trait that can be measured. Although
DNA molecules. a mental disorder may appear to run in families,
DNA mutations, changes in the DNA sequence, that is, it appears at a higher rate in some families
can occur whenever there is a loss or gain of one or than in the general population, the disorder may
more of the bases, or where one base is substituted not necessarily be heritable. In order for genes to
for another (e.g., A is replaced by a G). Another exert a substantial causal role in a mental disor-
source of DNA mutation is when a base substitu- der, and therefore for the disorder to be consid-
tion results in a change in the coding sequence, ered heritable, several lines of evidence must be
affecting the protein or amino acid used. established.
Healthy, normal individuals possess 22 pairs At the population level, heritability has been
of autosomes (numbered chromosomes 1 through defined as the proportion of phenotypic variance
22) and one pair of sex chromosomes (either that is attributable to genetic variance. Heritabil-
XX for females or XY for males). Chromosomal ity estimates range from 1, which indicates that
abnormalities can arise in several ways: an extra all the variability in the phenotype is from genetic
copy of an autosome, such as Trisomy 21 (Down factors; to 0, which means that all the phenotypic
syndrome) is an example of a chromosomal aber- variation is from environmental factors. Herita-
ration. Individuals may sometimes have an extra bility is important in terms of explaining indi-
X chromosome (e.g., XXY) or an extra Y chromo- vidual differences, and evidence that something
some (e.g., XYY). Generally, conditions in which has a heritable basis should not be construed in a
an entire chromosome is missing, such that the deterministic context. High heritability does not
individual only has one copy of the chromosome, imply lack of malleability by environmental inter-
are not viable. The exception to this is Turner’s ventions (e.g., PKU is a purely genetic disease that
syndrome (XO), in which females are missing one can be managed by environmental manipulation,
of their X chromosomes. Other chromosomal such as controlling one’s diet, beginning at a very
aberrations include situations where a large por- early age).
tion of DNA is missing (known as deletions), a Many psychiatric disorders (e.g., schizophre-
segment of the chromosome has been duplicated nia, bipolar disorder, depression, and autism) are
(known as duplication), or a chromosomal seg- genetically complex. By saying that a disorder is
ment breaks and becomes reattached in the oppo- genetically complex, one is conveying that the dis-
site orientation. order is neither autosomal dominant nor autoso-
mal recessive in its mode of genetic transmission.
Psychiatric and Behavior Genetics It is hypothesized that the disorder involves multi-
The term genetics refers to the science of genes, ple predisposing genes that interact among them-
namely, their structure, behavior, and variation selves as well as with the environment. Increas-
in living organisms. Psychiatric epidemiology ingly, investigators are recognizing the likelihood
focuses on the distribution and causes of psychi- that different sets of genes may be involved in
atric disease. In psychiatric genetics, the roles of causing psychiatric disorder in different families
genetic and environmental risk factors and their or different populations; this is known as genetic
interaction are examined in terms of the etiology heterogeneity.
of mental illness. Behavior genetics is a related It may be difficult to generalize from the results
field that focuses on individual differences and the of family studies to a particular situation in a
role of genes in behavioral and personality traits. clinical setting because of genetic heterogeneity.
Both psychiatric genetics and behavior genet- In genetic heterogeneity, many different genetic
ics therefore help explain the role of genes and variants may lead to the same phenotype. There-
environment in terms of how people differ from fore, because of genetic heterogeneity, it may not
each other and how people may develop various be possible for a health professional to tell fam-
illnesses and conditions. ily members whether an affected member’s ill-
A distinction is made between the genotype, ness reflects the presence of a particular genetic
the genetic composition of the individual, and defect (i.e., chromosomal deletion, duplication,
326 Genetics

or translocation) or whether it reflects the effects biological) risk from their environmental (i.e.,
of multiple genes of small effect. Because of com- rearing) risk. Over the past three decades, family,
plex inheritance, the causal factors require many twin, and adoption studies have provided consid-
interacting factors that do not always lead to one erable evidence indicating that many psychiatric
particular disorder; there may be multiple pos- disorders, such as schizophrenia, bipolar disorder,
sible outcomes. There may be severe forms of the and autism, have a large genetic component. For
disease, and there may be spectrum disorders, example, it is estimated that approximately 60 to
which are genetically related disorders that are 83 percent of the variance in schizophrenia can be
less severe. This is the case of autism and autism- attributable to genetic factors.
spectrum disorders, related disorders that are The Human Genome Project is a joint initia-
characterized by less severe emotional, communi- tive by the U.S. Department of Energy and the
cation, and social deficits than autism. National Institutes of Health. The goal of the ini-
tiative is to sequence the entire human genome,
Twin Studies and the Human locating and identifying all the disease genes on
Genome Project the chromosomes.
Comparing the similarities between monozy- Gene detection involves localizing a disease
gotic (MZ), or identical, twins who share 100 gene to a position on a specific chromosome. Gene
percent genetic overlap with each other versus detection is a difficult process, but gene discovery
dizygotic (DZ), or fraternal, twins who share can be even more painstaking and elusive. One
only 50 percent genetic overlap, affords a spe- particular scientific breakthrough in terms of gene
cial opportunity for studying the contribution of discovery came in 1993, when a group includ-
genetic factors to a disorder or trait. Presumably, ing Dr. Nancy Wexler from Columbia University
the differences between MZ twins are from envi- Medical Center isolated the gene causing Hunting-
ronmental factors, if one assumes that both sets ton’s disease. Huntington’s disease is caused by a
of twins share their environments to an equal single autosomal dominant gene, which means
degree. One way to avoid the possible confound that the neurological disorder follows the clas-
of the greater shared environments between sical Mendelian pattern of inheritance (i.e., only
monozygotic (MZ) twins is to study MZ twins one copy of the gene is necessary for a person to
reared apart (MZAs). However, MZAs are rare be affected, and an offspring of an affected person
and may not be representative of twins in gen- has a 50 percent chance of being affected). Most
eral. Increasingly, investigators studying twins psychiatric diseases are in direct contrast to Hun-
are gathering information regarding whether the tington’s disease because most mental disorders
twins shared environments in utero, because this are characterized by complex, rather than simple,
could render the MZ twins either more or less inheritance. It took nearly 10 years between the
similar to each other. According to A. G. Cardno time that the locus of the disease was identified on
and P. McGuffin, approximately 65 percent of chromosome 4 to the discovery of the gene. This
MZ twins share a common chorion, whereas DZ suggests that the search for the etiology of most
twins never do. Sharing a chorion means sharing psychiatric disorders, such as schizophrenia and
an intrauterine environment as well as resources depression, which are likely to be polygenic, will
(i.e., blood supply). be even more challenging.
Despite having 100 percent of their genes in
common, MZ twins can be discordant for a psy- Implications of Complex Inheritance
chiatric disorder. The observation that one of the Complex inheritance usually implies etiological
twins appears psychiatrically healthy, despite pos- heterogeneity. Many investigators maintain that
sessing the same genes conferring mental illness because of etiological heterogeneity, it is likely
as their affected twin, illustrates the distinction that scientists will discover some causal genes as
between an individual’s genotype and their phe- well as some susceptibility genes. This is what has
notype. Adoption studies are also quite useful for been observed in the case of dementia. In the case
behavior genetics because they provide an oppor- of most psychiatric disorders, what is inherited is
tunity to separate an individual’s genetic (i.e., the risk for the disease, not the disease itself. The
 Genetics 327

disease susceptibility, or liability, interacts with Genetic Counseling and Testing

nongenetic (i.e., environmental) factors, and it is Genetic counseling is the process of helping indi-
the combination of these liabilities, if sufficient viduals to understand the implications of genetic
enough, that will lead to expression of a mental contributions to disease. There are several situa-
disorder. Typically, in complex psychiatric disor- tions in which genetic counseling can be useful:
ders, multiple genes of small effect are involved; preconception, if either prospective parent has a
this is known as the multifactorial polygenic personal or family history of a known genetic dis-
threshold model, first developed by Dr. Irving order; prenatally, if there has been exposure to a
Gottesman, one of the most prominent behav- teratogen (i.e., any environmental substance that
ioral geneticists of the 20th century. is harmful to a fetus) or in the case of abnormal
Genetic factors and environmental factors act lab/sonogram tests; or anytime there is suspicion
and interact in a common pathway that con- of a genetic disorder, or there is discovery of a
trols gene expression. In this way, social factors family history of a chromosomal abnormality,
such as social stress, abuse, and deprivation can genetic disorder or increased risk for a common,
influence individual risk for illness. One of the chronic disease. There are basic components to
eventual outcomes of mapping the entire human all genetic counseling sessions, namely, education
genome sequence will be to identify all the genes about the etiological factors underlying the disor-
associated with psychiatric illnesses. However, der, discussion of the person’s family history, and
the expression of most mental disorders will not consideration of the person’s risk (which may or
be from a single gene, because most of the com- may not include genetic testing).
mon mental illnesses are multifactorial in nature, After a family pedigree is completed and specific
with complex etiologies. Thus, the mental ill- information is gathered, a risk assessment is done,
ness is most likely caused by a combination of and the relative risk(s) to various categories of
multiple genetic and nongenetic factors. That relatives is discussed. According to the principles
is, the inheritance of a multifactorial disorder of the National Society of Genetic Counselors,
such as schizophrenia, bipolar disorder, autism, genetic counseling is designed to be nondirective,
or depression will be the culmination of gene X though anticipatory guidance is often an impor-
environment interactions, epigenetics, and gene tant component of genetic counseling. Anticipa-
X gene interactions. tory guidance involves the counselor assisting the
Epigenetics regulates the rate by which DNA is client and their family to consider what it might
transcribed into RNA. Epigenetics describes the feel like if different outcomes regarding genetic
phenomena in which genetically identical cells risk were to occur. It is imperative that this antici-
or organisms express their genomes differently, patory guidance take place within the context of
causing phenotypic differences. Many complex psychological support.
psychiatric disorders are actually affected by epi- Genetic testing is not available for all disorders.
genetic processes, in addition to gene-gene inter- However, for disorders where there is a genetic
actions and gene X environment interactions. test available, there are four contexts in which
Simply having the disease genotype does not genetic testing can occur: tests may have high
necessarily mean that an individual will manifest or low predictive power, and there may or may
the disease (i.e., the disease phenotype). Disease not be effective, acceptable treatment available.
expression is dependent upon several factors, An example of a genetic test that has high predic-
including whether there is reduced penetrance or tive power for which effective, acceptable treat-
variable expressivity associated with the disorder. ment is available is the perinatal screening test
Reduced penetrance is seen when the genotype is that is done for phenylketonuria (PKU). In the
not always expressed as the full disease. Variable United States, all newborns are screened for PKU,
expressivity is seen when the same genotype may a heritable disorder in which the body is unable
lead to several phenotypic expressions, which to metabolize the essential amino acid phenyl-
vary in terms of symptoms and/or severity of alanine. In this case, the overriding issue is that
symptoms. For example, variable expressivity can of distributive justice; the goal is to ensure that
be seen in Huntington’s disease. all individuals have equal access to detection and
328 Geography of Madness

treatment of this genetic disorder as early as pos- including a mental illness. As further protection
sible. The other three categories of genetic testing against discrimination based upon one’s geno-
are less straightforward. However, most research type, a federal law, the Genetic Information Non-
participants who were surveyed feel that everyone discrimination Act, was enacted in 2008. Despite
should have access to confidential genetic testing these safeguards, the psychological consequences
and the choice whether they wish to be tested. of learning about one’s genetic susceptibility are
Consider the case of testing for the presence of powerful. This is particularly the case for psychi-
the Huntington’s disease gene, a test that has high atric disorders that are associated with consider-
predictive value, though there is currently no able social stigma. There are a number of ethical
treatment for the disorder. codes and guidelines currently in place, not only in
Not all at-risk family members may opt for test- the United States, but also adopted by the World
ing, though some may wish to know their status Medical Association, to protect human subjects
(i.e., are they carriers of the disease gene, to help involved in genetics research. The ethical issues
them with future planning). In addition to access surrounding psychiatric genetic research will con-
to confidential testing, ethical issues that arise in tinue to be explored as more advances are made
this case include the need for informed consent in this area, in terms of both gene identification
and respect for autonomy. Similar issues arise in and improvements in the predictive power of the
the case of susceptibility testing for the hereditary available genetic testing.
breast and ovarian cancer gene (BRCA1, BRCA2
mutation), a test for which there is low predictive Diane C. Gooding
power but for which there may be some preemp- University of Wisconsin, Madison
tive, effective treatments available (e.g., elective
mastectomy and/or hysterectomy). Sisters in a See Also: Biological Psychiatry; Environmental
family with a significant family history of heredi- Causes; Ethical Issues; Eugenics; Mind–Body
tary breast cancer may make different decisions Relationship.
regarding genetic testing or they may both opt for
testing, but may make different decisions in the Further Readings
anticipatory stage. Hoop, J. G. “Ethical Considerations in Psychiatric
Given the eugenics movement that rose in the Genetics.” Harvard Review of Psychiatry, v.16
1930s, it is no surprise that some members of the (2008).
public harbor misgivings concerning psychiatric McGuffin, P., M. J. Owen, and I. I. Gottesman.
genetics research as well as the Human Genome Psychiatric Genetics & Genomics. New York:
Project. There is considerable concern that the Oxford University Press, 2002.
Human Genome Project and other advances Smoller, J. W., B. R. Sheidley, and M. T. Tsuang,
made in psychiatric testing be coupled with safe- eds. Psychiatric Genetics: Applications in Clinical
guards related to ethical concerns for vulner- Practice. Arlington, VA: American Psychiatric
able populations, namely, individuals affected Publishing, 2008.
by psychiatric illnesses and/or other heritable Wexler, A. Mapping Fate: A Memoir of Family, Risk,
disorders. For example, individuals with genetic and Genetic Research. Berkeley: University of
risk for a psychiatric disorder may be subject to California Press, 1995.
discrimination in terms of health insurance, life
insurance, or even employment opportunities. In
1995, the Americans with Disabilities Act was
amended to include protection against discrimi-
nation on the basis of genetic information and/ Geography of Madness
or background.
This legislation was important in order to pro- There is a geography to “madness,” or mental ill-
tect individuals against discrimination in insur- ness, which has a number of dimensions: spatial
ance and/or employment on the basis of their variations in the apparent incidence of mental
personal or family history of a genetic disorder, ill health from place to place and from the local
 Geography of Madness 329

to the global; spatial variations in the locations Spatial Epidemiology of Mental Illness
occupied by institutions and facilities designed to Writers have long commented on mental health
treat mental ill health; different place-based expe- contrasts between “civilized” and “backward”
riences of feeling mentally unhealthy as related to regions, a concern being that “madness” is a
specific clusters of natural and human phenom- pathology associated with the march of civiliza-
ena; different environmental features enrolled, tion. In the 1930s, sociologists R. E. Faris and
more or less deliberately, in the creation of thera- H. W. Dunham produced their famous map of
peutic regimes for those experiencing mental ill schizophrenia in Chicago, showing a clear dis-
health; and historical changes in all of these geog- tance–decay in prevalence with increasing distance
raphies, not least as related to how older concep- from the city center. This study prompted numer-
tions of “madness” have been replaced by more ous geographers (from the early 1960s) to begin
modern conceptions of mental illness. investigating psychiatric geography, the general
Taking these geographical dimensions seri- finding being that the more stressful a local socio-
ously can add value to research on the cultural economic environment—as usually associated
sociology of mental illness, but too often they with the most poverty-ridden and rundown of
are neglected, leading to claims about the causes neighborhoods—the more likely it is to generate
and consequences of mental ill health that seem large numbers of residents with diagnosed mental
strangely ungrounded or inappropriately general- ill health. Exact spatial patterns remain incon-
ized. While such geographical features have been clusive, however, and even distinctions between
addressed by sociologists, historians, psycholo- urban and rural areas remain subject to dispute.
gists, epidemiologists, and other scholars of men- The imagery of the rural idyll suggests that men-
tal ill health, it has been left to the relatively small tal ill health will be more of an urban than a rural
subfield of mental health geography to offer an phenomenon, but there is evidence that serious
overall program of inquiry. Informed by broader mental health problems, albeit more the depres-
orientations from the parent discipline of geog- sions than the schizophrenias, can prevail in rural
raphy, chiefly concerning metalevel concepts of
space, place, environment, landscape, and loca-
tion, mental health geography has gained impetus
and critical mass since the early 1970s.
The main focus of this geographical work has
been mental ill health, with some researchers bor-
rowing from conventional medical-psychiatric
framings of the condition, while others remain
agnostic about the deeper causes behind the
alternative states of being experienced by peo-
ple with mental health problems. The theoreti-
cal frames adopted have also included insights
from antipsychiatry and postpsychiatry, as well
as ranging across the conceptual vocabularies of
psychoanalysis, phenomenology, political econ-
omy, and critical social theory. For this reason,
some of the geographers involved have elected
to speak of “madness,” rather than mental ill-
ness, partly to chime with the subversive possi-
bilities of reclaiming “madness” as a politicized
identity but partly to recognize that “madness”
has historically—in the West, and to an extent Three homeless men share a drink in the downtown east side of
elsewhere—been the prevailing grid of intelligi- Vancouver, British Columbia, Canada, July 2008. In the “mad”
bility overlaying the embodied realities of mental geographies of the streets, individuals struggle to provide self-
difference. care and, if possible, some moments of love and companionship.
330 Geography of Madness

districts. Collectively, these works of spatial epi- from asylum geographies, as laid down in past
demiology have underlined that explanations for centuries, through to the closure of the old asy-
mental ill health should not be lodged solely in an lums under the post-1960s drive to community
individual’s personal problems and biography but care, and issues emerge as stigmatized old asy-
must always recognize contextual factors char- lum sites become reoccupied by other land uses,
acterizing peoples’ local situations of living and groupings, and communities.
working. The shift in mental health care policy from insti-
One of the strengths of this research is its quan- tutional to deinstitutional solutions has entailed a
titative rigor, but an overreliance on quantification move from large closed spaces to a maze of small-
may also be a weakness, offering elaborate ways scale facilities, including day care centers, drop-
of describing spatial patterns and cross-correla- ins, group homes, sheltered homes, networks of
tions but not necessarily explaining causal con- mobile crisis teams, and diverse primary care sup-
nections. Moreover, the more qualitative, inter- port mechanisms dispersed across the spaces of
pretative aspects of the original Faris and Dunham everyday communities. This transition has effec-
study have arguably been overlooked, neglecting tively reintroduced into local settings a cohort
their original claims about mental ill health being previously spatially removed in both reality and
prompted by the social isolation of transitory, popular imagination. The pressures of deregu-
unattached, unanchored inner-city urban living. lation, a switch from the state to voluntary and
To tackle such claims requires a methodology of even private sectors, together with the overarch-
getting closer to the individuals involved through ing creep of neoliberalism, have mostly played
in-depth reading of case notes, interviewing, focus out in these changing geographies of care, with
groups, or participative ethnographies. Only once some identifying a fundamental rolling back of
it is realized exactly how different local situa- the psychiatric state but others seeing an inten-
tions are implicated in the mental health states of sifying web of psychiatric influence reaching out
vulnerable individuals, from inception through into a multitude of spaces beyond the asylum.
onset into possible recidivism, can it be inferred Some have emphasized problems arising because
what lies beneath the revealed spatial patterns of many communities, notably middle-class suburbs
incidence. Such a perspective suggests that some fantasizing themselves as purified spaces and fear-
places are integral to the in situ production of ful of threats to property values, adopt a “not in
mental ill health, but it also signals how people’s my back yard” (NIMBY) attitude toward men-
deteriorating mental health may be paralleled by tal health facilities and their clients. Others have
their drift from place to place. worried about small-scale mental health facilities
tending to cluster in specific parts of cities, creat-
Changing Locational Associations ing what some have termed the “asylum without
of Mental Health Care walls,” “psychiatric ghettos,” or “service-depen-
Geographical attention has been given to the dent ghettos” saturated with mental health cli-
lunatic asylums appearing across the landscapes ents. Others have critiqued a trend toward dein-
of western Europe, North America, and some stitutionalized ex-patients slipping through the
colonial possessions during the 18th and 19th care net into new spaces of homelessness, poverty,
centuries. Set within a longer story of conjoint drug dependency, and even reinstitutionalization
social and spatial separation between the sup- through the penal system.
posedly sane and the allegedly insane, researchers Another group of studies has examined how
have reconstructed the locations of the asylums, post-asylum geographies have been experienced
hospitals, and madhouses variously run by the from below by ex- or never-institutionalized men-
state, charities, and entrepreneurs. Typically sited tal patients. The extent to which everyday com-
in rural or exurban seclusion, questions have been munities have proved to be caring places has been
asked about how such locations were favored by considered, calling into question the ongoing stig-
medical, moral, economic, and police discourses matization of people with mental health problems
(moving troublesome people “out of sight, out as a grouping regarded as too different, by and
of mind”). Significant continuities can be traced large, for ready social inclusion. More positively,
 Germany 331

research has uncovered the self-help, advocacy, during the Nazi period, and many mental health
and arts for mental health networks materializ- professionals took part in activities today con-
ing among people with mental ill health, along- sidered criminal, such as the forced sterilization
side exploring how friendships fostered in more or euthanization of mentally ill persons. These
informal spaces such as cafés, soup kitchens, food abuses led to the creation of some of the first
counters, bus shelters, and other often hidden international statements of medical ethics. In Ger-
spaces comprise a largely invisible and fragile, yet many today, access to mental health care and com-
vital, immediate layer of caring practices. munity services is guaranteed by law, and matters
With this focus upon the “mad” geographies such as the rights of those receiving care and the
of everyday survival on the streets, the core issues accreditation of mental health facilities and pro-
arguably become routine care of the self, as indi- fessionals are also specified in German law. Per-
viduals struggle to eat and drink, keep warm, sons with mental illness (and all disabled people)
clothe themselves, find places to sleep, and if pos- are legally protected from discrimination and have
sible, secure snatched moments of love and com- an equal right to autonomy and participation in
panionship. This research has embraced matters life, as do persons without mental illness or other
of identity pertaining to how the people conceive handicaps. In addition, Germany has active pro-
of themselves, their bodies, and their place in the grams to combat discrimination against and the
world, and it has also begun to consider the role stigmatization of the mental ill. Compared to 21
not only of physical spaces in the world but also other European Organisation for Economic Co-
of virtual spaces (and the rise of online mental operation and Development (OECD) countries in
health collectives). 2007, Germany ranked near the top in terms of
population mental health, trailing only Norway,
Christopher Philo the Netherlands, and Ireland.
University of Glasgow Germany was a leader in the development of
scientific psychology and psychiatry; in fact, the
See Also: Community Mental Health Centers; term psychiatry (psychiatrie) was coined by Ger-
Deinstitutionalization; Group Homes. man physician Johann Christian Reil, an advo-
cate for the humane treatment of the mentally ill,
Further Readings in the early 19th century. The first mental hospital
Curtis, Sarah. Space, Place, and Mental Health. in Germany was founded in 1805, by I. G. Ianger-
Aldershot, UK: Ashgate, 2010. mann, in Bayreuth. Wilhelm Griesinger, a German
Parr, Hester. Mental Health and Social Space. Oxford, physician, pioneered the integration of mental ill-
UK: Blackwell, 2008. ness with physical illness and the insight that the
Philo, Chris. The Geographical History of symptoms of mental illness could have physical
Institutional Provision for the Insane From causes, although he did not discount psychologi-
Medieval Times to the 1860s in England and cal factors and experiences as influences. Emil
Wales. Lewiston, NY: Edwin Mellen Press, 2004. Kraepelin, a German psychiatrist and university
professor, is credited with many breakthroughs
in psychiatry, including placing an emphasis on
the physical and genetic causes of symptoms and
his development of a system for classifying men-
Germany tal illnesses. Magnus Hirschfeld was a pioneer in
the scientific study of sexuality; he founded the
Germany is a high-income country in northern Institut für Sexualforschung (Institute for Sexual
Europe and its residents currently enjoy a high Research) in Berlin in 1920, where he pioneered
standard of living and health care, including men- the scientific study of topics such as homosexual-
tal health care. Historically, Germany has been a ity, transvestitism, and transsexuality.
pioneer in the development of scientific psychol- Modern experimental psychology was largely
ogy, psychiatry, and psychoanalysis, although invented in Germany, with early pioneers in the
these professions were bent to political purposes field including Johannes Müller, Ernest Heinrich
332 Germany

Weber, Gustav Theodor Fechner, and Hermann The partition of Germany, particularly after
Ebbinghaus; their general approach to psychol- completion of the Berlin Wall in 1961, influ-
ogy was to adopt the methods of the sciences to enced the practice of psychology, as work in West
the study of psychological phenomena. The first Germany was influenced primarily by American
psychological laboratory was founded by Wil- models and that in East Germany by Soviet mod-
helm Wundt at the University of Leipzig in 1879; els. After reunification in 1990, the West German
Wundt’s work and writings were instrumental in model was adopted in the former East Germany
establishing psychology as an experimental sci- as well, and many psychologists moved from the
ence dealing with observable, measurable effects east to the west as soon as it was possible to do
(e.g., response to stimuli). A second school of so. As of 2000, over 20,000 Germans were mem-
thought, as exemplified by Hermann Cohen, Paul bers of the Professional Association of German
Natorp, and Ernst Cassirer, considered psychol- Psychologists (for psychologists working outside
ogy as a cultural science and was more concerned universities), and about 1,500 were members of
with examining processes of thought; while a the German Society for Psychology (for academic
third, including Wolfgang Köhler, Kurt Koffka, psychologists). Currently, the number of students
and Max Wertheimer, was largely concerned studying psychology at the university level is reg-
with perception and learning and the way that ulated by law, and as of 2000, admissions were
humans perceive a pattern of stimuli as a gestalt, limited to 4,000 annually.
or “whole.”
The rise of national socialism, followed by Psychoanalysis
World War II, caused an immediate and serious Psychoanalysis also has a long history in Ger-
decline in German psychology, as many lead- many, dating back to correspondence between
ing scholars were forced to flee the country, Austrian physician Sigmund Freud and Wilhelm
and the Nazi regime banned research (e.g., the Fleiss, a German physician practicing in Berlin, in
work at Hirschfeld’s institute) that did not fit its the 1890s. The Berliner Psychoanalytische Ver-
worldview. The Nazi regime invested substan- iningung (Berlin Psychoanalytic Association) first
tial national resources in psychological research met in April 1908, and the International Psycho-
and applications, although some were essentially analytical Association was founded in 1910 in
wasted in projects intended to support the ideol- Nuremberg. During World War I, psychoanalysis
ogy of the Nazi regime, including creation of fields was used to treat war neuroses, and this applica-
such as rassenpsychologie (race psychology) and tion was the theme of an international congress,
erbe-umwelt-psychologie (hereditary environ- attended by representatives of the German gov-
ment psychology). On the other hand, substan- ernment, which was held in Budapest in 1918.
tial resources were also invested in more ordinary Psychoanalysis was also embraced by German
concerns, including the application of psychology writers and artists, and Sigmund Freud was
to education, industry, and the military. awarded the Goethe Prize by the city of Frank-
Internationally recognized academic study furt in 1930.
and research in psychology in Germany resumed In 1933, the German government ordered
quickly after the conclusion of World War II; the that non-Aryans be excluded from the medical
Deutsche Gesellschaft für Psychologie (German profession, and psychoanalysis was discredited
Psychological Association), a primarily academic as a “Jewish” science; books written by Freud
organization, resumed activities in 1945, and the and other psychoanalysts were among those
Berufsverband Deutscher Psychologists (Organi- destroyed in the widely publicized book burning
zation of German Professional Psychologists), an staged on May 10, 1933. The Deutsches Institut
organization for those working in applied psy- für Psychologische Forschung and Psychothera-
chology, resumed operation in 1946. In 1960, the pie (German Institute for Psychological Research
19th Congress of the International Union of Psy- and Psychotherapy) was created in 1937, under
chological Science was held in Bonn, making it Nazi control, as the country’s professional orga-
the first international psychology congress held in nization for psychological research and practice.
Germany after World War II. During the Nazi era, psychiatrists participated in
 Germany 333

the national program of sterilization and eutha- participate in ongoing training, including training
nization of mentally ill persons, including serving in mental health care. Primary health care provid-
on the staffs at concentration camps where the ers are authorized to prescribe psychotherapeutic
mentally ill were systematically separated from medicines, and in 2008, 100 percent of general
the population and killed. practitioners in Germany had received obligatory
The Nuremberg Code, an early statement of retraining in the use of psychotropic drugs. Pri-
medical ethics, was formulated in 1947, when mary providers are also allowed to diagnose and
knowledge of these and other abuses, includ- treat mental disorders; the Association for Scien-
ing forced participation in medical experiments, tific Medical Societies has developed guidelines
became public knowledge. The Nuremberg Code for general practitioners who diagnose and treat
set out the principles for ethical medical research, mental disorders. In addition, in 2011, Germany
including voluntary and informed consent, avoid- had 15.2 psychiatrists per 100,000 population,
ance of unnecessary suffering, the requirement and 56.1 nurses working in the mental health sec-
that animal studies and other alternatives be used tor per 100,000 population.
whenever possible to minimize risks to humans, In 2011, total health care expenditures in
and the approval only of research expected to Germany constituted 11.4 percent of the gross
yield useful results for society. domestic product; expenditures for mental health
After the war, the Deutsche Psychoanalytische constitute 11 percent of this budget. Germany
Gesellschaft, or DPG (German Psychoanalytic had a total of 24,881 beds in mental health facili-
Society) was reestablished, and in 1949, it was ties, for a rate of 30.3 beds per 100,000 popula-
provisionally admitted to the International Psy- tion; a total of 3,151 of those beds were reserved
choanalytical Association. A rival organization, for children and adolescents, for a rate of 3.8
the Deutsche Psychoanalytische Vereiningung, or dedicated beds per 100,000 population. A total
DPV (German Psychoanalytic Association) was of 502 beds are available in day treatment facili-
founded in 1950 and was admitted to the Inter- ties, for a rate of 0.61 per 100,000; 131 of those
national Psychoanalytical Association in 1951. beds are reserved for children and adolescents, for
In 1996, the DPG and DPV each had about 500 a rate of 0.16 per 100,000.
members. In 2011, the rate of treatment in outpatient
mental health facilities was 55.97 per 100,000
Current Mental Health Care System population, with 23 percent of those treated age
and Epidemiology 17 or younger. The rate of admissions to mental
Responsibility for mental health care in Ger- hospitals was 641.5 per 100,000; however, short
many is split among three levels of government: lengths of stay were typical, with all patients dis-
national, state, and community. The basic spirit charged from mental hospitals within one year.
behind the current mental health care system is In 2007, the 12-month prevalence for any mental
that patients should receive care close to home, disorder in Germany was 9 percent, with 6 per-
and that care be offered within the community if cent prevalence for anxiety disorders, 4 percent
possible; integration of the mentally ill into the life for mood disorders, and 1 percent for substance
of the community is a guiding principle, although abuse. An estimated 30.9 percent of the global
it is not always achieved in practice. Reflecting burden of disease in Germany is caused by neuro-
this approach to care, the number of beds avail- psychiatric disorders. The suicide rate for males is
able in psychiatric hospitals in Germany has 17.9 per 100,000 population, and six per 100,000
declined by half since 1980. Home treatment for for females.
mental illness is provided as part of the German
system, as are community-based early interven- Sarah Boslaugh
tion and community-based rehabilitation services, Kennesaw State University
and all or almost all Germans are believed to have
access to these resources. The German health See Also: Euthanasia; Kraepelin, Emil; Nazi
care system since 2004 has focused on a system Extermination Policies; Psychoanalysis, History and
of family doctors, and physicians are required to Sociology of; Psychoanalysis and Popular Culture.
334 Global Mental Health Movement

Further Readings biological, psychological, and social factors all

Nassehi, Armin, Alma von der Hagen-Demszky, play a role in both mental and physical illness,
and Katharina Mayr. “The Impact of the WHO major advances in research and treatment were
on the German Mental Health Policy.” European taking place in the field of neuroscience. The
Commission, Knowledge and Policy in Education majority of psychiatric disorders could now be
and Health Sectors, Orientation 3, Supra-National successfully treated. The report recommended
Instruments. (April 2009). http://www.knowand that mental health care should be integrated
pol.eu/IMG/pdf/who.wp12.germany.pdf (Accessed within primary care and that the availability of
January 2013). pharmacological treatments, in particular, should
Organisation for Economic Co-operation and be increased. At the same time, it presented an
Development (OECD). “Society at a Glance 2009: alarming picture of the worldwide prevalence of
OECD Social Indicators.” (May 4, 2009). http:// mental illness and the burden it imposed: lifetime
www.oecd-ilibrary.org/social-issues-migration prevalence was estimated at 20 to 25 percent,
-health/society-at-a-glance-2009_soc_glance while mental illnesses accounted for 12 percent of
-2008-en (Accessed January 2013). the global burden of disease.
Sprung, Lothar and Helga Sprung. “History of
Modern Psychology in Germany in 19th and Launch of the Movement
20th-Century Thought and Society.” International The MGMH was publicly launched in a series
Journal of Psychology, v.36/6 (2001). of articles written for the Lancet in 2007. In
Strous, Rael D. “Psychiatry During the Nazi Era: 2008, the WHO set up the mhGAP program for
Ethical Lessons for the Modern Professional.” scaling up mental health services in developing
Annals of General Psychiatry, v.6/8 (2007). countries; and in 2010, the Grand Challenges in
World Health Organization (WHO) Regional Office Global Mental Health Initiative (GCIMH) was
for Europe. Policies and Practices for Mental launched by the U.S. National Institute of Mental
Health in Europe: Meeting the Challenges. Health (NIMH) and other predominantly West-
Copenhagen: WHO Regional Office for Europe, ern agencies. Both of these programs addressed
2008. mental, neurological, and substance use (MNS)
conditions, defined as conditions that affect the
nervous system, including depression, anxiety dis-
orders, schizophrenia, bipolar disorders, alcohol
and drug use disorders, mental disorders of child-
Global Mental Health hood, migraines, dementias, and epilepsy. The
MGMH continues to expand and attract addi-
Movement tional funding, focusing its efforts on spreading
biomedical psychiatry in LMI countries.
The Movement for Global Mental Health The MGMH has attracted criticism on various
(MGMH) is a campaign to increase the pro- grounds. To a large extent, these criticisms reflect
vision of mental health services in low- and doubts about the biomedical approach that cur-
middle-income (LMI) countries. The campaign rently dominates mainstream psychiatry in the
has attracted criticism for its ambitious claims West. Critics argue that this approach has failed
about the likely benefits that such expansion will to provide convincing explanations and effec-
bring to poorer countries and for its assumption tive treatments for the problems that it claims
that approaches developed in the West can be to solve; the optimistic view it projects of itself
exported to the rest of the world with only minor mainly reflects the desire of pharmaceutical com-
adaptations. panies and mental health professionals to expand
Prior to the launching of the MGMH, several their influence and income. The neurological ori-
of its leading figures were involved in a major gin of psychiatric disorders remains unclear, while
report by the World Health Organization (WHO) research on psychological and social causes—in
titled “Mental Health: New Understanding, New particular, on prevention—has stagnated for lack
Hope” (2001). This report claimed that while of funding. Systematic manipulation of research
 Globalization 335

results has led to exaggerated claims about the MGMH, there is a conspicuous lack of repre-
effectiveness of drug treatments and suppression sentation from lay people and user groups, and
of information about their damaging side effects. the movement draws primarily on theories and
These treatments are now aggressively promoted practices developed in the West. Grassroots ini-
in LMI countries, which provide a vast new mar- tiatives and indigenous approaches receive little
ket—five times greater than the population of attention, and are threatened with extinction
high-income countries—for the ailing pharma- by the large-scale importation of biomedical
ceutical industry. approaches.
Although the MGMH repeatedly claims to be An alternative to the MGMH would need to be
evidence based, critics point out that the evidence eclectic and self-critical, admitting a multiplicity
that it uses is selective and often dubious. Ade- of perspectives and giving priority to the views of
quate research in LMI countries hardly exists, so its supposed beneficiaries. It should be driven by
that estimates of the global prevalence and bur- local groups and interests rather than by external
den of MNS disorders have been based on arbi- agencies with different agendas and priorities. It
trary assumptions and unwarranted extrapola- remains to be seen whether the MGMH will be
tions. Claims about the effectiveness of treatment able to adapt to these requirements.
are often exaggerated; moreover, they assume that
figures found in the West will predict outcomes David Ingleby
anywhere in the world. University of Amsterdam
The explicitly biomedical orientation of the
MGMH leads it to view MNS disorders as con- See Also: Cross-National Prevalence Estimates;
ditions that can be objectively described, univer- Diagnosis; Diagnosis in Cross-National Context;
sally defined, and treated without regard for the Globalization; World Health Organization.
views that people may have about their prob-
lems. The message is that expressions of human Further Readings
suffering can be treated with simple medication, Shukla, Abhay, et al. “Critical Perspectives on the
just like migraine or epilepsy—supplemented NIMH Initiative ‘Grand Challenges to Global
where necessary by standard Western psycho- Mental Health.’” Indian Journal of Medical Ethics,
therapy techniques. The substantial body of v.4 (2012).
knowledge about the cultural dimensions and Summerfield, Derek. “Afterword: Against ‘Global
social origins of mental disturbances, built up Mental Health.’” Transcultural Psychiatry, v.49
by medical anthropologists and transcultural (2012).
psychiatrists over the last half century, hardly Summerfield, Derek. “How Scientifically Valid Is the
receives mention. Knowledge Base of Global Mental Health?” British
How do critics of the MGMH propose to tackle Medical Journal, v.336 (2008).
the problems on which the movement has focused Timimi, Sami. “Globalising Mental Health: A Neo-
attention? The main issue concerns whether the Liberal Project.” Ethnicity and Inequalities in
problems have been correctly formulated in the Health and Social Care, v.4 (2011).
first place. Is it appropriate, for example, to frame
the suicide of farmers in rural India or alcoholism
and drug addiction in the slums of big cities in
terms of neuropsychiatric disorders? Should not
the social, economic, and political roots of these Globalization
problems be investigated and tackled first?
Another issue concerns who should be driving The notion of globalization is used in a wide range
the search for solutions. Should it be profession- of contemporary disciplines. An understanding of
als with their Western ideas and vested interests, globalization rooted in conflict theory privileges
or should action come from the affected peoples? its fundamental economic properties, the liber-
Although Asian, African, and South American ated flow of capital, and the restricted flow of
mental health professionals participate in the labor and families.
336 Globalization

Hyperglobalizer, Skeptic, and derived from modern medicine, let alone commu-
Transformationalist Perspectives nication technologies.
A Marxist perspective on globalization empha- The transformationalist view argues that glo-
sizes exploitation and unjust global trade rules balization may offer something new, but its effect
that limit the distribution of life-saving medicines. on the world’s poor is uncertain. From this per-
In contrast, a neoliberal position on globalization spective, globalization is an open-ended process,
emphasizes the creation of new markets, new sup- offering many different possibilities for local,
ply chains, and rising levels of prosperity in the regional, national, and global connections. That
world. Cultural theorists emphasize the global is, rather than globalization marking a new, dis-
expansion of social norms, language, and behav- tinct era in human history, it is best understood as
iors. These perspectives form the foundations of an extension of pre-existing economic, cultural,
the three major schools of thought that can be and political processes. While something new
discerned in the literature on globalization: the may be happening, it should be seen in deep his-
hyperglobalizer, skeptic, and transformationalist torical terms. From this perspective, globalization
perspectives. offers hope for a more equitable world, but that
Along with deep-rooted differences in how result is by no means assured. Thus, this position
different scholars conceptualize the notion of may emphasize that the current organization of
globalization, researchers have posited radi- global governance, dominated by nondemocratic
cally different ideas regarding the health effects bodies such as the International Monetary Fund,
of globalization. For some, globalization offers World Bank, and World Trade Organization, has
the potential to further standardize disease con- resulted in the grossly unequal distribution of the
structs, paving the way for a more universal, evi- benefits of globalization.
denced-based approach to medicine, and mental This perspective links a variety of different
health in particular. For others, globalization thinkers, from the revolutionary ideas and actions
primarily impacts health research through its of the Zapatistas to the reformist perspective of
influence on the social determinants of health, the Nobel Prize–winning economist Joseph Sti-
including its effects on living and working con- glitz. From the transformationalist perspective,
ditions in the global south, the global trade in Anthony Giddens offers an influential definition
pharmaceuticals, and the international migra- of globalization as “the intensification of world-
tion of health workers. wide relations which link distant localities in such
The hyperglobalizer sees globalization as a a way that local happenings are shaped by events
whole new era in history, a fundamental break occurring many miles away and vice-versa.”
over what existed before. This position sees a
truly borderless world, where individuals have a Globalization Scholarship
new-found freedom to engage with anyone across Scholarship on globalization has arguably made
the globe. Often focused on the promise of com- its strongest impact on the health literature in
munication technologies to enable people to work relation to the social determinants of health.
collaboratively across great distances, this is a Paul Farmer has advanced the notion of struc-
fundamentally optimistic account of globaliza- tural violence—social, political, and economic
tion, seeing it as a route to global prosperity. arrangements that harm people and populations.
The skeptic position responds to the hyperbolic His analyses of human immunodeficiency virus
elements of these ideas and argues that although and acquired immune deficiency syndrome (HIV/
globalization has created new ties around the AIDS) and tuberculosis highlight the global inter-
world, it does not represent a fundamental break connections that link seemingly disparate popu-
in human history. Despite great advances in com- lations, including poor peasants in Haiti, urban
munication technologies, global networks, and slum dwellers in Peru, and prisoners in Siberia.
other celebrated aspects of globalization, the Farmer advances the notion that growing levels
majority of the world’s poor will continue to live of transnational inequalities should be at the root
and die as they have in previous decades, often of of health inequity research, urging researchers
treatable diseases, and without any of the benefits to go beyond traditional nation-state boundaries
 Grandiosity 337

toward understanding the global pathways of dis- advanced, and the feasibility of international
ease, capital, resources, and ideas. In this regard, comparisons of mental health outcomes is a
he advances the seminal work of Richard Wilkin- source of ongoing debate.
son on the pathogenic effects of income inequality,
which has been linked to a wide range of health Fernando G. De Maio
outcomes, from obesity to mental health. DePaul University
Globalization has also deeply influenced schol-
arship on the global trade in pharmaceuticals, See Also: Cultural Prevalence; Human Rights;
and in particular the production and distribution International Comparisons.
of generic medicines. Much of this work relates
to the negative effects that activists and scholars Further Readings
from the global south have identified as stemming Cockerham, G. B. and W. C. Cockerham. Health and
from stipulations in World Trade Organization Globalization. Cambridge, UK: Polity Press, 2010.
regulations, including the controversial Trade- Farmer, P. Pathologies of Power: Health, Human
Related Aspects of Intellectual Property Rights Rights, and the New War on the Poor. Berkeley:
Agreement. University of California Press, 2003.
Globalization offers mental health research a Petryna, A., A. Lakoff, and A. Kleinman, eds. Global
profoundly important analytic concept. It enables Pharmaceuticals: Ethics, Markets, Practices.
analyses of the pharmaceutical industry in terms Durham, NC: Duke University Press, 2006.
of its growth but also in terms of its day-to-day
operations. The globalized clinical trial industry,
for example, is the source of much of the data
published by brand-name pharmaceutical compa-
nies, yet little is known about the regulation of Grandiosity
trials in the global south.
Analyses rooted in the notion of globalization In contemporary psychiatric nosology, grandi-
may also make particularly important contribu- osity is the primary characteristic of narcissistic
tions to the understanding of disease constructs, personality disorder (NPD). A person with gran-
with ethnographic research increasingly challeng- diosity is characterized as having an exagger-
ing the universality of core disorders—such as ated sense of self-importance, believes that they
post-traumatic stress disorder (PTSD)—that are possess special powers, are selfishly motivated,
defined in the Diagnostic and Statistical Man- envious of others, and lack empathy. They also
ual of Mental Disorders. Seeing PTSD from the have an inflated sense of entitlement, a persis-
perspective of globalization enables research- tent need to be admired, and judge themselves as
ers to question the validity and reliability of the superior to others. People with this personality
underlying disease concept, questioning if PTSD disorder inhabit a world that maintains this real-
means the same thing in countries with records of ity. Because of their condition, they have trouble
widespread political violence like Guatemala as it maintaining relationships because they believe
does in industrialized countries like Canada and that they have little in common with others, and
France. Similarly, ethnographic research has ques- thus few people can understand them or provide
tioned the universality of other major diagnostic them with the admiration that they require. In the
entities, including bipolar disorder. United States, the lifetime prevalence rate of NPD
The recent World Health Organization Com- is estimated at 1 percent. Some researchers have
mission on the Social Determinants of Health suggested that cases of NPD have doubled in the
emphasized the effect of globalization on mental last 10 years and estimate that the lifetime preva-
health through the effects of precarious employ- lence rate could be as high as 6 percent.
ment. It integrated mental health measures into An NPD person has an unrealistic view of
its proposed comprehensive national health themselves as more powerful, important, and
equity surveillance framework. However, the indestructible than others. This exaggerated self-
precise formulation of these measures was not perception commonly results in the NPD person
338 Grandiosity

Adolf Hitler, leader of the National Socialists, emerges from the party’s Munich headquarters on December 5, 1931. Scholars have
noted how Hitler’s egocentrism and grandiosity were fostered early in his childhood; they culminated when he eventually saw himself
to be supernaturally appointed to be master of the world. Grandiosity is the primary characteristic of narcissistic personality disorder.

experiencing a state of euphoria and/or intense while narcissistic people rarely harm themselves.
pleasure. In the narcissist’s mind, they are infal- The similarity of NPD to histrionic personality
lible, believe that nothing is impossible, and are disorder is the need for constant attention. How-
able to resolve any problem. Given their perceived ever, a distinction between histrionic and border-
reality, the narcissistic person will impulsively ini- line personality disorders is that they have a strong
tiate ambitious projects and/or activities that are need for maintaining relationships, whereas
typically unrealistic. those with NPDs are characterized by interper-
sonal detachment. People with bipolar disorder,
Similarity to Other Disorders when experiencing manic/hypomanic episodes,
Grandiosity is primarily coupled with NPD but are similar to those with grandiosity. The main
also has similarities to other personality disorders difference between mania and grandiosity is that
and psychiatric illnesses. Personality disorders those experiencing a manic episode are proactive,
with similarities to grandiosity are borderline and aggressive, and even all-powerful.
histrionic personality disorder and bipolar disor- Persons with psychiatric illnesses also display
der. NPD has similarities to borderline personal- pathological narcissism, including grandios-
ity disorder, but those with borderline personality ity. The difference is that psychopaths will use
disorder are characterized by having suicide ide- violence to achieve their goals/desires, while it
ation, attempting suicide, and are self-injurious, is rare for narcissists to be violent. In addition,
 Grandiosity 339

grandiosity is different than persons experienc- Grandiosity is the central diagnostic attribute
ing grandiose delusions, such as schizophrenics. of NPD and pathological narcissism. There are
A difference is that an NPD person is cognizant two types of pathological narcissism. The first
that their behavior is unique or unusual, whereas type is the grandiose state of mind found in ado-
as those with grandiose delusions are typically lescence and young adulthood, which is typically
unaware that their behavior is unusual. However, rectified by life experiences. The second type is
the distinction is not clearly separated when the based on the fourth edition of the Diagnostic and
NPD person’s condition is severe. When grandi- Statistical Manual of Mental Disorders, text revi-
osity is severe, they may break from reality and sion (DSM IV-TR), which diagnosis NPD (grandi-
become delusional about their talents and/or osity—in fantasy or behavior) by a person exhib-
capabilities. iting at least five of the following nine criteria.
The first criterion is an unrealistic and exag-
Causes and Treatment gerated view of talents, abilities, and accomplish-
Grandiosity is not caused by drug or alcohol use/ ments. For example, the person will talk about
abuse or a head injury. It is also not the result of themselves as if they are the only capable per-
an acute psychotic episode or other mental and/or son and characterize themselves as performing
physical illness. The appearance of the condition heroic feats single-handedly for family, friends,
becomes noticeable around adolescence or early and/or at the workplace. Second, the NPD per-
adulthood. Most mental health professionals son may view themselves as invulnerable and not
explain NPD with a multicausation model called recognize their limitations. Third, an NPD per-
the biopsychosocial model. The biopsychosocial son may have grandiose fantasies. Fourth, they
model views grandiosity associated with narcis- do not need other people. Fifth, the NPD per-
sism as originating from a combination of bio- son downgrades other people and projects and
logical/genetic, social/environmental, and psycho- has dreams that are unrealistic. Sixth, the NPD
logical factors. Other health professionals operate person may view themselves as more exceptional
from two different theories. These theories have when comparing themselves to others. Seventh,
prognosis implications. For example, one theory they may view themselves as superior to others,
argues that NPD is a developmental disorder and that others who are not as superior (as them)
(biological/genetic). Thus, the condition is irre- are worthless. They also have a strong desire to
mediable or lifelong. The other theory is that the be praised, complimented, and for others to be
behaviors associated with grandiosity are learned habitually envious of them. Eighth, the NPD
(such as social/environmental/psychological) and person is self-centered and will take advantage
thus can be unlearned via treatment and therapy. of others to get what they want, without consid-
The problems of NPD are significant in inter- eration of others’ feelings. Ninth and last, they
personal relationships. Grandiosity is commonly may conduct themselves in a boastful and/or con-
associated with impulsivity and poor judgment. ceited manner.
To others, an NPD person may appear rude, The effectiveness of treatment is limited
boastful, conceited, and condescending. These because of multiple factors. Typically, a person
behaviors result in making new friends or main- with NPD is unable or unwilling to change their
taining relationships challenging for the NPD behavior and will commonly blame others for any
person. At the workplace, the NPD person may problems that occur. Next, the NPD person rarely
have trouble with interpersonal relationships and/ enters treatment, in part because they view them-
or can believe that they have special abilities not selves as special or superior, and can be reluctant
possessed by their supervisor and/or employer. to participate in treatment. If in treatment, the
The NPD person may challenge the supervisors narcissistic person may be unwilling to open up
and/or employer over decisions, resulting in dis- to a therapist, making therapy strained, like other
agreements and arguments. The poor judgment interpersonal relationships. The NPD person’s
associated with grandiosity can result in the NPD self-reports are not dependable because lying and
person making impetuous financial decisions and exaggerating are a common trait of the condition.
experiencing financial losses. The NPD person can also exaggerate about other
340 Group Homes

people’s actions and behaviors to give the impres- least restrictive environments; the latter required
sion that they are liked and have good interper- states to provide community-based services for
sonal relations. Another problem with therapy is people with mental disabilities if treatment pro-
the length of time needed for treatment. Insurance fessionals determine that it is appropriate and the
coverage is short term, and/or the NPD person affected individuals do not object to such place-
may not complete treatment or stay in treatment ment. Under Olmstead, states are responsible
long enough to make progress because of finan- for community-based placement if they have the
cial, motivational, and other personal consider- resources to provide them. States must also dem-
ations. Various pharmaceutical treatments for onstrate that they have a comprehensive, effective
NPD, such as serotonin reuptake inhibitors, have working plan, including timetables and progress
very limited utility. reports, for placing qualified people in less restric-
tive settings.
Andrew Hund Group care alternatives to hospitalization for
Umea University those needing some form of supervised living
arrangements include a variety of facilities: unli-
See Also: Antisocial Behavior; Dangerousness; censed board and care homes, licensed residential
Delusions; Personality Disorders; Self-Esteem. care homes, halfway houses, transitional facili-
ties, quarter-way houses, and psychosocial reha-
Further Readings bilitation facilities. Mentally ill individuals are
Behary, W. “Disarming the Narcissist: Surviving and also housed in nursing facilities, long-term care
Thriving With the Self-Absorbed.” Oakland, CA: facilities, and institutions for mental disease (local
New Harbinger, 2008. facilities of the nursing home variety that house
Campbell, W. K. and J. Miller. “The Handbook of more than 50 percent of residents with mental
Narcissism and Narcissistic Personality Disorder: illness as a primary diagnosis). The passage of
Theoretical Approaches, Empirical Findings, and Supplemental Security Income (SSI, funding resi-
Treatments.” Hoboken, NJ: John Wiley & Sons, dence in board and residential care) and Medicaid
2011. (funding nursing care for the indigent) provided
Coolidge, Frederick L., Felicia L. Davis, and Daniel funding for supervised residences and spurred
L. Segal. “Understanding Madmen: A DSM-IV the creation of these residential care industries.
Assessment of Adolf Hitler.” Individual Differences The SSI stipend functioned as a voucher, enabling
Research (2007). people with mental illness to purchase a place in
Lowen, A. “Narcissism: Denial of the True Self.” residential group facilities.
New York: Simon & Schuster, 2004. Residential group care facilities (RGCFs) vary
Victor, George. Hitler: The Pathology of Evil. Dulles, in size from two to several hundred. Initially, they
VA: Potomac, 2000. had no oversight by state governments. They
generally opened in less expensive housing areas
where they would experience less resistance from
the community and where their clientele would
more readily fit in. Data from the National Cen-
Group Homes ter for Health Statistics focuses on facilities with
more than four individuals and indicates that
Group care facilities for people with mental ill- in 2010, RGCFs numbered 31,100, providing
ness developed during the last 40 years to meet the 971,900 beds. Approximately one-half of RGCFs
need for supervised community residences result- were small facilities with 4 to 10 beds (50 per-
ing from the closure of state mental hospitals. The cent). The rest were medium facilities with 11 to
deinstitutionalization of these people was prod- 25 beds (16 percent), large facilities with 26 to
ded by landmark court decisions such as Wyatt 100 beds (28 percent), and extra-large facilities
v. Stickney (1972) and Olmstead v. L.C. (1999). with more than 100 beds (7 percent). One-tenth
The former dealt with the right to treatment and of all RGCF residents lived in small RGCFs, and
decisions related to housing individuals in the about that percentage (9 percent) lived in medium
 Group Homes 341

facilities, while the majority resided in large (52 For example, the individual has repeatedly failed
percent) or extra-large (29 percent) RCGFs. in independent living arrangements. He or she
About 4 in 10 RCFs had one or more residents has been unable to overcome isolation, tempta-
who had some or all of their long-term care ser- tion regarding substance abuse, or needs support
vices paid by Medicaid. Larger RCGFs were more to accommodate disability in a long-term setting.
likely than small RCGFs to be chain-affiliated and Such support might include the provision of some
to provide occupational therapy, physical therapy, personal care service and the facilitation of social
social services counseling, and case management. service contacts.
The individual’s disability requires oversight,
Characteristics of Group Care but not necessarily onsite treatment. If the latter
The group care facility aspires to be a normal- is required, it can generally be accomplished on
ized setting where residents are provided a “least an outpatient basis. Group care is also indicated if
restrictive alternative” to hospitalization or other the prospective resident desires to live in a group
forms of institutional care. It should facilitate inte- setting.
gration into its host community. It should facili- Perhaps the greatest strength of supervised
tate access to community resources and social group care placement is matching the prospective
and health services. It should provide behavioral resident to an appropriate setting. The strength
supervision and minimal personal care services of group care placement is in its diversity of envi-
to the extent that an individual cannot do so for ronments and thus the ability to obtain a place-
themselves. ment that can best accommodate the needs and
The goals of group care placement are pri- disabilities of the individual. Group care should
marily patient-need driven and are secondarily be a flexible environment that avoids the often
defined by available alternatives: hospital, nurs- rigid routines of hospital or nursing home set-
ing home, and community placement either with tings. The individual can thus use his or her per-
family or in an independent living situation. Such sonal strengths and assets to achieve a more inde-
goals include providing the following: pendent and improved quality of life. One can
maximize the benefits of person/environment fit
1. A short-term bridge to independent living to facilitate this goal.
in situations where the resident cannot Prospective long-term-care residents may also
return to his or her family or previous need expanded social networks and social inter-
living arrangements—for example, to actions. Supportive environments in such facilities
prevent a patient in a vulnerable state as opposed to transitional high-expectation envi-
from becoming homeless and to avoid ronments enhance network size and interactions.
social situations that have contributed to Contraindications for placement come from
patient relapse in the past three different sources: resident characteris-
2. Long-term care to ensure maintenance of tics and need, facility characteristics, and loca-
physical and mental health and to provide tion. Group home placement is contradicted if
helper-supported social functioning residents express strong objection to the place-
3. Long-term care for those not requiring ment. Long-term placement has been shown to
the intensive intervention of hospital reduce independent social functioning and family
or nursing home care—a less restrictive involvement if not monitored, yet may be indi-
alternative to these institutions cated when residents are vulnerable and isolated.
4. An alternative to community placement Management-centered (i.e., highly structured
with family or an independent living facilities) produce institutional dependency and
situation often differ little from the old mental hospital
in character. Access to community resources via
Indications and Contraindications location of facility and/or public transportation
for Group Care is important to maintain independent social func-
One indication for group care is that the individ- tioning. Facilities located at a distance from such
ual’s disability requires a supervised placement. resources, in threatening/dangerous areas, or in
342 Group Homes

isolated benign suburban or rural settings requir- local social service agencies. For example, in Cali-
ing a car to get about make it difficult to make use fornia, only 16 percent of facility managers failed
of community resources without dependence on to identify at least one service provider who came
facility care operators. Further, negative commu- regularly to the facility and thus was familiar with
nity reaction can also inhibit independent social residents and their service needs.
functioning. Facility stays in group care settings that are
advertised as transitional may be as much as two
Setting Provisions and Facility Management years, given an absence of alternative placements.
Residential group care facilities seek to provide Most residential board and care facilities have no
a supervised setting, approximating the charac- limitation on the duration of residence.
ter of normal independent living situations to the Facilities providing specialized short-term
extent such approximations are possible given accommodation vary considerably in the exper-
residents’ disabilities and supervisory require- tise that they require. Crisis settings providing an
ments. These facilities provide a bed of last resort alternative to hospitalization may have affiliated
for people who have no other place to go. They professionals trained in psychiatry, social work,
provide a service on the residential continuum nursing, or other allied mental health profes-
of care, indicative of increasing need for supervi- sions. Generally, line personnel have limited pro-
sion, and developed in a patchwork ad hoc way fessional training, and their jobs are often entry
to meet a need and in response to available fund- paths to the helping professions.
ing. Facilities provide protective oversight to For long-term care settings, no formal training
residents (i.e., some services beyond room and is required for facility managers. In fact, opening
board and basic maintenance such as laundry). such facilities has often been a minority business
Ideally, oversight does not restrict the residents’ for new entrepreneurs. Trained social workers
ability to engage in responsible independent or nurses often function as placement personnel
action. Such oversight may include nighttime and monitor their clients in such facilities. Con-
staff coverage, facilitating access to health and tinuing education courses are generally available
social services, recreational programming, help to facility managers in all aspects of the business.
with management of finances, and even some Managers involved with local adult residential
personal care services. care operator associations have been found to
Facilities may serve one or more category of provide a more enriched environment for resi-
needy persons, such as the mentally ill, develop- dents. Isolated managers often have isolated resi-
mentally disabled, the dually diagnosed, and the dents and do not take advantage of the available
aged. Facilities, to the extent possible, enable their spectrum of outpatient health and mental health
residents to make use of community-based health services.
mental health and social services. To maintain the
normalized atmosphere of the setting, in-house Advantages and Limitations of
programming is limited. Facilities also do not Residential Group Care
provide medical care with facility funds. Medical The cost of RGCF is a maximum of one-third of
care is purchased by the individual via third-party hospitalization and two-thirds of nursing care. At
payments or from private resources. minimum, it can be as low as 10 percent of the cost
While all facilities provide room and board, the of the hospital. There is a great diversity of envi-
definition of board varies. Most facilities provide ronmental options, “normalized” environments,
all meals for residents, but some expect residents and community placements, with opportunity
to purchase their food and prepare their meals. for modest amounts of personal care, facilitated
Many surveyed facilities in the United States access to social services, expanded social support,
report providing some personal care services and protection of health and mental health status,
(approximately half, bathing; a third, dressing, with expanded opportunity for social interactions.
brushing of hair, and shaving; and a fifth, eating In a 10-year follow-up of such facilities, resi-
and toileting). Managers of facilities also report dents establishing a stable placement—staying on
significant effort facilitating relationships with in the same facility—showed improved health,
 Group Homes 343

mental health, and supported social functioning provision, has made this vulnerable population
when compared to those who exited the settings more of a commodity to be exploited for their
and their baseline. However, they showed less government subsidies.
independent social functioning.
Facilities vary a great deal in quality of care Steven Paul Segal
provided, with greater availability of poor-qual- University of California, Berkeley
ity than high-quality care. Motivation of man-
agement to provide good care is significant, and See Also: Board and Care Homes; Community
especially in small facilities, it makes a great deal Mental Health Centers; Deinstitutionalization;
of difference. The licensing of facilities guarantees Hospitals for the Criminally Insane; Mental
only a modicum of protection against abuse of Institutions, History of; Nursing Homes.
the physical aspects of care (e.g., physical ameni-
ties, food quality, and fire safety). It is difficult to Further Readings
take a license from a facility, and this usually hap- Lester, Helen and Jon Glasby. Mental Health Policy
pens only in extreme abuse cases. and Practice. New York: Palgrave Macmillan, 2010.
It is more difficult to define and enforce social Park-Lee, E., C. Caffrey, M. Sengupta, A. J. Moss,
quality of care standards. Governmental over- E. Rosenoff, and L. D. Harris-Kojetin. Residential
sight agencies usually do not have enough person- Care Facilities: A Key Sector in the Spectrum of
nel to adequately police these environments. Offi- Long-Term Care Providers in the United States.
cials therefore respond primarily to major abuses. ACDC National Center for Health Statistics, 2011.
It is necessary for the mental health placement Rogers, Anne and David Pilgrim. A Sociology of
professionals to know and monitor the qual- Mental Health and Illness. Maidenhead, UK: Open
ity of the facilities to which they refer patients. University Press, 2010.
A New York Times exposé of larger facilities in Schutt, Russell and Stephen Goldfinger. Homelessness,
the New York area revealed significantly elevated Housing, and Mental Illness. Cambridge, MA:
death rates in such facilities. The normalization Harvard University Press, 2011.
objective is very difficult to maintain in the larger Segal, S. P. and P. L. Kotler. “Sheltered-Care
facilities where most people reside. The establish- Residence and Personal Outcomes Ten Years
ment of these diverse privatized systems of group Later.” American Journal of Orthopsychiatry,
care, in a market with limited housing options, the v.63/1 (1993).
alternative often being the homeless shelter or the U.S. Department of Health and Human Services.
street, while portending an era of consumer-driven “Data Brief No. 78.” (December 2011).
 H
Hallucinations (taste) systems. In Western cultures, visual and
auditory hallucinations are the most common,
Hallucinations are historically defined as the and olfactory and gustatory hallucinations are
perception of external stimuli in the absence of the least common. Although words to describe
an external stimulus. The word hallucinate was hallucinations have come about since the 1600s,
derived in the late 1500s and early 1600s from the occurrence of hallucinations has been well
the Latin word alucinatus and the later hallu- documented throughout history in almost every
cinatus, which translate today as “to wander country in the world. Hallucinations can be the
in mind.” Webster’s Encyclopedic Unabridged product of several factors that impact the brain,
Dictionary (1996) defines a hallucination as “an including biological factors (hypoxia or poison-
apparent sensory experience of something that ing), traumatic injury, physical and psychiatric ill-
does not exist outside the mind.” The Diagnos- ness, and toxic exposures (medications, drug use,
tic and Statistical Manual of Mental Disorders and sensory deprivation).
(2000) defines a hallucination as “a sensory per- Western cultures most commonly view hal-
ception that has the compelling sense of reality of lucinations as problematic and pathological.
a true perception but that occurs without exter- Examples of illnesses that produce hallucinations
nal stimulation of the relevant sensory organ.” It include schizophrenia, major depressive illness,
further distinguishes a hallucination from an illu- and substance intoxication. In these cases, indi-
sion where “an actual external stimulus is misper- viduals are encouraged to seek treatments that
ceived or misinterpreted,” rather than generated. resolve the underlying issue or help reduce the
The essence of the clinical and lay definitions common symptoms of Western illnesses. Anti-
of a hallucination is that there is the perception psychotic and antidepressant medications may be
of an external stimulus via a sense organ that is prescribed to eliminate hallucinations or decrease
associated with an experience that is not induced their frequency, duration, and intensity. Behav-
by an external source. This general definition ioral therapies are often also implemented to
implies that there is an experience induced by assist the patient to function more adaptively and
a sense organ that is the product of internal or to understand and better control their symptoms.
brain activity, or even sensory deprivation. Hallu- For example, in the case of a visual hallucination,
cination, hence, can be associated with the visual, the patients may be encouraged to close their eyes
auditory, tactile, olfactory (smell), or gustatory and reach out in the direction of what they are

345
346 Hallucinations

of the elderly, norms for childrearing, and deter-

mination of head of house. Culture influences
how individuals perceive illness, what treatments
they pursue, and under what conditions. Hence,
culture impacts how groups of individuals experi-
ence and view hallucinations. Individuals living in
Western culture may view hallucinations as unde-
sirable and evidence of underlying illness; how-
ever, some subcultures within Western society and
many cultures outside Western society see halluci-
nogenic experiences as normal.
Within Western cultures, illicit substances are
often used as a means to induce hallucinations.
For example, hallucinogenic mushrooms are com-
monly used as a recreational drug in the United
States and other Western cultures. Many of those
same drugs are not illicit in Eastern cultures and
are viewed as more common and acceptable. For
example, many medicine men (shamans) commu-
nicate with the afterlife using hallucinogens and
are respected and hold high positions in the com-
munities for their unique abilities to engage drug-
induced sensory experiences and communicate
An Urarina shaman of the Peruvian Amazon Basin, 1988. These those experiences to the general community.
shamans (medicine men) use ayahuasca to diagnose a patient’s Medicine men of South Africa include substance-
illness on a spiritual level. Ayahuasca causes increased heart induced hallucinations as part of healing rituals.
rates, sight and hearing stimulation, and fear and hallucination. Medicine men are often trained from adolescence
to be healers and communicate with God via hal-
lucinations and dissociative experiences. Medicine
men of the Kung people who reside in the Kala-
seeing. If the vision is not accompanied by an asso- hari Desert communicate with hallucinations as a
ciated tactile experience, the patient can be taught vehicle to deliver information from God, and to
to ignore the visual stimulus. When the visual heal the sick. Hallucinations are combined with
stimulus is accompanied by tactile stimulation, ritualistic dances and other activities to produce
the patient has more confidence that the visual cures for a range of afflictions. Many subcultures
experience is real and can respond accordingly. in the Western Hemisphere view hallucinations as
beneficial and as a special gift only experienced by
Role of Culture a select few. Hallucinations in these cultures are
Western management of a hallucination is not also seen as medicinal, cleansing, and therapeutic.
universal, nor is the conceptualization that a hal- For example, the impact of peyote, a cactus indig-
lucination is associated with an illness, rather enous to the arid regions of the United States, is a
than an advantage or gift; an individual’s view of hallucinogen that reportedly promotes healing and
hallucinations is often intimately linked to their conflict resolution among Native Americans.
culture. Culture is used to describe many aspects Culture may also impact the definition of what
that are unique to a group of people. The cul- constitutes the experience of a hallucination. In
ture of a group is governed by acceptable and various cultures, including some African Ameri-
expected norms for thinking patterns, emotions, cans in the southern United States, individuals
and behavior for that specific group. Common may report hearing voices and actively seeing and
aspects of culture may include dietary preference, communicating with God and ancestors. Such
choice of dress, views and delineation of the role incidents are commonly experienced while in
 Health Insurance 347

a place of worship, or when an individual feels La Barre, W. “Primitive Psychotherapy in Native

vulnerable. The experience of seeing, hearing, or American Cultures: Peyotism and Confession.”
interacting with individuals who are not present Journal of Abnormal and Social Psychology, v.42
is also common among Latino populations. Simi- (1947).
lar to African Americans, individuals may experi- Lata, J. “Visual Hallucinations in Hispanic Clinic
ence the presence of a deceased family member or Patients: A Need to Assess for Cultural Beliefs”
religious figure. Because many Latinos subscribe (2003). ProQuest. http://www.proquest.com
to the Catholic faith, key images associated with (Accessed April 2013).
hallucinations include the Virgin Mary, relevant Onwuanibe, R. C. “The Philosophy of African
saints, and Jesus. Medical Practice.” Issue: A Journal of Opinion,
In African Americans and Latinos, these expe- v.9 (1979).
riences often meet criteria for the definition of
hallucinations, but not the Western definition of
pathology. The distinction between psychopa-
thology and an adaptive, culturally appropriate
response to loss or insecurity is measured by the Health Insurance
effect that these hallucinations have on the indi-
vidual experiencing them. When the experience Insurance principles came to health care in the
generates distress and impairments in functioning, 1920s as the cost of health care dramatically
it is generally considered psychopathology. When increased. New technologies and practices, includ-
the experience produces calmness, soothing, and ing x-ray machines, immunization, antiseptic
a sense of enhanced control in the absence of dis- processes, and other scientific methods required
tress or impairment, it is generally conceptualized expensive equipment, sterile facilities, and a pro-
as an adaptive coping response. fessionalized workforce. Public and private health
In summary, the meaning and utility of a hal- insurance systems have now become integral to
lucination should always be considered within a financing and accessing health care in America.
cultural context. It is important to consider the Reimbursement practices are built into deci-
beliefs of the dominant culture where the indi- sions about which treatments, medications, ther-
vidual resides or was reared and whether the apeutic personnel, and other resources are made
hallucination produces an adaptive versus mal- available to patients. Throughout its history,
adaptive response for that context. Hallucina- insurance industry practices designed to maximize
tions alone are insufficient to indicate pathology; profits and minimize costs, along with a variety
pathology can only be determined as the interac- of public policy decisions, have limited coverage
tion of a thought, emotion, or behavior evaluated of mental health conditions and continue to limit
as a function of the social context, culture, and reimbursement for mental illness treatment. This
environment. has prevented many people from accessing effec-
tive mental health care, changed the practice of
Christopher Edwards psychiatry, and restricted the types of treatment
Duke University available. Efforts to achieve coverage and reim-
Mary Wood bursement parity for mental illness treatment are
Duke University Medical Center ongoing.
Melanie McCabe In 1900, medical care was primitive and inef-
North Carolina Central University fective, but cheap. The average American spent
$5 per year on health care ($100 in today’s cur-
See Also: Delusions; Drug Abuse; Spiritual Healing. rency). People addressed most medical issues
within the home and summoned the doctor only
Further Readings when a person became deathly ill. Hospitals were
American Psychiatric Association (APA). Diagnostic viewed as a last resort, places for indigent end-of-
and Statistical Manual of Mental Disorders. 4th life care. Mental illness care was merely custodial,
ed. Washington, DC: APA, 2000. concentrated in state asylums.
348 Health Insurance

Blue Cross and Blue Shield Plans on ability to pay. The first plans began opera-
The first health insurance schemes arose in the tion in 1939, and affiliated in 1946, becoming
late 1920s. Hospitals sought to increase utiliza- known as Blue Shield. Unlike Blue Cross plans,
tion of their increasingly expensive facilities by which were designed to flatten the price of hos-
attracting comparatively healthier patients and pital services, Blue Shield plans were designed so
spreading out the cost of care. Baylor University that physicians could continue to price services at
in Dallas developed a plan for public school teach- whatever rate they chose, or even charge different
ers that offered access to the hospital in exchange patients different amounts for the same service.
for a payment of $0.50 per month. During the Plans paid defined amounts for services, with the
1930s, a time of widespread unemployment, this patient responsible for the rest of the bill.
plan (later known as Blue Cross) was marketed Although the nonprofit Blue Cross and Blue
to employers throughout most of the United Shield plans were primarily marketed to employ-
States but spread relatively slowly. In the 1940s, ers, they were “community rated,” priced to
a time of labor shortages, employers began to reflect the health risk of the community as a whole.
promote Blue Cross coverage as a “fringe ben- This evened out the cost of claims and permitted
efit” to attract employees, and Blue Cross cover- plans to enroll the most costly, sickest individu-
age became widespread. Tax policies that made als, even if healthier, low-risk individuals opted
health insurance nontaxable for employees as well out. When commercial firms entered the health
as a tax write-off for employers made Blue Cross insurance market, they used “experience rating”
even more popular. By the 1960s, 70 percent of to reduce premium prices for healthier individu-
the population was covered by private, voluntary als and increase premiums for sicker individuals.
health insurance plans. This proved a significant competitive advantage.
Blue Cross plans differed from conventional By the mid-1950s, commercial insurers had more
insurance products in several respects. They were subscribers than Blue Cross and Blue Shield. As
designed by hospitals, not the insurance industry, the industry matured, it developed various risk-
and aimed to reduce price competition among management and cost-reduction strategies, includ-
hospitals. Special enabling legislation at the state ing exclusion of preexisting conditions, lifetime
level allowed Blue Cross plans to operate as non- limitations on claims, pre-coverage health screen-
profit entities, exempt from reserve requirements ings, and claims investigation protocols aimed at
that applied to the commercial insurance indus- finding reasons to deny claims.
try. And because Blue Cross was underwritten by
hospitals, hospitals contracted to provide services, Medicare and Medicaid
even when plans lacked funds for reimbursement. In the 1960s, Medicare and Medicaid legislation
Insurance schemes for physician services devel- created government-funded insurance schemes
oped separately from Blue Cross, and much more for people excluded from employment because of
slowly. Physicians recognized that insurance had age or disability. Private insurance concepts and
the potential to level prices for medical services methodologies pervade these complex public sys-
and interfere with the physician–client relation- tems. For example, claims processing and reim-
ship. Nonetheless, in the mid-1930s, faced with bursement rate determination are typically man-
the growing popularity of Blue Cross, the pros- aged by private insurance firms.
pect of hospital-underwritten insurance for phy- Today, Medicare is the basic federal health
sician services, and the potential for compulsory insurance program for people over age 65 and
national health insurance following the passage for many people with disabilities, funded through
of the Social Security Act, the American Medi- a social insurance model. Workers become eli-
cal Association began to encourage local medical gible for benefits through the payment of Medi-
societies to create their own plans. The AMA rules care taxes and, once enrolled, continue to pay
governing these plans ensured physician control, a share of health care costs and premiums for
denied nonphysicians a role in supervising phy- some types of coverage. Medicare has developed
sicians, and preserved the right of physicians to multiple “parts” or lines of coverage. Medicare
charge different clients different amounts based Part A covers hospital care and some follow-up
 Health Insurance 349

services, skilled nursing facility care, and hospice rate for the population served. In many commu-
care. Medicare Part B covers doctors’ visits, lab nities, hospitals and provider organizations are
tests, outpatient services, and medical supplies. consolidating. The resulting megasystems manage
Part B is optional insurance and involves a pre- an array of facilities and personnel, and the flow
mium paid for by the covered individual. Because of reimbursement dollars, as well as patient care.
Medicare does not typically pay for dental care, In recent years, electronic health records have
eye care, or routine checkups, many recipients connected personal health data with payment
also carry private supplemental insurance. Med- systems, creating opportunities for megasystem
icaid Part C, known as Medicare Advantage, con- managers to manage the health outcomes of large
sists of plans offered by private companies that populations. This has led to the development of
contract with Medicare to provide beneficiaries accountable care organizations, which share cost
with both Part A and Part B benefits. Medicare savings with Medicare if populations achieve
Advantage plans vary substantially and include health targets.
health maintenance organizations, preferred pro- In today’s economy, health insurance is the cus-
vider organizations, private fee-for-service plans, tomary source of payment for all types of medical
special needs plans, and medical savings account service, except for mental health. People who need
plans. Medicare Part D covers prescription drug mental health care must often pay out-of-pocket
expenses. Eligible beneficiaries select from a vari- or do without. In 2010, fewer than 20 percent of
ety of vendor plans. people receiving inpatient treatment reported that
Medicaid is a health insurance program for private insurance paid most of the cost. Over 25
people with low income and limited assets, with percent of adults who received outpatient men-
costs shared between the state and federal govern- tal health services reported that they or a family
ments. Although the majority of people enrolled member paid most of the costs. This is because
in Medicaid are young families and children with- of coverage and payment differentials that have
out disabilities, the majority of Medicaid expen- always existed within insurance systems.
ditures pay for services to people who are aged, Medicare has always restricted coverage of
blind, or disabled. The menu of services available mental health treatment. It has always paid a
to Medicaid beneficiaries significantly varies from smaller share of mental health costs compared
state to state. to other types of care. This differential affects
In 2011, the total cost of U.S. health care was Medicare beneficiaries who have mental or cog-
$2.7 trillion, or $8,680 per person. Private health nitive impairments (approximately one in five
insurance represented 33 percent of the total. older adult beneficiaries, and over half of people
Medicare accounted for 21 percent of the total. enrolled in Medicare on account of disability).
Medicaid accounted for 15 percent of the total. By Medicaid, the largest funder of mental health ser-
2021, federal, state, and local government health vices in the United States, is a patchy benefit sys-
care spending is projected to be nearly 50 percent tem that varies considerably from state to state.
of national health expenditures, with the federal Beginning in the early 2000s, state-level funding
government accounting for approximately two- cuts have even further limited access to care for
thirds of the total government share. The 2010 individuals who depend on Medicaid or who
Affordable Care Act, designed to increase enroll- have no access to other funding. Private insurance
ments in private health plans and in Medicaid, systems have also contained significant limita-
further entrenched the role of insurance schemes tions on coverage for mental health services, with
in the delivery of health care services. plan limits on inpatient days and outpatient visits
Reimbursement strategies are increasingly used increasing sharply between 1997 and 2003. These
to manage the overall health care economy. Begin- differentials persist despite parity legislation
ning in the 1980s, Medicare has reimbursed hos- aimed at reducing mental health coverage gaps.
pitals based on the patient’s admitting diagnosis,
not the particular treatment. Many organizations Deinstitutionalization
now operate under “capitated” reimbursement Coverage differentials connect with the history
schemes, in which providers are paid a per-person of mental health care in the United States. In the
350 Health Insurance

1920s through the 1950s, as the health insurance Medicaid, and private health insurance were spe-
system was developing, mental health care was cifically designed to prevent states from transfer-
concentrated within state-funded asylum systems. ring the costs of institutionalization to the federal
At the time the asylum system developed, these government, the developing deinstitutionalized
institutions were more like poorhouses for des- system eventually became somewhat better at
titute, vulnerable people, not medical treatment delivering treatment (which was funded) than it
facilities designed to restore people’s capacity to was at providing care (which was not funded).
function in the larger world. By the mid-20th cen- Over time, the advent of managed care prac-
tury, institutional care was one of the most costly tices within private and public insurance sys-
items within state budgets. Asylums offered what tems, together with persistent coverage limita-
would be characterized today as custodial care tions and funding cuts, resulted in a system where
and comparatively little treatment. The medical care is both rationed based on clinical need or
treatment aspects of asylum life increased over other factors and stretched out through technol-
time. Many treatment approaches rejected today ogy. In many areas of the country, patients wait
as inhumane or ineffective were developed and for months to access psychiatric care delivered
put into widespread use in psychiatric institutions. through a video system. Insurance companies
Examples of these include insulin shock therapy have almost exclusively focused on psychiatric
and transcranial lobotomy. When treatments that medication for outpatient care and have reduced
reduced agitation, opposition, and hyperactiv- reimbursement rates for psychotherapy. Today’s
ity (treatments that tranquilized the population) public systems rarely make psychotherapy avail-
became available, they were regarded as positive. able and restrict access to family therapy and
The era of deinstitutionalization began in other personnel-intensive treatments.
1963, when John F. Kennedy signed into law the Health insurance practices have profoundly
Mental Retardation Facilities and Community changed psychiatric care. Today, the practice of
Mental Health Centers Construction Act of 1963 psychiatry is frequently experienced as 10-minute
(CMHCA). The legislation, signed one month medication update visits. Therapy, when available
before Kennedy’s death, created new planning at all, is offered by social workers and paraprofes-
entities within states charged with developing a sionals. One psychiatrist profiled in a 2011 New
network of federally funded, community men- York Times article with respect to the economics
tal health centers. The intended transition from of modern-day psychiatric practice reported that
institutions to communities encountered difficul- the care he offered had become more impersonal,
ties from the start. Communities did not have the with lowered goals for treatment.
capacity to serve large numbers of people who Pressure relating to resources and reimburse-
required medication to manage difficult behav- ment has even distorted diagnostic tools. For
iors. The promised federal mental health center example, an Indiana mental health system com-
funding never materialized at the level Kennedy mittee developed a computerized algorithm that
envisioned, was subsequently reduced by the reinterpreted standardized assessment so that no
Richard Nixon and Gerald Ford administrations, children would qualify for expensive residential
and was finally eliminated by the Ronald Reagan care. Once the algorithm was in place, rigged to
administration. States continued to fund their eliminate residential care, the system wiped it out.
asylum systems, even as institutionalized popula- In 2008, the Ohio attorney general investi-
tions decreased. Not until 1993 were more state- gated, and later settled, a case involving allega-
controlled mental health dollars allocated to com- tions that although Anthem Blue Cross and Blue
munity care than to the state institutions. Shield advertised and sold health insurance poli-
The state-funded institutions were designed to cies claiming that psychotherapy was available as
house people and maintain order. They mainly a covered service, none of the therapists listed on
provided care. The population released from the company’s roster accepted new clients.
institutions needed more expensive treatment, People with mental illness have also experi-
including medical services paid for by Medicaid enced difficulty accessing psychiatric medications
or private health insurance. Because Medicare, under public and private health insurance plans.
 Help-Seeking Behavior 351

Many plans either have restricted formularies from others. Help-seeking behavior is defined
(lists of approved drugs) or approval processes as actions related to seeking help from others
that restrict consumer access to more expensive to optimize wellness. Help may be sought to
antidepressant and antipsychotic medications. treat or alleviate distressing psychological symp-
People with mental illness find it more difficult toms, thoughts, feelings, or behaviors. There
than others to navigate the bureaucratic process are a variety of factors that may act as barriers
that is required to obtain prescribed medication. to help-seeking behavior, including gender, cul-
The frustrations and stress can lead patients with ture, stigma, severity of symptoms, religion, and
mental illness to abandon their medication regi- social implications. One’s social support system
mens and worsen. or knowledge regarding the possible therapeutic
benefits of mental health treatment can promote
Paul Komarek help-seeking behavior.
Independent Scholar Estimates of the number of men and women
living with psychological disorders are often cal-
See Also: Costs of Mental Illness; culated using data from mental health facilities;
Deinstitutionalization; Economics; Medicalization, however, because many men and women with
History of; Medicare and Medicaid; Mental mental health problems do not seek professional
Institutions, History of; Social Security. help, these estimates are often low. Similarly, it is
nearly impossible to measure how individuals uti-
Further Readings lize nonprofessional sources of help (e.g., a friend
Centers for Medicare and Medicaid Services. “NHE or significant other).
Fact Sheet.” (2013). http://www.cms.gov/Research A study conducted in 2008 by the National
-Statistics-Data-and-Systems/Statistics-Trends-and Institute of Mental Health examined incidence
-Reports/NationalHealthExpendData/NHE-Fact rates of mental illnesses and help-seeking behav-
-Sheet.html (Accessed June 2013). iors among adults in the United States. The
Harris, G. “Talk Doesn’t Pay, so Psychiatry Turns research found that 13.4 percent of the general
Instead to Drug Therapy.” New York Times population received treatment either in an inpa-
(March 6, 2011). tient or outpatient setting, or through the use of
Ohio Deptartment of Mental Health. “History prescription medications. The same study noted
of the Public Mental Health System.” http:// that of those suffering from a serious mental ill-
www.mh.state.oh.us/who-we-are/system-history ness, only 58.7 percent sought and received treat-
(Accessed June 2013). ment. Young adults, ages 18 to 25, suffering from
Substance Abuse and Mental Health Services a serious mental illness were the least likely to
Administration, Center for Behavioral Health seek help, with only 40.4 percent receiving treat-
Statistics and Quality. “The NSDUH Report: ment. Furthermore, the study indicated that only
Sources of Payment for Mental Health Treatment 50 percent of children (ages 8 to 15) with a men-
for Adults” (July 7, 2011). http://www.samhsa.gov tal disorder received treatment.
(Accessed June 2013). In addition to seeking out a professional or
family member for help, individuals often rely
on bibliotherapy, a form of literature aimed at
helping oneself through reading. Bibliotherapy
includes self-help books. While often used by
Help-Seeking Behavior mental health professionals as a therapeutic
adjunct, people often purchase self-help books as
Individuals with distressing thoughts or feelings a means of individual assessment and improve-
frequently contemplate asking for help from fam- ment. Estimates show that Americans spent over
ily members, peers, or strangers or seeking out $4 million on self-help books in 2009. As a form
psychological or medical professionals. Multiple of help-seeking behavior, self-help books are
factors can influence one’s decision to address very popular because they allow an individual to
an issue or ailment alone, or to seek assistance help him- or herself in private, without the cost
352 Help-Seeking Behavior

of professional assistance. Though the effective- than Caucasians. However, measurement of such
ness of self-help books and other bibliotherapy informal resources is difficult. Examining the
literature is debated and difficult to assess, many role of culture in help-seeking behavior of mul-
people opt for self-help literature to improve psy- ticultural populations is complex and involves
chological wellness. cultural values, satisfaction with formal mental
Gender differences exist in the help-seeking health resources, demographics, and adequacy of
behaviors of men and women. Regardless of age cultural resources.
and ethnicity, men are far less likely to seek help Mental health resources are underutilized by
than women. Research suggests that because help- men and women in the United States because of
seeking behaviors are largely affected by past cultural values, societal norms, past experiences
social experiences and learned behavior, men often with help seeking, and socioeconomic limitations.
learn to evoke masculine stereotypes of stoicism Beliefs regarding help-seeking behavior form as a
and independence and therefore are less likely result of these (and other) factors and affect one’s
than women to seek help for issues like depres- tendency to seek formal assistance. Mental health
sion, anxiety, and substance abuse. In addition, professionals work to educate adults and children
societal norms portray the ideal man as “strong” about the benefits of seeking professional help,
and “tough.” These expectations can inhibit men’s developing appropriate help-seeking behaviors,
help-seeking behaviors because these roles suggest as well as to “normalize” mental illnesses in order
that seeking help is at odds with masculine behav- to decrease stigma and encourage help-seeking
ior. Research has suggested that men are most behavior. Increasing healthy help-seeking behav-
likely to seek help from a professional when their iors will encourage more people to seek treatment
symptoms or level of distress become severe. and thus live more fulfilling, healthy lives.
Cultural views and norms regarding mental
health, wellness, and suffering largely influence Lindsay Labrecque
help-seeking behaviors of individuals within that Brown University
culture. The experience of psychological or psy- Joanna Elmquist
chosocial suffering is culturally specific because University of Tennessee, Knoxville
different cultures assign varied meanings to both Andrew Ninnemann
wellness and suffering. Different cultures uti- Brown University
lize formal mental health services and informal Gregory L. Stuart
resources in varying degrees according to cultural University of Tennessee, Knoxville
values and traditions.
In the United States, rates of formal mental See Also: Mental Illness Defined: Sociological
health seeking are relatively low for all racial Perspectives; Racial Categorization; Self-Help;
groups. However, racial minorities are believed Stigma: Patient’s View.
to utilize professional mental health resources far
less than other groups. Among the wide array of Further Readings
barriers to help-seeking behaviors, some of the Barker, Gary. “Adolescents, Social Support and
more prominent issues may be a lack of diversity Help-Seeking Behaviour: An International
in language and cultural knowledge of profession- Literature Review and Programme Consultation
als, unfavorable cultural beliefs regarding mental With Recommendations for Action.” Geneva:
health professionals and their ability to provide World Health Organization, 2007.
culturally specific understanding and assistance, Katz, Alfred. Self-Help: Concepts and Applications.
inaccessibility, financial constraints, and variation Philadephia: Charles Press, 1992.
in the way that distressing symptoms are cultur- McAlpine, Donna D. and Carol A. Boyer.
ally experienced and interpreted. Research sug- “Sociological Traditions in the Study of Mental
gests that African Americans, Latino Americans, Health Services Utilization.” In Mental Health,
Asian Americans, American Indians, and other Social Mirror, William R. Avison, Jane D. McLeod,
groups tend to utilize resources such as family and Bernice A. Pescosolido, eds. New York:
members or religious leaders more frequently Springer Science and Business Media, 2007.
 Homelessness 353

Homelessness The homeless population continued to grow until

the 1940s, when World War II led to opportuni-
Since the beginning of recorded history, there have ties for employment, education, and housing.
been references to the presence of homeless peo- In December 1948, with the United States as
ple. Although the reasons for becoming homeless, a signatory, the Universal Declaration of Human
the stigma associated with not having a home, and Rights was adopted by the United Nations Gen-
societal efforts to address this issue have evolved eral Assembly. This declaration acknowledged
over time, homelessness remains a national and the right of all people to basic necessities such as
international concern. Worldwide there are an food, clothing, medical care, and housing. The
estimated over 100 million people who lack ordi- Housing Act of 1949 was intended to provide a
nary, lawful access to living quarters, known as decent home for all American families. The dein-
primary homelessness, and more than one billion stitutionalization of mentally ill people without
people who live in temporary or inadequate hous- sufficient outpatient social services resulted in an
ing, defined as secondary homelessness. increase in the homeless population. From 1955
to 1980, the resident population in state pub-
History and Causes of Homelessness lic mental health hospitals fell from 559,000 to
The causes of homelessness vary between devel- 154,000 people.
oped and developing countries. In developing During the 1980s, a recession, high unemploy-
countries, urban sprawl has been identified as ment, and an inadequate supply of affordable
a key contributing factor to homelessness. As
rural land is developed into city space, coun-
tries that lack relocation and rehousing policies
leave displaced citizens without homes and live-
lihood. Additionally, the application of building
codes that require electrical wiring and plumbing
for these new structures make home ownership
beyond the reach of most who desire to remain
in the area.
In developed countries such as the United
States, there has been a slow but steady rescission
of welfare programs that provide housing assis-
tance, accompanied by a growing emphasis on
initiatives that promote community reintegration
of homeless people. However, in many instances,
these efforts have not always been adequately
supported by policies or programs that help peo-
ple remain in their homes. During the 1820s, the
homeless population grew significantly due to
urbanization and industrialization. In the 1840s,
the first homeless shelters were spare rooms
located in police stations. In the 1870s, the term
tramp was used to describe men who hopped
railcars, worked reluctantly, and often traveled
in groups. Two decades later, the term hobo was
used to describe migratory laborers who worked
and wandered from site to site seeking employ-
ment. In 1880, the Salvation Army formed the A homeless man rests on a park bench in Seattle, Washington,
Bowery Mission to deliver “soup, soap, and sal- August 2011. Homeless people are more likely to have a mental
vation” to transients and alcoholics, sometimes illness compared to the general population, with homeless
called “bums,” who were living on the streets. veterans even more likely to have some form of mental illness.
354 Homelessness

housing led to a resurgence of homeless people in Homelessness in America Today

America. In response to the growing numbers, the Approximately one in 194 of the general popula-
1987 McKinney Act authorized millions of dol- tion experiences homelessness during the course
lars for housing. Despite these efforts, homeless of a year. These odds increase dramatically for
people remained a permanent fixture in American people who are at or below the federal poverty
society. It became increasingly clear that although line (one in 29), poor veterans (one in 10), people
shelter, meals, and medical care were important who are staying with friends or family, or doubled
and needed, providing these services was not up (one in 12), recently released prisoners (one in
enough to solve the root causes of homelessness. 13), and young adults who have aged out of the
A significant paradigm shift occurred during the foster care system (one in 11).
past decade in which the focus on helping home- In 2011, the National Alliance to End Home-
less people by offering emergency shelters, medi- lessness estimated that approximately 636,017
cal care, and food services (such as soup kitchens) Americans, or 21 per 10,000, were homeless
was changed to providing housing to people as on a given night. Of this group, approximately
a way to end homelessness. The availability and 392,316 (38 percent) were unsheltered people,
accessibility of social services and housing has 236,181 (37 percent) were families with children,
improved considerably, due in part to initiatives and 67,495 (11 percent) were veterans. Accord-
by the U.S. Department of Housing and Urban ing to HUD, there were more homeless men than
Development (HUD), the U.S. Department of women (62 percent and 38 percent, respectively),
Health and Human Services, the U.S. Department with a majority (37 percent) between the ages of
of Veterans Affairs, and several nongovernmental 31 and 50. Younger people follow, with 21.8 per-
organizations and collations. cent under the age of 18 and 23.5 percent between
the ages of 18 and 30. Older people were the least
Acute and Chronic Homelessness likely subgroup to be homeless (2.8 percent).
The recession of the early 2000s has changed the Homeless people are more likely to have a
face of America’s homeless population. More peo- mental illness (26 percent) compared to the gen-
ple experienced acute homelessness, also referred eral population (5 percent). HUD reports that
to as situational homelessness, than ever before. one-third (35 percent) of the sheltered homeless
Situational homelessness occurs due to job loss, population had substance abuse problems.
medical bills, divorce, disaster, and domestic Most homeless people live in metropoli-
abuse. In 2008, 40 percent more families were tan areas. Not surprisingly, New York and Los
staying in homeless shelters in New York City, Angeles, as the two most populous cities in the
Massachusetts, Connecticut, Minneapolis, and nation, report the highest numbers of homeless
Los Angeles compared to the previous year. Fami- people (66,269 and 57,153, respectively). Home-
lies with children struggled to find employment less people are more likely to live in metropolitan
and places to live. Most people who experience areas because of the housing market, economic
acute homelessness will go to great effort not to conditions, demographic factors, available social
be homeless in the future. services, and climate.
People who are chronically homeless are more Compared to the general population, homeless
likely to have health problems and disabling con- youth are more likely to have mental health disor-
ditions, but no health insurance, than those who ders and substance abuse issues and be the victims
are experiencing acute homelessness. An esti- of past abuse. Approximately 20 percent identify
mated 40 percent of the homeless population has themselves as lesbian, gay, bisexual, transgen-
some type of disability. This subgroup has higher der, or questioning their sexuality (LGBTQ). The
rates of alcohol and substance abuse and incar- LGBTQ subgroup is at higher risk for experienc-
ceration for nonviolent acts related to mental ill- ing sexual and physical abuse and mental health
ness or lack of resources. According to the U.S. issues and are more likely to attempt suicide.
Interagency Council on Homelessness, on a given Approximately 42 percent of those who were in
night in 2011, 107,148 adults reported that they the foster care system experience homelessness
were chronically homeless. once discharged from the service.
 Homelessness 355

Homeless veterans are usually male, between improve their lives. Generally, there are minimal
the ages of 31 and 50, and from single house- restrictions or requirements for enrolling in Hous-
holds. However, since 2000, the number of home- ing First–type programs, in contrast to traditional
less female veterans has been growing. Compared models in which substance use rehabilitation or
to the homeless general population, homeless vet- mental health programs must be completed prior
erans are more likely to have some form of mental to placement.
illness (45 percent) or have substance abuse prob- To reduce the number of people who are home-
lems (70 percent). In recent years, homeless ser- less, their needs should be considered in context
vice providers and the federal government have with the resources of the community. Connecting
been able to reduce chronic homelessness and homeless people to appropriate programs such as
address acute homelessness with targeted initia- case management, Temporary Assistance to Needy
tives like the HUD–Veterans Affairs Supportive Families, cash-assistance programs, employment,
Housing Program. and Medicaid is important. Although new and
innovative programs are currently being devel-
Current Efforts to End Homelessness oped, implemented, and evaluated, it is likely that
in the United States there will always be homeless people, as the pri-
Approaches to address homelessness have mary root causes (prison, foster care, substance
shifted over the years from the traditional emer- abuse, and mental illness) will always be present.
gency shelter and transitional housing “systems”
to prevention and permanent housing. Federal Lisa M. Brown
and state agencies have made funding avail- University of South Florida
able to local communities to develop programs Roger J. Casey
that offer emergency assistance for those at risk VA National Center for Homelessness
for homelessness and rapid rehousing of those Among Veterans
recently homeless. This assistance can include
temporary financial assistance for rent and/or See Also: Adolescence; Age; Alcoholism; Case
utilities, transportation services, housing coun- Managers; Community Mental Health Centers; Costs
seling, legal services, and daily living services. of Mental Illness; Deinstitutionalization; Economics;
As evident by the Homelessness Prevention and Employment; Family Support; Human Rights; Jails
Rapid Re-Housing Program, which received and Prisons; Law and Mental Illness; Life Course;
$1.5 billion under the 2009 American Recovery Mental Institutions, History of; Neighborhood
and Reinvestment Act, prevention of homeless- Quality; State Budgets; Veterans; Veterans’ Hospitals;
ness became a significant policy shift for the fed- Welfare.
eral government.
Additionally, program designs incorporating Further Readings
Housing First program principles have been sup- Burt, M. R., C. Pearson, and A. E. Montgomery.
ported by a number of alliances, associations, “Strategies for Preventing Homelessness” (2005).
and government agencies, promoting permanent Urban Institute. http://www.urban.org/pub
housing programs as a method to end homeless- lications/1000874.html (Accessed August 2013).
ness. The Housing First model provides housing Smith, T. E. and L. I. Sederer. “A New Kind of
as well as intensive case management, assistance Homelessness for Individuals With Serious Mental
in obtaining employment, and financial counsel- Illness? The Need for a ‘Mental Health Home.’”
ing. Initially developed for those diagnosed with Psychiatric Services, v.60/4 (2009).
a serious mental illness and a history of chronic Tsemberis, S. Housing First: The Pathways Model to
homelessness, this model has now been adapted End Homelessness for People With Mental Illness
for other homeless populations. Key to this model and Addiction. Center City, MN: Hazelden, 2010.
is allowing participants to quickly acquire hous- U.S. Interagency Council on the Homeless. “Opening
ing that is assured, ameliorating the most imme- Doors: Federal Strategic Plan to Prevent and End
diate situational problems, ensuring they have Homelessness” (2010). http://www.usich.gov/
the stability to work on other factors that would opening_doors (Accessed August 2013).
356 Hospitals for the Criminally Insane

Hospitals for the standards for insanity. These included clear proof
during the commission of a criminal act that the
Criminally Insane individual (due to a mental illness) did not know
the nature or quality of their act and, if he or she
The history of hospitals for the criminally insane did know its nature or quality, they did not know
is inextricably linked to the history of mental that it was “wrong.” The “right or wrong” por-
health care. Individuals who were deemed crimi- tion of the M’Naghten Rules, now referred to as
nally insane and those with severe mental illnesses the M’Naghten Standard, was widely adopted
were often housed together in prisons, asylums, and remains the standard in many U.S. jurisdic-
or workhouses. Historically, both groups have tions for contemporary criminal law cases involv-
been persecuted and vilified. Their odd behavior ing insanity. Some states using the M’Naghten
was considered strange, unexplainable, and often Rules have added an “irresistible impulse” provi-
associated with the devil. Insanity was believed to sion recognizing that on some occasions, defen-
be a supernatural phenomenon. “Treatment” was dants can distinguish right from wrong but can-
often administered by members of the clergy rather not resist the impulse to commit the act, despite
than mental health professionals, and their efforts knowing that it is wrong. Research suggests that
primarily focused on the exorcism of demons. some version of the M’Naghten Standard is uti-
In 1815, England’s Bethlem Hospital at Moor- lized in approximately half the states.
field’s was one of the first hospitals to establish sep- Other states have adopted different rules to
arate “criminal blocks” for “criminal lunatics.” determine insanity, including the Durham Rule
Individuals housed at Bethlem included those and the American Law Institute (ALI) rule, also
who became insane during their prison sentence, known as the Brawner Rule. Originally known
those who had been found insane on arraignment, as the Product Rule, the Durham Rule was first
and those who had been tried and acquitted. They established in the 1869 New Hampshire case
were not allowed contact with other patients and State v. Pike. The Durham Rule effectively states
were virtually never discharged. Several infamous that an individual is insane if the crime that he or
“criminal lunatics” were housed in Bethlem hos- she has committed is the “offspring or product
pital, including Margaret (Peg) Nicholson, who of” a mental illness. In the original 1954 case,
attempted to stab King George III in 1786; James Monte Durham was charged with housebreak-
Hadfield, who attempted to assassinate the King ing and larceny, two crimes to which he pled
in 1800 and was ultimately found not guilty by insanity. The Durham Rule required the signifi-
reason of insanity; Edward Oxford, who at the cant involvement of mental health professionals
age of 18 attempted to shoot Queen Victoria and to assess whether a defendant was influenced by
successfully utilized the insanity defense against his or her mental illness at the time of the crime.
the charge of high treason; and the infamous Dan- Ultimately, it was determined that it was too dif-
iel M’Naghten, an allegedly paranoid and delu- ficult for mental health professionals to deter-
sional man who in 1843 shot and killed Edward mine precisely how much a mental illness influ-
Drummond, an individual he mistook for British enced an individual’s participation in a crime. In
Prime Minister Sir Robert Peel. 1976, mental health professionals were no longer
allowed to give testimony concerning the influ-
The Origins of Insanity in Criminal Cases ence of mental illness upon the commission of a
Many regard the 1843 case of M’Naghten as defendants’ crime.
being transformative with regard to the use of the The ALI drafted a new standard in 1962 within
insanity defense in criminal cases. At the time, the its Model Penal Code that effectively combined
M’Naghten verdict outraged the public as well as the “right and wrong” portion of the M’Naghten
Queen Victoria and the government. In response, Rule with the “irresistible impulse” test. The ALI
the House of Lords was asked to provide specific standard, adopted with the 1972 ruling in United
answers to a set of five questions about how to States v. Brawner, required that an individual
define legal insanity. Their answers became known lack the “substantial capacity” to understand the
as the M’Naghten Rules, which established wrongfulness of their behavior. It also excluded
 Hospitals for the Criminally Insane 357

defendants who engaged in repeated criminal Individuals who are deemed criminally insane
behavior from effectively utilizing this defense. require treatment for their mental illnesses. Within
Unlike the M’Naghten Rule, the ALI standard the United States, these individuals are typically
considers both emotional and cognitive deter- sent to state hospitals for mental health treatment.
minants of criminal behavior. Approximately 18 State hospitals typically provide treatment for a
states utilize the ALI model in insanity cases. variety of forensically linked individuals, which
The most recent development with regard to includes those found guilty of a crime by reason
the insanity defense is “guilty but mentally ill,” of insanity, those not competent to stand trial, sex
which was first adopted in 1975 in Michigan after offenders, pretrial evaluation patients, and indi-
a series of individuals deemed not guilty by rea- viduals who have been found guilty but mentally
son of insanity were subsequently released from ill. Individuals who have been found guilty of a
hospitals and then committed violent crimes. crime by reason of insanity and those found not
Defendants can be found guilty but mentally ill competent to stand trial occupy a majority of the
if they are guilty at the time of the offense, men- forensic state hospital beds. With rare exceptions,
tally ill at the time of the offense, and not legally patients are not placed in community-based treat-
insane at the time of the offense. Individuals who ment facilities because they are considered too
are found guilty but mentally ill begin treatment dangerous. Generally, treatment programs for
at a hospital and are subsequently transferred to forensically involved individuals differ consid-
a prison for the remainder of their sentence. Pro- erably, depending on the state, its political and
ponents of the guilty but mentally ill plea believe organizational structure, and its designated finan-
it is a fair compromise because defendants receive cial funding of forensic patients.
treatment but will not be released before complet- Forensic patients also typically require special-
ing their sentence. Unlike individuals who have ized programs to ensure that their care and treat-
been deemed not guilty by reason of insanity, ment are consistent with the patient’s current legal
individuals found guilty but mentally ill are held circumstances. Clinicians working with this pop-
criminally responsible for their crimes. At least 20 ulation require specialized training, which may
states utilize guilty but mentally ill pleas. include assessing an individual’s competency to
stand trial or determining an individual’s respon-
Criminal Insanity sibility or mind-set at the time of the offense. Cli-
An inmate is considered criminally insane if he or nicians must also possess the ability to effectively
she has been convicted of a crime that was commit- manage the risk associated with potentially vio-
ted when the individual was so impaired by a men- lent behavior.
tal illness that they were not aware their actions
were wrong. There are no specific mental illnesses State Hospitals and Changing Trends
that are consistently associated with criminal Over the past 50 years, many state hospital facili-
insanity. Commonly associated illnesses include ties have closed because of changes in policies asso-
those with psychotic features involving delusions ciated with deinstitutionalization, which emerged
and/or hallucinations. Other mental health symp- in the 1950s and refers to the process of closing
toms associated with the criminally insane include state psychiatric institutions and moving patients
severe aggression, disorganized speech, disorga- into the community for treatment. Prior to deinsti-
nized thought, loose associations, psychomotor tutionalization, individuals housed in psychiatric
agitation, and self-injurious behavior. facilities were generally those with severe mental
Individuals who are deemed criminally insane illnesses and not necessarily forensic patients. The
have been convicted of crimes that vary greatly in annual number of admissions to state hospitals
severity. The range includes convictions for child was at its highest in 1955 (559,000). Studies have
molestation, rape, murder, and a number of lesser shown that during the 1990s, more state psychi-
crimes, including burglary, robbery, and theft. atric hospitals closed than during the previous
Many of the criminally insane remain within state two decades combined. Studies in 2002 estimated
facilities indefinitely, though some are condition- that there were approximately 160,000 state psy-
ally and incrementally released back into society. chiatric hospital patients in the United States.
358 Human Rights

Trends in state psychiatric hospital admis- men and women are housed in American prisons.
sions have been changing. A 2009 study of eight The increasingly larger numbers of jail and prisons
states reported the first increase in state psychi- housing psychiatric populations have led some to
atric hospital admissions since 1971. This rever- conclude that they have become the nation’s larg-
sal in trends is thought to be due to the larger est de facto psychiatric institutions.
numbers of patients entering the state psychiatric
hospital system through the criminal justice sys- Christine M. Sarteschi
tem. In some states, the majority of state psychi- Chatham University
atric hospitals are occupied by forensically linked
patients. One such example is California’s Napa See Also: Architecture; Asylums; Courts;
State Hospital. A 2001 San Francisco Chronicle Deinstitutionalization; Insanity Defense; Jails and
report described a situation in which the hospital Prisons; Law and Mental Illness; Moral Insanity;
was ill equipped to handle its violent patients. As Policy: Police; Violence.
stated in the report, the hospital had been expe-
riencing a severe employee shortage. The nursing Further Readings
staff was barely able to attend to the patient’s Allderidge, Patricia H. “Criminal Insanity: Bethlem to
medical needs and felt unprepared to deal with Broadmoor.” Proceedings of the Royal Society of
the many violent outbursts among patients. Staff Medicine, v.67/9 (1974).
were fearful of patients, and patient-on-patient Doyle, Jim and Peter Fimrite. “Criminally Insane
violence was a growing concern. The majority of Taking Over State Hospitals: Violent Patients
the staff were female nurses caring for criminally Assault Infirm, Elderly, Even Staff—At Times With
insane men. Critics of the hospital suggested that Deadly Consequences.” San Francisco Chronicle
it was effectively a prison that was warehousing (July 22, 2001). http://www.sfgate.com/health/
the criminally insane rather than treating them. article/Criminally-insane-taking-over-state
State officials contended that the hospital was -hospitals-2897717.php (Accessed October 2012).
providing a high-level quality of care and meeting Huss, Matthew T. “Forensic Psychology: Research,
the needs of its patients. Practice, and Applications.” West Sussex, UK:
Other state hospitals in California were alleged Wiley-Blackwell, 2009.
to have similar problems. Across the state, hospi- Manderscheid, Ronald W., Joanne E. Atay, and
tal officials reported a significant increase in the Raquel A. Crider. “Changing Treads and State
number of criminally insane patients. It was esti- Psychiatric Hospital Use From 2000 to 2005.”
mated that of the 4,227 patients in California state Psychiatric Services, v.60 (2009).
mental hospitals between 1999 and 2000, 3,336 Scalora, Mario J. “No Place Else to Go: The
were forensically linked patients (79 percent). Changing Role of State Hospitals and Forensic
There are no national statistics with regard to Mental Health Services.” New Directions in
the number of hospitals that house the criminally Mental Health, v.84 (1999).
insane or the number of patients who are housed Steadman, Henry J., Fred C. Osher, Pamela Clark
in these hospitals. States individually determine Robbins, Brian Case, and Steven Samuels.
where to place the criminally insane. Some are con- “Prevalence of Serious Mental Illness Among Jail
fined to specific wards of state hospital psychiatric Inmates.” Psychiatric Services, v.60 (2009).
facilities, which are increasingly being managed by
departments of corrections. In other cases, individ-
uals who are deemed criminally insane live within
the prison system. Historically, these individuals
would have been placed in state psychiatric hos- Human Rights
pitals; however, many remain incarcerated because
of state psychiatric hospital shortages. Prevalence Human rights are universal, egalitarian, and
estimates suggest that 14.5 to 31 percent of women peremptory entitlements that all humans have
housed in American jails have serious mental ill- under international law by virtue of their being
nesses. A similar percentage of severely mentally ill human. While the concept of natural rights can
 Human Rights 359

be traced back to ancient Greek and Roman unique vulnerabilities arising from disability, it was
laws, the English Magna Carta, the writings of necessary for the United Nations (UN) to adopt
Enlightenment philosophers such as John Locke, additional human rights instruments to address
and the political discourse of the French and such vulnerabilities, such as the Principles for the
American Revolutions, the legal principles upon Protection of Persons with Mental Illness and for
which modern human rights claims are made did the Improvement of Mental Health Care (MI Prin-
not crystallize until after World War II, with the ciples) in 1991 and the Convention on the Rights
adoption of the Universal Declaration of Human of Persons with Disabilities (CRPD) in 2006. The
Rights by the United Nations General Assem- MI Principles set forth human rights standards and
bly in 1948. Rights established in the declara- procedural guarantees for individuals diagnosed
tion include, among others, freedom of speech, with mental illnesses. The CRPD formally recog-
movement, association, thought, conscience, and nizes persons with disabilities as having a right to
religion; freedom from torture, slavery, arbitrary independent living and equal access to commu-
arrest and detention, and arbitrary attacks on nity services and facilities and affirms their right
one’s reputation; the right to life, liberty, security to enjoy the highest attainable standard of health
of person, work, education, and standards of liv- without enduring discrimination based on disabil-
ing adequate for the health and well-being of one- ity (Article 25, Health). Health care providers in
self and one’s family; and the right to a fair and states that have ratified the CRPD are legally, pro-
public trial if accused of a criminal offense. fessionally, and ethically obliged to ensure that the
Human rights scholars traditionally draw a dis- provisions of Article 25 are satisfied.
tinction between negative rights (which require
the state to refrain from intervening in people’s Violations of Psychiatric Patients’
lives such as by not engaging in torture and intim- Human Rights
idation) and positive rights (which require the In spite of recent advances, legally binding instru-
state to intervene in people’s lives such as by insti- ments such as UN conventions are powerless
tuting social security, housing, educational, and if not given expression in local, regional, and
employment programs). In practice, most of these national legal codes and infrastructures. Up to
human rights cannot be realized without system- a quarter of the world’s countries currently have
atic legislative and administrative effort. no mental health legislation, and legislation that
does exist elsewhere tends to address persons with
Disability Rights Movement psychiatric disabilities not as individuals with
The claim that human rights instruments are uni- natural rights but as subjects of welfare and char-
versal in scope has been challenged by the global ity programs. In 2003, the WHO reported that
disability rights movement. Since the 1980s, dis- 15 percent of countries with mental health laws
ability rights scholars have argued that discrimina- enacted their laws before 1960, prior to the devel-
tion against disabled people arises not from their opment of current understandings of psychiatric
functional impairments per se but from sociocul- etiology and recovery. Although low- and middle-
tural, ideological, and attitudinal responses to income countries encompass over 80 percent of
their impairments. In its 1997 and 2001 classifica- the world’s population, they account for less than
tions of disease, the World Health Organization 20 percent of the world’s total mental health care
(WHO) formally adopted this framework, moving resources. The existence of mental health laws
away from a conception of disability as something and custodial facilities is no guarantor of human
localized within individuals and focusing instead rights for people with psychiatric diagnoses, as
on how societies fail to accommodate human many countries’ laws restrict access to other vital
difference and how legislation can redress these determinants of mental health, such as housing,
failures. This conceptual shift was central to the education, medication, and noncustodial after-
installment of disability, including psychiatric dis- care. Poorly designed legislation may also be used
ability, under the purview of human rights laws. to legitimize human rights abuses and neglect by
Because the Universal Declaration of Human health care workers, courts, law enforcement per-
Rights was written without taking into account sonnel, and the state at large.
360 Human Rights

Because people with psychiatric diagnoses are Human Rights as Central to the Promotion
frequently believed to have a diminished capacity of Mental Wellness
for logical thinking and rational decision mak- Mental health may be conceptualized as an out-
ing, debates about how and when their freedoms come rather than a determinant of a person’s
may be curtailed or qualified have unfolded in enjoyment of human rights. Like all people, peo-
many jurisdictions. As Mary O’Hagan, a former ple with psychiatric diagnoses cannot exercise
chair of the World Network of Users and Survi- their full complement of rights without concerted
vors of Psychiatry, has observed, “International legislative action that makes housing, social ser-
human rights agencies have rightly objected to vices, employment opportunities, and other vital
the psychiatric incarceration of political dissi- resources accessible and affordable to them and
dents in some countries while turning a blind eye safeguards them from racial, ethnic, sexual, reli-
to the compulsory regimes imposed upon ordi- gious, and age discrimination. As the constitution
nary citizens diagnosed with mental illness in of the WHO affirms, health is “a state of complete
other countries.” physical, mental, and social well-being and not
The contradiction that O’Hagan identifies merely the absence of disease or infirmity.” Thus,
arises from two interlinked factors. Health care health, including mental health, is not merely a
professionals may readily see how psychiatric biological status but a socially emergent process
patients in other societies have been detained on that requires ongoing environmental, physical,
the basis of politically or culturally transgressive political, and symbolic nourishment.
behaviors but may believe their own society’s While most national health agencies and pro-
diagnostic practices to be value neutral and more grams in the West acknowledge this definition,
objective. This perception can result in forms of it is not always reflected in policy and legisla-
paternalism that are detrimental to the dignity tion. For example, the Public Health Agency of
and welfare of patients, such as the premature Canada recognized in 2003 that major precon-
identification of surrogate decision makers or ditions for health include, among other things,
guardians for psychiatric patients whose wishes income equality, job security, adequate working
depart from those of medical personnel as well as conditions, food security, education, and peace.
the premature imposition of chemical or physical Nonetheless, Canadian disability support pro-
restraints on patients with serious diagnoses but grams continue to legitimize a narrow definition
no personal history of violent conduct. of mental health by covering psychiatric medica-
In March 2013, Juan E. Méndez, the United tions while making few provisions for other fac-
Nation’s Special Rapporteur on torture and other tors that decisively impact the consolidation and
cruel, inhuman, or degrading treatment or pun- maintenance of mental wellness, including access
ishment, reported that severe human rights abuses to education and information, adequate nutri-
continue to be perpetrated in mental health care tion, outlets for satisfying intellectual and cre-
settings worldwide, whereby patients’ choices are ative needs, and substantive participation in the
commonly overridden on the basis of their sup- political life of one’s community.
posed best interests as interpreted by medical In addition, public health campaigns rarely
personnel. This has led to the widespread use of mention social justice as a crucial ingredient of
rehabilitative practices that, in his view, are not mental health, despite a long-standing epidemio-
meaningfully distinguishable from torture—soli- logical consensus that women, sexual minorities,
tary confinement, prolonged restraint, segregation members of minority ethnic and religious groups,
from family and community, forced medication, and people living in extreme poverty suffer worse
psychosurgery, electroshock, and the terror and mental health.
anxiety that such treatment incurs when forced
upon unwilling individuals. Méndez suggests that Critiques of Human Rights-Based
the reframing of human rights abuses in health Frameworks
care settings as prohibited torture may afford vic- Mental health care laws that rely on a human
tims of such abuses stronger legal protections and rights framework have been critiqued for simply
enhanced access to redress. transferring the authority to detain people with
 Huntington’s Disease 361

psychiatric diagnoses from clinicians to courts. Mental Illness, Discrimination, and the Law.
Some legal scholars argue that many states now Oxford, UK: Wiley-Blackwell, 2012.
employ human rights rhetoric to strengthen their Dudley, Michael, Derrick Silove, and Fran Gale, eds.
powers of preventive detention on the grounds Mental Health and Human Rights: Vision, Praxis,
that the public has a right to be protected from and Courage. Oxford: Oxford University Press,
the potential danger that mental patients repre- 2012.
sent. Other researchers suggest that rights-based McSherry, Bernadette and Penelope Weller, eds.
laws promote the idea that psychiatric patients Rethinking Rights-Based Mental Health Laws.
enjoy equitable treatment while eliding society’s Oxford: Hart Publishing, 2010.
widespread deference to medical authority and Méndez, Juan E. “Statement by Mr. Juan E. Méndez,
the impact of this deference on patients’ opportu- Special Rapporteur on Torture and Other Cruel,
nities in life, credibility in discussions concerning Inhuman or Degrading Treatment or Punishment.”
their treatment, and access to services. 22nd Session of the Human Rights Council,
The promotion of access to health care as a Agenda Item 3. Geneva: UNHRC, March 4,
human right can also come at the expense of less 2013.
localizable rights. As psychiatrist Derek Summer- O’Hagan, Mary. “Foreword.” In Mental Health
field has noted, Western aid workers’ emphasis on and Human Rights: Vision, Praxis, and Courage,
psychiatric trauma relief in war-afflicted regions Michael Dudley, Derrick Silove, and Fran Gale,
diverts attention and resources away from the eds. Oxford: Oxford University Press, 2012.
root causes of refugees’ suffering—geopolitical Summerfield, Derek. “A Critique of Seven
injustices and economic inequalities—and mis- Assumptions Behind Psychological Trauma
guidedly transforms the understandable pain of Programmes in War-Affected Areas.” Social
war into an illness. Anthropologists and postco- Science & Medicine, v.48/10 (1999).
lonial scholars have also critiqued the WHO for United Nations. “Convention on the Rights of
framing access to psychiatric services as a human Persons With Disabilities” (2006). http://www.un
right that is lacking in developing nations with- .org/disabilities/convention/conventionfull.shtml
out acknowledging Western psychiatry’s role in (Accessed May 2013).
imperialism. World Health Organization. “Constitution of the
World Health Organization: Basic Documents.”
Eugenia Tsao 45th ed., supplement (2006). http://www.who.int/
University of Toronto governance/eb/who_constitution_en.pdf (Accessed
May 2013).
See Also: Compulsory Treatment; Courts; World Health Organization (WHO). Mental Health
Dangerousness; Disability; Disasters; Ethical Issues; Legislation and Human Rights. Geneva: WHO,
Eugenics; Euthanasia; Exclusion; Global Mental 2003.
Health Movement; Homelessness; Inequality;
Informed Consent; Law and Mental Illness;
Marginalization; Mechanical Restraint; Nazi
Extermination Policies; Patient Rights; Policy:
Federal Government; Prison Psychiatry; Race; Race Huntington’s Disease
and Ethnic Groups, American; Religion; Right
to Refuse Treatment; Right to Treatment; State Huntington’s disease is a rare neurodegenerative
Budgets; Sterilization; Trauma, Psychology of; genetic disorder with psychological, physiologi-
Violence; Vulnerability; War; Women; World Health cal, and social repercussions. It is characterized
Organization. by the onset of psychiatric symptomology, declin-
ing muscle coordination, and loss of cognitive
Further Readings abilities. Although genetic in nature, Huntington’s
Callard, Felicity, Norman Sartorius, Julio Arboleda- disease is significantly impacted by culture in a
Flórez, Peter Bartlett, Hanfried Helmchen, Heather number of ways. Among them are risk factors for
Stuart, Jose Taborda, and Graham Thornicroft. the disease, variation in prevalence rates among
362 Huntington’s Disease

countries, interpretation of symptoms, and treat-

ment and responses to the illness.

Background
Prior to first being identified as a separate disorder,
people with Huntington’s disease were sometimes
thought to be witches or possessed by demons
and later were simply lumped together with “the
insane.” This resulted in people with the disorder
being shunned or exiled from their communities.
In 1872, George Huntington noticed that this
particular collection of symptoms ran in families,
suggesting a genetic origin to the disorder.
Because Huntington’s disease is caused by a
genetic defect, the increase of prevalence and ear-
lier age of onset are less likely due to cultural influ-
ences; rather, the factors include better detection
and an increase in incidence of cases. These new
cases are attributable to how the genetic defect
causing Huntington’s disease is passed from parent
to child at a rate of approximately 50 percent as
well as how the genetic repeat increases with each
new generation. In 1993, Huntington’s disease
was attributed to a genetic defect on chromosome Folk musician Woody Guthrie in 1943. By the late 1940s,
4. A section of DNA known as a CAG repeat hap- Guthrie’s health was declining and various diagnoses such as
pens significantly more often in people with the alcoholism and schizophrenia attempted to explain his erratic
disorder. In most people, the CAG repeat occurs behavior. In 1952, he was diagnosed with Huntington’s disease.
between 10 and 28 times; however, for those with
Huntington’s disease, the repeat occurs up to 120
times. As this genetic repeat is passed from parent
to child, the repeats increase, resulting in an earlier depression and suicide among sufferers. Notice-
age of onset for the next generation. able changes in gait and movement are noted, such
Because most cases of Huntington’s disease as facial grimaces, sudden jerking movements,
have an age of onset during midlife, in the absence tremors, and rigid or slow movements. In the later
of genetic testing, many people with the disorder stages of the illness, individuals with the disease
have already had children by the time they realize no longer are able to walk, communicate, and eat
that they have the disease. About 10 percent of by themselves, but they are still conscious and able
identified cases have juvenile Huntington’s disease to recognize family members.
with an onset prior to age 20. The wide array of symptomology has been dif-
ferently interpreted by various cultures. It is not
Symptoms and Risk Factors uncommon for traditional cultures to attribute
Huntington’s disease manifests as various cogni- such a collection of symptoms and behaviors as
tive, behavioral, mental health, and psychomotor resulting from a magic spell or curse.
symptomology. Symptoms of dementia such as A child of someone who is inflicted with Hun-
memory loss, confusion, and loss of judgment and tington’s disease runs a 50 percent chance of
speech are common. Behavioral and mental health inheriting the disorder. However, approximately
symptoms characterized by mood changes, psy- 8 percent of Huntington’s disease cases are attrib-
chosis, hallucinations, and anxiety are reported. In uted to new genetic mutations and are not inher-
particular, caregivers of those with Huntington’s ited from a parent. Huntington’s disease is just as
disease are often warned of the increased risk of common regardless of gender. However, distinct
 Huntington’s Disease 363

ethnic trends are partly due to how Huntington’s disease, although some medications have been
disease has developed. It is commonly believed found to manage some of the symptomology.
that the Huntington genetics repetition devel- Given that Huntington’s disease is a progres-
oped independently in Europe, Japan, and Africa, sively worsening condition requiring 24-hour
resulting in distinct varieties of the genetic muta- care in the later stages, economic resources and
tion. However, those with European ancestry have cultural values play a significant role in how those
the greatest incidence of Huntington’s disease. with the illness receive care. Traditional cultures
with strong family values often provide care
Prevalence Rates by Country themselves, whereas more modern and mobile
Although Huntington’s disease is found in vari- cultures often seek out residential care for those
ous countries and cultures around the world, family members in later stages of the illness.
prevalence rates vary by culture of origin. The Economic resources are vital for the extensive
highest rates of Huntington’s disease exist in care required to manage Huntington’s disease.
Europe and countries where Europeans have For those individuals without health insurance
settled, such as Australia, Canada, and the or who live in countries with poorly established
United States. Countries with the lowest rates of health care systems, the burden of care often
Huntington’s disease are China, Japan, and the falls on family members. This can be devastating
nations of Africa. More specifically, the compar- to families, given that the genetic nature of the
ative prevalence rates per 1 million people are disorder causes many families to have multiple
United States (100), Japan (1 to 4), Hong Kong members with Huntington’s disease. For exam-
(3.7), South Africa (0.6), and European coun- ple, in the previously mentioned state of Zulia,
tries (40 to 100). However, much of the varia- Venezuela, Huntington’s disease is so common
tion in prevalence rates around the world can be that almost every household has members in vari-
attributed to European migration patterns. ous stages of the illness. As a result, children are
One interesting exception is the drastically often not able to attend school as they are either
lower prevalence rates in Finland, with only six inflicted with the disease or are caring for a family
cases per 1 million people, as compared to other member with it.
European countries. This is attributed to Finland’s Since the overall number of people afflicted
genetically distinct lineage. Some reports suggest with the disease is relatively small, research into
that the largest prevalence rates of Huntington’s a cure for Huntington’s disease offers little in the
disease exist in Zulia, Venezuela. Researchers way of financial reward. In the United States, it
attribute this large concentration of people with is estimated that about 30,000 people currently
the disorder to the isolated and impoverished have Huntington’s disease. Pharmaceutical inter-
nature of this area. The geographic isolation of vention research has historically been limited
this area increases the likelihood of both parents because of the small market of people inflicted
being genetically predisposed to developing the with Huntington’s disease.
disease and, due to financial constraints, genetic
testing prior to having children is not employed. Social Challenges
As a result, children in this area can run a three in Given the established genetic link to developing
four chance of developing the disease. Huntington’s disease and the particular sympto-
mology, people with Huntington’s disease endure
Treatment and Care significant legal and social difficulties related to
For an adult sufferer, once the early signs of the the disease. Historically, people with the disease
disease manifest and a person is diagnosed with the have been unable to secure health insurance due
disorder, symptoms usually progress over the next to the genetic nature of this degenerative disorder.
15 to 20 years until death. This progression occurs With no established treatments to stop the pro-
more quickly for an individual with early-onset gression of the disease, those diagnosed will even-
Huntington’s disease, usually between 10 to 15 tually require 24-hour care, which is extremely
years. Currently there is no known treatment that costly. In addition, people with Huntington’s dis-
will slow or stop the progression of Huntington’s ease often endure discrimination in the workplace.
364 Hydrotherapy

Many of the symptoms indicative of Huntington’s Hydrotherapy

disease, such as behavioral disturbances, moodi-
ness, slurred speech, and unsteady gait are com- Hydrotherapy is a part of medicine that involves
monly misinterpreted as intoxication. This can the use of water to treat illness and promote health.
lead to tremendous discrimination and stigma for While water has been regarded as a therapeutic
those suffering with Huntington’s disease, as well agent since ancient times, it became a therapeutic
as their families. intervention for mental illnesses in the late 19th
Moreover, it is also difficult for the children of century and represents one of the earliest efforts
sufferers, given that they run a 50 percent chance at treating psychiatric illness through somatic or
of developing the disease themselves. Cultural bodily interventions.
and religious beliefs also impact the decision to The resurgent 19th-century interest in the ther-
genetically test—prior to the development of apeutic value of water flowed from the influence
symptoms—children who are at risk of develop- of hydropathy, a popular alternative-healing sect.
ing the disorder. Some cultures are more familiar Hydropathy originated with Vincenz Priessnitz
with genetic testing, while in others it is relatively (1799–1851), an Austrian peasant who viewed
uncommon. water as a means to expel poisons and return the
body to its natural condition of health. His move-
Stephanie Elias Sarabia ment reacted against contemporary medical prac-
Ramapo College tices, including administering drugs, purges, and
bleedings, which he saw as impeding the healing
See Also: Board and Care Homes; Children; Cultural powers of nature. Priessnitz established a spa at
Prevelance; Family Support; Genetics; Incidence Gräfenberg in Austrian Silesia, where he offered
and Prevalence; Measuring Mental Health; Policy: numerous treatments that stimulated perspira-
Medical. tion, which were often followed by immersion in
cold baths. At a time when it was popular to visit
Further Readings spas and mineral baths, Priessnitz’s establishment
Bates, G., P. Harper, and L. Jones. Huntington’s was widely visited by upper-class health seekers.
Disease. 3rd ed. Oxford: Oxford University Press, Impressed with Priessnitz’s institution, numerous
2002. physicians established their own water therapy
Bonelli, R. M. and P. Hofmann. “A Systematic clinics in which they treated various medical
Review of the Treatment Studies in Huntington’s conditions, including psychological illnesses, for
Disease Since 1990.” Expert Opinion on a middle- and upper-class clientele. In this envi-
Pharmacotherapy, v.8 (2007). ronment, advocates for hydrotherapeutic prac-
Bonelli, R. M. and G. K. Wenning. “Pharmacological tices performed research articulating the scien-
Management of Huntington’s Disease: An tific legitimacy for their belief in water’s curative
Evidenced-Based Review.” Current Pharmaceutical power and paved the way for the development of
Design, v.12 (2006). hydrotherapy as a part of medicine.
Penaranda, E., A. Garcia, and L. Montgomery. “It Hydrotherapy’s adoption within psychiatric
Wasn’t Witchcraft—It Was Huntington’s Disease!” hospitals was at first gradual due to the high costs
Journal of American Board of Family Medicine, involved in building and maintaining hydrothera-
v.24 (2011). peutic facilities. However, hydrotherapy made
Quarrell, O. W. Huntington’s Disease: The Facts. 2nd inroads into psychiatric hospitals when psychia-
ed. New York: Oxford University Press, 2008. trists noted that water possessed a tranquilizing
Quarrell, O. W., H. M. Brewer, F. Squiteri, R. A. effect that allowed them to control disruptive
Barker, M. A. Nance, and B. Landwehrmeyer. patient behaviors. Psychiatrists also believed
Juvenile Huntington’s Disease. Oxford: Oxford hydrotherapy to be therapeutic through its ability
University Press, 2009. to encourage sweating and prescribed hydrother-
Roos, R. A. “Huntington’s Disease: A Clinical apy in response to various conditions, including
Review.” Orphanet Journal of Rare Diseases, v.5 excitement, depression, autointoxication, or sim-
(2010). ply when relaxation was desired. By the 1910s,
 Hypersexuality 365

psychiatric institutions across the United States Braslow, J. Mental Ills and Bodily Cures. Berkeley:
and Europe generally employed a variety of hydro- University of California Press, 1997.
therapeutic practices, including applying sponges, Jackson, J. “Hydrotherapy in the Treatment
cold packs, or hot packs to the body and admin- of Mental Diseases: Its Forms, Indications,
istering showers, sprays, or warm baths. Hydro- Contraindications, and Untoward Effects.” Journal
therapeutic technologies could in themselves serve of the American Medical Association, v.64 (1915).
as restraints. For example, wrapping a patient Jagielski, V. “The Therapeutic Action of the
in warmed sheets not only possessed a calming Turkish Bath.” Journal of the American Medical
effect but also restricted the patient’s mobility. As Association, v.27 (1896).
psychiatric institutions adopted hydrotherapeutic Legan, M. “Hydrotherapy in America: A Nineteenth-
practices, numerous theories appeared in medical Century Panacea.” Bulletin of the History of
literature proposing the physiological and bio- Medicine, v.45 (1971).
logical mechanisms by which hydrotherapy cured Porter, R. The Greatest Benefit to Mankind. W. W.
mental illness. Research proposed, for example, Norton, 1997.
that hydrotherapy’s stimulation of the peripheral Richardson, D. and S. Walker. “The Rise and Decline
vascular system relieved cerebral congestion or of Psychiatric Hydrotherapy.” http://www.cornell
that water treatment expelled the toxic chemicals psychiatry.org/history/osk_die_lib/hydrotherapy/
believed to have caused insanity. default.htm (Accessed June 2013).
While the types of hydrotherapeutic practices Shepard, C. “Insanity and the Turkish Bath.” Journal
employed in psychiatric hospitals changed little of the American Medical Association, v.34 (1900).
into the 1950s, the use of water was gradually Shorter, E. A History of Psychiatry: From the Era of
displaced by more powerful means of controlling the Asylum to the Age of Prozac. New York: John
disruptive behavior. Insulin shock therapy in the Wiley & Sons, 1997.
late 1930s and electroshock therapy in the early Strecker, E. “The Continuous Bath in Mental
1940s reduced the use of hydrotherapy in hos- Disease.” Journal of the American Medical
pitals. The development of chlorpromazine and Association, v.68 (1917).
other psychotropic drugs in the 1950s saved hos- Winslow, F. “The Turkish Bath in Mental Disorders.”
pitals the staffing costs of operating hydrotherapy Journal of the American Medical Association, v.27
equipment and further led to the decline of hydro- (1896).
therapy. By the 1970s, the use of hydrotherapy in
psychiatric institutions had virtually disappeared.
Nevertheless, hydrotherapy remains an impor-
tant example of the ways in which the late 19th-
and early 20th-century patient’s body became an Hypersexuality
important site of therapeutic intervention and a
model by which empirical outcomes (e.g., calming There is variance in how hypersexuality is defined
agitated patients) gave rise to biological explana- and used, both as a popular and clinical term.
tions for those observed outcomes. For some, it is used to describe individuals who
have sexual desires, urges, or behaviors that are
Alex Kertzner believed to be outside their control, often referred
University of California, Los Angeles to as sex addiction (a controversial concept).
Likewise, it may include a diagnosis or labeling
See Also: Electroconvulsive Therapy; Electrotherapy; of an individual from a partner, therapist, physi-
Insulin Coma Therapy. cian, or community for a desire or behavior con-
sidered excessive or outside the norm. A patho-
Further Readings logical view of hypersexuality contends that it is
Adler, H. “Indications for Wet Packs in Psychiatric emotionally, socially, or physically harmful to the
Cases: An Analysis of One Thousand Packs.” individual or others, and requires treatment. Yet,
Paper presented at the Psychopathic Hospital, beliefs, behaviors, laws, practices, and values on
Boston, Massachusetts, 1916. sexuality also vary across cultures, contributing
366 Hypersexuality

to difficulties in defining what ought to be consid- particularly anonymous or for-pay sex. In some
ered normal, permissible, or pathological. Despite quarters, paraphilia disorders might be included,
the lack of standardized diagnostic criteria, the although these have been classified differently in
term hypersexuality, along with “sex addiction,” the fourth edition of the Diagnostic and Statisti-
has grown in popularity, particularly in high-tech cal Manual of Mental Disorders (DSM-IV).
countries that have seen Internet use proliferate Critics argue that determining what is sexu-
among their populations. ally excessive depends upon personal and cul-
Throughout much of written history, individu- tural judgments about sexual norms. Personal
als operating outside contemporary norms gov- beliefs, partners, and communities contribute to
erning sexual behavior have attracted stigmatiz- what is considered hypersexual. Furthermore,
ing labels. Historical terms such as nymphomania age, culture, experience, gender, place in history,
and satyriasis are still used to categorize sexual and religion influence what is considered sexually
behaviors considered deviant. Presently, there are normal. Across different cultures, some approach
many exchangeable terms both in the culture at- sex as only procreative, whereas others regard it
large and in the professional literature related to as more recreational. Views on marriage, mari-
hypersexuality. Terms such as compulsive mas- tal affairs, masturbation, pornography, prostitu-
turbation, compulsive sexual behavior, cybersex tion, and sadomasochism can vary significantly,
addiction, dysregulated sexuality, excessive sex- even in the West. Gender plays a complex role.
ual drive, impulsive-compulsive sexual behavior, For example, across some cultures, females may
paraphilia-related disorder, sexual addiction, and bear an unfair burden under the law for infidel-
sexual compulsivity are often indistinguishable ity; recent examples would include capital pun-
terms used for hypersexuality. ishment for adultery and honor killings. By con-
trast, in Anglo-centric countries, the emphasis for
Diagnosing Hypersexuality hypersexual behaviors may be placed on male-
Some of the significant and ongoing discussion oriented behaviors such as paraphilias, pornogra-
points working toward a diagnostic criterion for phy, and soliciting prostitutes or strippers. More
a hypersexuality disorder include the following: research is needed to show what role values play
cross-culturally in hypersexuality.
• Excessive sexual behaviors, desires, and
fantasies Prevalence of Sexual Deviance
• An addiction or an inability for a person Estimating the prevalence of hypersexuality
to change or control their sexual behav- cross-culturally remains challenging, without a
ior or desires standardized criteria for assigning individuals to
• The incapacity to change leads to emo- this status. Likewise, collecting data is difficult
tional, physical, or social stress and because most individuals, because of embarrass-
dysfunction ment, guilt, illegality, or shame, may be uncom-
• The sexual behavior appears to be con- fortable discussing their sexuality. In addition to
tinuous, habitual, or repetitive (maybe these challenges, cross-cultural studies on hyper-
lasting six months are longer), and may sexuality or sex addiction are nonexistent. Rates
be associated with substance abuse or a for the United States show that 3 to 6 percent of
medical condition the population may suffer from hypersexuality,
• The sexual behaviors may be related to although it is unknown how these estimates have
the individual’s mood, such as anxiety, been calculated.
boredom, depression, and irritability, or Meanwhile, media references in popular cul-
a reaction to low self-esteem or stressful ture, not only in the West, but also in other high-
events tech countries like China and India, continue
to increase, which indirectly encourages more
Described hypersexual behavior might include individuals to seek out treatment. In some cases,
cybersex, excessive masturbation, excessive use cybersex and sex addiction have become impor-
of pornography, and sex with multiple partners, tant subcategories to Internet addiction research.
 Hypnosis 367

Notable celebrities seeking treatment, such as See Also: DSM-5; Impulse Control Disorder;
David Duchovny in 2008 and Tiger Woods in Mania; Obsessive-Compulsive Disorder; Personality
2010, put the spotlight on treatment for sexual Disorders; Psychiatry and Sexual Orientation;
addiction. But, sensational media stories with Sadomasochism; Sex; Violence.
noncelebrities, such as Brazilian Ana Catarina
Bezerra, have promoted hypersexuality. She Further Readings
earned the legal right to masturbate at work fol- Bhugra, Dinesh, Dmitri Popelyuk, and Isabel
lowing a diagnosis as hypersexual. Concurrently McMullen. “Paraphilias Across Cultures: Contexts
with the media exposure, there has been a rise and Controversies.” Journal of Sex Research,
in sex addiction treatment centers and programs v.47/2–3 (2010).
that provide a clinical or professional diagnosis Kafka, Martin P. “Hypersexual Disorder: A Proposed
for sexual addiction. Diagnosis for DSM-5.” Archives of Sexual
Hypersexuality as a psychiatric disorder Behavior, v.39/2 (2010).
remains a contentious issue. Questions remain Kaplan, Meg S. and Richard B. Krueger. “Diagnosis,
concerning its classification and description as a Assessment, and Treatment of Hypersexuality.”
disorder, whereas some contend that it doesn’t Journal of Sex Research, v.47/2–3 (2010).
exist at all. The DSM-IV does not categorize Kuzma, John M. and Donald W. Black.
hypersexuality as a disorder. The DSM-III-R used “Epidemiology, Prevalence, and Natural History of
“nonparaphilic sexual addiction,” but did not Compulsive Sexual Behavior.” Psychiatric Clinics
provide any criteria for diagnosis. Later, it was of North America, v.31/4 (2008).
removed from the DSM-IV because of a lack of Ley, David J. The Myth of Sexual Addiction. New
supporting empirical research. The World Health York: Rowman & Littlefield, 2012.
Organization offers another diagnostic classifi-
cation, called the International Classification of
Diseases (ICD). The ICD-10 F52.7 lists “exces-
sive sexual drive” but does not provide any crite-
ria. Ongoing discussions continue to add a hyper- Hypnosis
sexuality disorder to the DSM.
The DSM plays an instrumental role in estab- Though its roots are less than scientific, hypno-
lishing criteria for psychiatric disorders world- sis as it is currently conceptualized is the subject
wide. The criteria can be criticized for being of a great deal of legitimate scientific research
Western centric, and has previously presented and practical applications. Phenomena similar
some diagnostic difficulties for non-Western cul- to current conceptualizations of hypnosis have
tures. Furthermore, past changes to the DSM been described for centuries across numerous
raise questions about its objectivity, and even cultures (e.g., ancient India and ancient Greece).
more so in the area of sexuality, where significant The work of Franz Mesmer (1734–1815) in late-
changes have occurred; for example, the dropping 18th-century Vienna and Paris, where he placed
of homosexuality as a disorder, and the removal individuals into a trance-like state, is a precursor
of gender identity disorder. Concerned about the to modern-day hypnosis. An official investigation
lack of objectivity, the British Psychological Soci- ordered by the French king (one of whose mem-
ety voiced criticism of the American Psychologi- bers was the American ambassador to France,
cal Association in 2011 for making psychiatric Benjamin Franklin) revealed that his method had
disorders out of normal behaviors. Questions some effect on individuals; however, his theory
remain about how successful diagnostic criteria of the mechanism by which this effect occurred,
for sexual disorders relevantly address psychiatric termed animal magnetism, was rejected, with the
sexual issues across cultures, whether in diagnosis results of his treatment instead attributed to the
or treatment. power of suggestion.
James Braid (1795–1860), who coined the
Scott Alexander Vieira term hypnosis as it is used today, rejected the
Sam Houston State University notion that a hypnotic state could be induced by
368 Hypnosis

something outside the realm of observable scien- There remains some debate as to how to define
tific phenomena, such as Mesmer’s animal mag- and explain the phenomenon of hypnosis. The
netism. His work influenced that of Jean-Martin Society of Psychological Hypnosis (Division 30 of
Charcot (1825–93) and his students, Pierre Janet the American Psychological Association) defines
(1859–1947) and Sigmund Freud (1856–1939), hypnosis as a process wherein an individual’s
who pioneered the use of hypnosis in the treat- thoughts, feelings, or behaviors are changed per
ment of psychological disorders. Freud subse- the suggestion of a hypnotist. Subjects may also
quently rejected hypnosis in favor of his method learn how to hypnotize themselves in the absence
of “free association.” of another person, such that they perform the
Modern investigations of hypnosis are consid- roles of both hypnotic subject and hypnotist.
ered to have begun with the work of experimen-
tal psychologist Clark L. Hull (1884–1952), who Hypnotic Induction and Hypnotic
conducted numerous studies in an effort to deter- Suggestions
mine the role of motivation and suggestion in The process of hypnosis consists of two compo-
hypnosis. The development of standardized mea- nents: the hypnotic induction and hypnotic sugges-
sures of hypnotizability in the 1950s and 1960s tions. The hypnotic induction is an introduction to
by researchers such as Ernest Ropiequet Hilgard the hypnotic state, facilitated by suggestions to (for
(1904–2001) and André Muller Weitzenhof- example) concentrate on a particular thing (e.g., a
fer (1921–2004) further facilitated the scientific small mark on the wall, or imagery). Some indi-
exploration of hypnosis and provided a standard- viduals may require a longer, more intense induc-
ized means by which to evaluate an individual’s tion to enter the hypnotic state than others, and
potential to benefit from the use of hypnosis in whether induction is necessary or not to the pro-
clinical settings. cess of hypnosis remains an area of some debate.

A 1887 painting by the French artist Pierre-André Brouillet depicts Jean-Martin Charcot demonstrating the symptoms of hysteria in a
clinical lecture at the Clinique à la Salpêtrière. Believing hysteria to be the result of a hereditarily weak neurological system, Charcot
hypnotized his patients in order to induce and then study—but not cure—their symptoms. He based this work on his belief that a
hypnotized state was very similar to a bout of hysteria. Alfred Binet, Pierre Janet, and Sigmund Freud were among Charcot’s students.
 Hysteria 369

Once the subject has entered a state of hypnosis, a variety of theoretical orientations. For example,
the hypnotist may suggest to the subject that he or there is evidence to suggest that individuals in cog-
she will undergo some change in experience. nitive behavioral therapy who receive hypnosis as
Subjects can also be taught self-hypnosis, a pro- an adjunct to treatment exhibit better outcomes
cess by which an individual experiences hypnosis than those who receive cognitive behavioral ther-
without the assistance of another person. There apy alone. In cases such as this, researchers sus-
are several types of hypnotic suggestions, includ- pect that hypnosis serves to enhance the effects
ing ideomotor suggestions, wherein it is suggested of these treatments among individuals who are
to the subject that he or she will experience a hypnotizable.
motor movement (e.g., “You are holding a very
heavy object in your right hand, so heavy that it Hope Brasfield
is becoming difficult to keep your arm raised”); Heather Zucosky
challenge suggestions, wherein it is suggested Jeniimarie Febres
that the subject will be unable to do something Gregory L. Stuart
that he or she is asked to attempt anyway (e.g., University of Tennessee, Knoxville
“Your eyes are glued shut. It would be very dif-
ficult to open your eyes. You probably could not See Also: Mesmerism; Psychoanalysis, History and
do so even if you tried. Just try to open your eyes Sociology of; Psychoanalytic Treatment.
now. Try”); and cognitive suggestions, wherein
it is suggested that the subject will experience Further Readings
some change in thoughts, feelings, sensations, or Fromm, E., D. P. Brown, S. W. Hurt, J. Z. Oberlander,
perceptions (e.g., “Although you did not notice A. M. Boxer, and G. Pfeifer. “The Phenomena and
before now, you have begun to notice a fly buzz- Characteristics of Self-Hypnosis.” International
ing about the room”). Journal of Clinical and Experimental Hypnosis,
Individuals range in their levels of hypnotiz- v.29 (1981).
ability. Standardized measures of hypnotizabil- Green, J. P., A. F. Barabasz, D. Barrett, and G. H.
ity, such as Ernest Hilgard and André Weitzen- Montgomery. “Forging Ahead: The 2003 APA
hoffer’s Stanford Hypnotic Susceptibility Scales, Division 30 Definition of Hypnosis.” International
rely on behavioral observations of an individu- Journal of Clinical and Experimental Hypnosis,
al’s responses to suggestions while hypnotized. v.5 (2005).
Though some individuals are exceptionally hyp- Nash, M. R. and A. J. Barnier, eds. The Oxford
notizable, and others are essentially unhypnotiz- Handbook of Hypnosis: Theory, Research, and
able, most individuals are able to experience hyp- Practice. New York: Oxford University Press,
nosis to some degree. Further, hypnotizability is a 2008.
stable individual trait, meaning that individuals’ “People and Discoveries: Jean-Martin Charcot, 1825–
hypnotizability stays roughly the same through- 1893.” PBS. http://www.pbs.org/wgbh/aso/data
out their lives. However, there is little evidence for bank/entries/bhchar.html (Accessed June 2013).
its association with other traits, such as personal-
ity characteristics or intelligence.
Practical applications of hypnosis exist in a
variety of fields, such as psychology and medi-
cine. Hypnotherapy, wherein hypnosis is used in Hysteria
conjunction with psychotherapy, has been found
to be effective in the treatment of various anxiety Hysteria refers to illnesses in which psychologi-
and mood disorders, pain management, irritable cal distress manifests itself in bodily symptoms, a
bowel syndrome, and addictions. It is not the process often termed somaticization. Historically,
experience of hypnosis that is thought to facilitate hysteria was commonly used as a medical diag-
change but rather the experiences facilitated by nosis for patients presenting with a broad range
specific suggestions made while the subject is hyp- of physical maladies including convulsions, irreg-
notized. This allows for the use of hypnosis across ular speech or mutism, loss of hearing, sexual
370 Hysteria

dysfunction, and gastrointestinal or genitourinary worked with hysterical patients at the Salpêtrière
complaints. The characteristic symptoms of hys- teaching hospital in France, presenting hysteri-
teria vary widely across cultures. Hysteria is dif- cal patients to medical students and other inter-
ferent from “acting out” or malingering, though ested parties in popular lectures. Patients at the
the distinction in practice is often hard to draw, Salpêtrière exhibited an extreme range of symp-
and those suffering from hysteria are often sus- toms, illustrating the tendency for hysteria to vary
pected of faking their symptoms. The physical broadly, depredating on context and the type of
effects of psychological distress have a real and interventions employed. Catatonia, or the “wax-
often debilitating effect on health and have gener- like” behavior of limbs so that they become fixed
ally been understood since the late 19th century in unusual positions, was a particularly salient
to be motivated by unconscious conflicts, fears, feature of early cases of hysteria.
and desires. Hysteria has also been linked to the Sigmund Freud (1856–1939) studied under
experience of trauma, especially at a young age or Charcot and later published Studies on Hyste-
in an unfamiliar cultural milieu. ria with his colleague Josef Breuer (1842–1925),
Although hysteria shares characteristics with the most well-known text on the disorder. Freud
conversion disorders and somatoform disorders emphasized the sexual etiology of many cases of
as described in the fourth edition of the Diag- hysteria, suggesting that the disease stemmed from
nostic and Statistical Manual (DSM-IV), the term sexual drives, desires, and fears that were largely
has fallen out of use as a diagnostic category. unconscious. After World War I, the diagnosis of
The term is used colloquially in many cultures to “shell shock” in traumatized soldiers shared char-
describe displays of emotional distress, especially acteristics with hysteria, adding to evidence that
those judged to be of an excessive nature, and traumatic experiences of various kinds might trig-
to refer to a social phenomenon such as “mass ger or exacerbate cases of hysteria.
hysteria,” where panic spreads quickly through
social contact and is evidenced by embodied Diagnosis and Treatment
symptoms or behaviors, such as in riots or cases Hysteria is sometimes used interchangeably with
of social and/or moral panic. Briquet’s syndrome, named for Paul Briquet
(1796–1881), who described patients reporting
Origins of Hysteria symptoms with no known medical cause that
The word hysteria comes from the Greek for often affected multiple organs. Some practitio-
“uterus.” The term is often associated with a ners distinguish between the two disorders by
belief in early Greek medicine that unexplained suggesting that hysteria emphasizes the role of
physical disorders in female patients were caused the unconscious. Briquet, by contrast, focused
by movement of the uterus within the body. The on the potential involvement of the nervous sys-
discovery of the constellation of disorders related tem, contributing to the development of hysteria
to this perceived problem is often attributed to the as a nervous disease that persists today in the
Greek physician Hippocrates (460–370 b.c.e.). labeling of visible expressions of anxiety as hys-
However, historian and linguist Helen King terical behavior.
has shown that the medical literature attributed Hysteria is most often diagnosed in young
to Hippocrates does not use the term hysteria. adults and has been more commonly diagnosed
Instead, Hippocrates refers to the womb as a com- in women throughout its history, although Freud
mon origin of diseases and focuses on “hysteric” was a notable voice in arguing for the prevalence
maladies, many of which were related to diagnos- of the disorder in men. Men have often been diag-
able medical conditions, such as pregnancy. nosed instead with neurasthenia. Some research-
The association of hysteria with “nervous fits” ers have suggested that the tendency for men to
and other physical expressions of psychological be diagnosed with neurasthenia and women to
distress developed during the 19th century, as the be diagnosed with hysteria reflects a social rather
presumed nexus of disordered behavior shifted than a medical distinction. Neurasthenia is also
toward the brain and nervous system rather seen as a problem of higher-class persons, a char-
than the womb. Jean-Martin Charcot (1825–93) acteristic “nervous disorder” of the wealthy.
 Hysteria 371

Hysteria has fallen out of favor as a common in hysteria across cultures. For example, somatic
diagnosis. The symptoms of hysteria are particu- symptoms related to reported experiences of
larly difficult to describe, not only because of their witchcraft in England and early America have
variety, but also because hysterics often appear to been attributed to strict religious practices, expo-
experience symptoms that mimic common dis- sure to tainted food, and vitamin deficiency. How-
eases and mirror or transgress socially expected ever, the question of whether any particular case
behaviors. It is also possible that historical case of hysteria can be explained in whole or in part
studies of individual pathologies diagnosed as by nonpsychogenic factors remains unanswered.
hysteria might be interpreted as evidence of dis-
eases that did not exist or were not easily detect- Sociology of Hysteria
able during the life of the patient. Hysteria is associated with modern phenomena
Freud referred to psychoanalytic interventions such as social and moral panics and mass hysteria.
with hysteric patients as the “talking cure.” He The manifestation of these kinds of group behav-
found that encouraging patients to talk about iors varies broadly across cultural contexts. In
the unspoken and often primarily or completely the United States, unexplained manifestations of
unconscious psychological conflicts underlying embodied symptoms similar to hysteria have been
hysteria helped dispel physical symptoms. Silas attributed to causes as broad as exposure to envi-
Weir Mitchell, an American neurologist, pio- ronmental contaminants and alien abduction. The
neered the “rest cure.” The rest cure generally individual response to epidemic disease, economic
required patients to leave their everyday lives in crisis, and political unrest also mirrors symptoms
favor of isolation and bed rest, sometimes accom- of hysteria. Some theorists and practitioners have
panied with dieting and electrotherapy treatment. referred to disorders such as Gulf War syndrome
Electroconvulsive therapy was sometimes used as and chronic fatigue as modern hysterias.
a treatment for hysteria. Institutionalization of The apparent social contagion of certain acts
patients with hysteria was a common intervention. and beliefs—from fads to mass shootings to the
response to pandemic disease—has also been
Hysteria, Race, and Culture related to hysteria or mass hysteria. Triggers
Hysteria has often been associated with marginal- for hysteria and hysterical behavior vary widely
ized populations, including women and minori- across cultures. Western cultures that have tra-
ties. For example, civil rights activists and other ditionally focused on disease as individualized,
social reformers have been referred to as hysteri- rather than socially contingent, may be more
cal. Socially acceptable expressions of embodied likely to diagnose in ways consistent with hyste-
racial and gender identity might be labeled as ria, whereas non-Western cultures that consider
hysteria when taken out of context. Cultural his- influence between individuals might view disease
torian Sander Gilman points out how visual rep- as possible evidence of social contagion rather
resentations of hysteria perpetuate judgments of than psychosomatic illness. Historian and scholar
racial and ethnic groups based on physiognomy, of literature Elaine Showalter argues that hysteria
suggesting that the visual presentation of hysteria persists as a cultural phenomenon rather than a
in 20th-century Europe was employed to stigma- medical phenomenon, calling theorists and practi-
tize and stereotype the Jewish body in a reflection tioners who use the disease to direct investigations
of anti-Semitic and eugenic thinking in the medi- of sexuality and gender identity, culture, politics,
cal establishment of the time. and personal histories “New Hysterians.”
Hysteria is a highly mutable phenomenon,
notable for its tendency to take on culturally sig- Kira Walsh
nificant features and change over time. Hysteria’s Emory University
adaptability is one of its most salient and persis-
tent characteristics, as somatic symptoms akin See Also: Diagnosis; Diagnosis in Cross-National
to hysteria have been reported across the world. Context; Freud, Sigmund; Psychoanalysis, History
Some researchers have proposed organic, environ- and Sociology of; Somatization of Distress; Trauma,
mental influences as an explanation for variations Psychology of.
372 Hysteria

Further Readings Scull, Andrew. Hysteria: The Disturbing History.

Ellenberger, Henri F. The Discovery of Psychoanalysis: Oxford: Oxford University Press, 2012.
The History and Evolution of Dynamic Psychiatry. Showalter, Elaine. Hystories: Hysterical Epidemics
New York: Basic Books, 1970. and Modern Culture. New York: Columbia
Gilman, Sander L., Helen King, Roy Porter, and University Press, 1997.
Elaine Showalter. Hysteria Beyond Freud. Berkeley: Slavney, Phillip R. Perspectives on Hysteria.
University of California Press, 1993. Baltimore, MD: Johns Hopkins University Press,
Scull, Andrew. Hysteria: The Biography. Oxford: 1990.
Oxford University Press, 2009.
 I
Iatrogenic Illness and difficulties in walking. Because of its slow
onset, tardive dyskinesia may not be recognized
Iatrogenesis means literally “brought forth by a or may be incorrectly diagnosed as a mental ill-
healer.” Iatrogenic illness therefore refers to ill- ness rather than a neurological disorder. This can
ness that does not have a naturally emerging cause lead to further iatrogenic complications in that
but is instead created through human medical additional neuroleptics may be prescribed, which
intervention or advice. Iatrogenic illness can arise then further increase the condition’s severity.
through errors (of both commission or omission), Although the adverse effects of prescription
through misconduct, or as a result of the known drugs are generally recognized, a less obvious iat-
risks associated with particular interventions. rogenic side effect of medication is addiction. For
There are a number of clear examples of iatro- example, poor prescription practices related to
genic illness that relate to mental illness. These benzodiazepines can include prescription beyond
include, but are not limited to, the side effects of the appropriate length of time, uncalled for pre-
medication and psychosurgery as well as issues scription, and nontapered withdrawal. Such prac-
relating to diagnosis. tices have been implicated both in the iatrogenic
creation of addiction and in creating unnecessary
Medication Side Effects suffering during withdrawal.
It is recognized that drugs can rarely be admin-
istered without the creation of at least some side Psychosurgery
effects. Whenever drugs are administered, consid- Surgery can also create iatrogenic illness, as can
eration must therefore be given as to whether the be seen in the historical use of lobotomy, which
therapeutic benefits outweigh any possible harm. involved cutting the connections to and from the
An extreme example of iatrogenic illness from prefrontal cortex of the brain. However, the sur-
drug administration is tardive dyskinesia. This gery was crude and used blind-cut procedures
is created through the administration of certain that did not allow full awareness of the damage
antipsychotic medications, usually when given the surgery was creating. It was also irreversible.
over a long-term period or at high dosages. Tar- It is now accepted that in almost all cases, physi-
dive dyskinesia is characterized by involuntary cally normal brain tissue was cut or removed. The
and repetitive movements of the face, limbs, and iatrogenic illness effects created by lobotomies
torso, including rapid eye blinking, grimacing, included incontinence, obesity, loss of cognitive

373
374 Iatrogenic Illness

A diagnosis itself can be seen holistically as creating iatrogenic illness because of the controversial nature of the criteria used to
diagnose mental health conditions. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which
has been heavily criticized for pathologizing natural and understandable behaviors, even irritable children who throw frequent temper
tantrums can be diagnosed with what the DSM classifies as “disruptive mood dysregulation disorder.”

abilities, loss of motor function, blunting of per- diagnosis), both of which can be considered as
sonality and emotion, and learning disabilities. creating iatrogenic illness. Although the propo-
Lobotomies were not just used for those who had nents for diagnostic criteria claim scientific and
been labeled as mentally ill but also to treat condi- objective bases, the criteria can be considered far
tions as diverse as hyperactivity in children, alco- more subjective than these claims acknowledge.
holism, and homosexuality. The technique was Even where criteria are appropriate, they can lead
also used on convicts and those labeled juvenile to problems if clinicians overly depend on them
delinquents. This suggests the primary aim was to or apply them in a crude and un-nuanced fashion,
control behavior seen as unacceptable by society as this can lead to overdiagnosis.
rather than as a true therapeutic intervention. It has also been suggested that some generally
accepted disorders might be iatrogenic rather than
Issues in Diagnosis true disorders, at least partially if not wholly, such
Diagnosis can be seen holistically as creating iatro- as dissociative identity disorder (DID), somato-
genic illness because the criteria used to diagnose form disorders, bipolar disorder, and post-trau-
mental health conditions are surrounded by con- matic stress disorder. However, such claims are
troversy. The Diagnostic and Statistical Manual of highly controversial and weight of evidence does
Mental Disorders (DSM), which offers standard- not support the suggestion.
ized criteria for diagnosis, has been criticized for The DSM does include conditions that have
proliferating the number of disorders for vested been argued to have been included for political
interests (disease mongering) and for pathologiz- rather than scientific reasons and so may be iat-
ing natural and understandable behaviors (false rogenic, such as paraphilias, which are sexual
 Identity 375

urges focused on objects, nonconsenting part- Further Readings

ners such as children, or suffering and humilia- Currie, J. “Manufacturing Addiction: The Over-
tion. Past versions of the DSM included homo- Prescription of Benzodiazepines and Sleeping Pills
sexuality as a disorder, whereas the American to Women in Canada.” Vancouver, Canada: British
Psychiatric Association now accepts it as a natu- Columbia Centre of Excellence for Women’s
ral variation of sexual orientation. Despite this, Health, 2003.
conversion therapy (also known as reparative Morgan, R. F. The Iatrogenic Handbook: A Critical
therapy) still occurs, albeit outside mainstream Look at Research and Practice. Chico, CA:
psychiatry. Conversion therapy attempts to Morgan Foundation, 2005.
change sexual orientation from homosexual or Rende, Richard. “Should Disruptive Mood
bisexual to heterosexual. This form of therapy is Dysregulation Disorder Be in DSM-5?” Parents
considered harmful in many professional circles, (May 29, 2013). http://www.parents.com/blogs/red
and its results may themselves be considered iat- -hot-parenting/2013/05/29/health/should-disrup
rogenic illness. tive-mood-dysregulation-disorder-be-in-dsm-5
That said, any categorization of pathology (Accessed June 2013).
does not occur outside a sociopolitical context Robertiello, R. C. “Iatrogenic Psychiatric Illness.”
and so is rarely value free; therefore, any diagno- Journal of Contemporary Psychotherapy, v.7/1
sis could be said to contribute to an all-pervasive (1975).
form of iatrogenic illness if mental illness is a
social construct.

Other Factors
It has been suggested that the conduct of prac- Identity
titioners can generate psychiatric illnesses. For
example, misconduct such as sexual liaisons with Identity is a central concept in the sociology of
patients or other abuses of power can lead to ill- health and illness, commonly used in discussions of
ness effects. The breach of trust involved and allied illness experience. It can be understood as an indi-
confusion can generate iatrogenically induced con- vidual’s subjective image of the self and is constitu-
ditions such as anxiety and depression. Coercive tive of who one is. However, it is socially embed-
interventions, in which individuals do not wish to ded and relational, influenced by how people see
have psychiatric therapies, for example, can also each other. Individuals consider identity in relation
be considered to result in iatrogenic illness, even to themselves and others in terms of social role,
if the resultant changes appear to be beneficial position, and value. As such, it is socially organized
to everyone other than the individual concerned. and influences the possibilities for social action.
Researchers’ misconduct is also implicated in iat- Identity is multifaceted; certain aspects may
rogenic illness, as falsified data leads to inappro- become especially relevant at particular times,
priate conclusions that may then translate into dominating other possible identities. Key social
unintentionally inappropriate practices that in identities are constructed around gender, sexu-
turn can lead to iatrogenic illness. Social policies ality, social class, ethnicity, and age. People are
can also create or contribute to iatrogenic illness; identified with these social categories that inter-
for example, systemic restrictions of health care to sect; for example, someone may be identified as
the poor can lead to or maintain illness. “middle class” or a “middle-class Asian woman,”
imputing associated characteristics such as parent-
Vivienne Brunsden ing style, health behaviors, and newspaper choice.
Nottingham Trent University Such identities have social effects that are linked
to underlying social structures and inequality.
See Also: Diagnosis; Laing, Ronald David;
Lobotomy; Malpractice; Psychiatry and Sexual Health and Illness
Orientation; Szasz, Thomas; Tardive Dyskinesia; Illness and impairment, especially associated
Thorazine and First-Generation Antipsychotics. with serious chronic conditions, are also strongly
376 Identity

constitutive of identity, at times competing with individuals, as a form of psychosocial scaffolding

other aspects of identity. Illness therefore may or skeleton. Individuals may not be aware of all
become part of someone’s identity—at times, even aspects of their identity until it is challenged. It
the primary defining characteristic. Depending often works on a subconscious level, defining an
upon the context, an individual may be consid- individual and what they do, only coming into
ered first in terms of their disease label and the relief when its integrity is threatened or damaged
features associated with it, and second in relation as, for example, by illness.
to their other characteristics. Analysis of accounts of people living with dif-
In relation to health and illness, lay and patient ferent types of illness has highlighted the central-
identities are focal points for scholarship and ity of identity to understanding illness experi-
research. Understanding lay identities is important ence, including responses to diagnosis, coping,
for understanding how people consider health, day-to-day management, and social relation-
disease, and illness, in particular how they assess ships. Michael Bury identified how diagnosis with
their risk of developing disease and the relevance chronic illness may lead to “biographical disrup-
of prevention. They do this by constructing iden- tion,” or a challenge to an individual’s self-con-
tities of people associated with particular diseases cept and their unconscious expectations of their
and make assessments of their own risk accord- life trajectory. There is interplay with the social
ingly. The term patient is a label that positions structural features of identity such as ethnic-
people with disease and needs to be viewed criti- ity and social class, contributing to the possible
cally. People with illness become patients when identities an individual can lay claim to. Qualita-
they engage with health care systems and inter- tive research has also shown how people adapt
act with health professionals. Access to patient their lives to cope with illness, reconstructing
identities involves moral judgments regarding the their identities. They may negotiate new forms of
entitlement to be ill and temporarily opt out of meaning and set up identities that enable success-
social responsibilities such as work. ful adjustment to serious illness.
Talcott Parsons described health systems in Medicalization has led to an increase in avail-
terms of patient and professional roles, rights, able identities around illness. However, there is
and responsibilities, with the patient legitimately resistance to social pressures to adopt illness iden-
entering the “sick role” depending upon their tities, especially in relation to mental illness. For
acceptance of particular social conditions such as example, despite higher suicide rates compared to
complying with medical advice. The individual women, men are less likely to seek medical help
is expected to take on the patient identity for a for depression and emotional problems, seeing
period of time while they are recovering from ill- this as inconsistent with masculine identity. Black
ness. This much-critiqued model has been pivotal Caribbean mothers in the United Kingdom who
in developing theory around illness identity, espe- are at relatively high risk of postnatal depression
cially in relation to how societies manage acute have been found to resist adopting such an illness
illness. It is less useful for considering chronic label and the health care associated with it, pre-
illness where complete recovery is not possible ferring to draw upon their identity as a “strong
and a person has to live with a long-term con- black woman” to enable them to cope.
dition. However, chronic illness is often consid- People with mental illness have much to contend
ered through a framework of acute care, with the with regarding self-perception and perceptions of
assumption that illness causes temporary disrup- others. Illness identities are linked to social value.
tions. On the contrary, Kathy Charmaz and oth- Generally negative social attitudes toward men-
ers have found that serious chronic illness may tal illness mean that it is stigmatized and it may
entail an ongoing “loss of self,” with expectations overshadow other available identities. Whereas
of living a “normal” life becoming a symbol of the narrative turn has led to a sharing of personal
the valued self. illness stories about many illnesses, which is con-
Qualitative research studies that explore expe- sidered to be supportive and promote increased
riences of illness have shown how identity can be understanding, this has been more limited in men-
seen as something that holds people together as tal illness. Stereotyping and discrimination means
 Imperial Psychiatry 377

that people often resist associating themselves is today. By shifting its center of operations from
with such an identity and are reluctant to dis- geographically isolated rural asylums to univer-
close, which can have an impact on expectations sity-based clinics and dramatically altering the
of care and help seeking. scientific paradigm underlying its teaching and
research, psychiatry was able to gain control of
Conclusion psychiatric practices and their administration.
For sociologists, identity is understood as a
socially constructed phenomenon, which struc- History
tures human experience. It is socially organized The mid-19th-century mental asylum as envi-
around factors such as ethnicity, social class, gen- sioned by its practitioners (such as Heinrich Laehr)
der, sexuality, age, and illness, which intersect. was meant to serve as a place of solitude and calm
Mental illness is challenging both for individu- situated in the countryside, a haven from the
als with mental illness and for society in general, unhygienic city. It was intended to provide ample
which struggles to accommodate it beyond the opportunity for recovery without distraction and
social margins. Although social movements pro- allow for the complete separation of different
moting better understandings of mental illness groups so that patients would not be disturbed by
have made progress in destigmatizing it, there is others. In this setting, the doctor sat at the pin-
a need for more positive identity work in relation nacle of the institution, the head of the household;
to mental health. he dedicated himself wholly to it, residing in it and
setting an example for its personnel so that at all
Moira J. Kelly times the patient would be conscious that only one
Queen Mary University of London authority governed the healthy and sick, and that
authority was the doctor.
See Also: Gender; Help-Seeking Behavior; Labeling; By the end of the 19th century, German psy-
Patient Accounts of Illness; Peer Identification; Role chiatry had become a radically different institu-
Strains; Social Class; Stigma; Stigma: Patient’s View. tion as imagined by a new cohort of practitioners
(such as Wilhelm Griesinger and Emil Kraepelin).
Further Readings No longer known as the asylum but now “the
Bury, Michael. “Chronic Illness as Biographic clinic,” psychiatry attempted to integrate teach-
Disruption.” Sociology of Health & Illness, v.4/2 ing and scientific research, motivating doctors
(1982). with the spirit of scientific discovery. The peda-
Charmaz, Kathy. “Loss of Self: A Fundamental Form gogical aim was to teach doctors the scientific
of Suffering in the Chronically Ill.” Sociology of understanding of mental illness and train them to
Health & Illness, v.5/2 (1983). recognize and treat those diseases early and com-
Edge, D. and A. Rogers. “Dealing With It: Black petently. Reformers argued that clinical psychia-
Caribbean Women’s Response to Adversity and try could not be learned solely from books and
Psychological Distress Associated With Pregnancy, lectures but instead required firsthand examina-
Childbirth, and Early Motherhood.” Social Science tion and observation of patients. Because medical
& Medicine, v.61 (2005). schools were located in urban areas, this meant
Parsons, T. The Social System. Glencoe, IL: Free shifting psychiatric practice from the countryside
Press, 1951. to the city.
In 1891, the first independent psychiatric hospi-
tal was built and funded by the Prussian ministry
of education in Halle, Germany. The clinic repre-
sented the culmination of years of jurisdictional
Imperial Psychiatry wrangling between academic and applied psychi-
atry, neuropathology, and other medical special-
Imperial psychiatry refers to late-19th-century ties dating back to the midcentury. Clinics such
German psychiatry as it evolved from a set of asy- as the one in Halle as well as other urban, uni-
lum-based practices to the academic discipline it versity-based facilities superseded the traditional
378 Imperial Psychiatry

rural asylum. By the end of the first decade of the taking control of psychiatry’s cognitive content,
20th century, academic psychiatry had become its research and daily practices, the curriculum
an independent discipline with powerful state for its dissemination, workspaces, and institu-
support and modern institutional arrangements, tional contexts. In addition, academic psychiatry
including full academic chairs and professorships. was able to extend its sphere of influence widely.
For example, medical students are now required
University Psychiatric Clinics to study psychiatry as a mandatory component of
University psychiatric clinics like the one in Halle, their training.
Germany, were sites where academic psychiatrists
revolutionized the profession, altering the asy- Importance of Studying Psychiatry
lum-based medical system forever. The ground- in Imperial Germany
work for these changes was laid by Griesinger, While psychiatry’s ambitions were neither purely
who urged his colleagues to relinquish the ideal altruistic nor solely hegemonic, the dramatic
of the rural-based asylum in favor of the univer- changes in the site and daily practices of psy-
sity-based clinic, where practitioners would not chiatry fostered the profession’s enhanced status
find themselves overburdened with managerial society-wide and exemplified how the politics of
tasks and would have more time for developing professional authority operate. By understand-
their diagnostic skills. The central strategy was ing how changes in work practices impact juris-
meant to ground psychiatry in medical science, dictional control, the underlying relationship
and neurology in particular, in order to make between professional power and knowledge
the brain the focal point for the study of mental becomes apparent. The institutional framework
illness. While this goal served to unite the study of the university psychiatric clinic as the site of
of mental disorders with practices of the natural disciplinary practice raises the issue of the politi-
sciences, it amounted to a reductionism that was cal role of the clinic and its broader social func-
problematic in its own right. Kraepelin and oth- tion as a mechanism of social control.
ers countered this trend with a call for system- However, the rise of the psychiatric profession
atic observation of living patients, experimental was not simply a means by which state appa-
diagnostic research, and meticulous recording ratuses were able to extend their reach society-
of clinical observations. To this end, Kraepelin wide in order to more effectively monitor and
developed an influential classification system of control deviant behavior. Patients, psychiatrists,
mental disorders that served as the basis for diag- and broader social constituencies were all subject
nosis and treatment of illness. to rules and norms governing the recognition,
prevention, and treatment of mental illness and
Psychiatric Jurisdiction deviance, broadly construed. Although the study
Systematic observation in a clinical setting and of psychiatric clinics only partially uncovers the
experimental research ended up changing psychi- link between the psychiatric profession and the
atric practice and revolutionizing jurisdictional state, it extends beyond simple analysis of profes-
disputes between psychiatrists and other medical sional practice and expertise by offering a deeper
interlopers. The psychiatric profession became a and richer perspective on the struggle in Wil-
preeminent force through modification of day- helmine society of the various actors and institu-
to-day tasks and activities, which made asylums tions within one of the most powerful subfields in
less relevant to the profession than university psy- medicine.
chiatric clinics. For example, when mental illness
became defined as a brain disease, apparatuses Matthew Archibald
and specimens (such as laboratories and cadav- Lloyd L. Liang
ers) necessary to investigate it as such, along with Colby College
experts in their deployment, determined who
took control of work and where it took place. See Also: Architecture; Germany; Kraepelin, Emil;
Academic psychiatrists were able to wrest con- Mental Institutions, History of; Psychoanalysis,
trol of the profession from other challengers by History and Sociology of.
 Impulse Control Disorder 379

Further Readings of its negative consequences to self or others and

Archibald, Matthew E. “Book Review: Clinical the experience of gratification, pleasure, or relief
Psychiatry in Imperial Germany: A History when the action takes place. There is a continu-
of Psychiatric Practice.” American Journal of ing challenge to identify the degree to which typi-
Sociology, v.110/6 (2005). cal behaviors—such as sex, eating, and Internet
Engstrom, Eric J. Clinical Psychiatry in Imperial use—become pathological. ICDs often occur with
Germany: A History of Psychiatric Practice. other disorders, including obsessive-compulsive
Ithaca, NY: Cornell University Press, 2003. disorder, bipolar depression, eating disorders, and
Oosterhuis, Harry. “Review of: Engstrom, Eric J. substance abuse.
(2003): Clinical Psychiatry in Imperial Germany: The dual-process theory proposes that disor-
A History of Psychiatric Practice.” Journal of the ders of impulse control involve conflict between
History of the Behavioral Sciences, v.41/1 (2005). approach behaviors (reward seeking) and
restraint (inhibition). Impulsivity is related to
personality traits relating to emotionality, consci-
entiousness, and sensation seeking. Impulse con-
trol problems are also associated with decreased
Impulse Control frontal lobe activity, which regulates executive
functioning such as inhibition, planning, and
Disorder organization. Impulsive behaviors may be driven
by the individual seeking a return to homeosta-
Impulse control disorders (ICDs) are character- sis or by cues associated with rewards for their
ized by failures of self-control relating to exces- behavior.
sive behaviors causing harm to oneself or others. Reward and pleasure-seeking behaviors are
Existing ICD research is based on the American partly influenced by dopamine, so drugs regu-
Psychiatric Association’s Diagnostic and Statis- lating dopamine transmission are often used to
tical Manual of Mental Disorders (DSM) and treat ICDs. Dopaminergic medications used to
the World Health Organization’s International manage motor symptoms of Parkinson’s disease
Classification of Diseases (ICD-10). The DSM-5 can result in the onset of ICD as a side effect.
(2013) reclassifies ICDs within the broader cat- Combinations of psychotherapy and psychotro-
egory of Disruptive, Impulse-Control, and Con- pic medications are used across ICDs with varied
duct Disorders, removed trichotillomania (TTM) success, depending on the type of ICD and coex-
and pathological gambling (PG) from this cat- isting disorders. Although opioid antagonists,
egory, and proposes Internet gaming disorder for mood stabilizers, and serotonin reuptake inhibi-
further study. Several other behaviors are charac- tors (SSRIs) are among the most studied phar-
terized by impulsivity and the inability to resist maceutical interventions for ICDs, more clini-
urges, such as compulsive buying, pathological cal research is required to confirm their efficacy.
skin picking, compulsive sexual behavior, and Psychotherapeutic interventions typically include
problematic Internet use. Cognitive behavioral CBT, family therapy, group therapy, and social
therapies (CBT) and pharmacological treatments skills training.
yield mixed results and vary according to the dis- Classifications of ICD include pyromania,
order. Globally, ICDs create high costs to both intermittent explosive disorder (IED), kleptoma-
the individual and society. Societal laws (such as nia (KM), trichotillomania (TTM), pathological
legalization of gambling), varying ICD criteria, gambling (PG), and Internet gaming disorder.
and limited research make the estimated preva- Individual classifications have their own unique
lence rates difficult to ascertain. set of behaviors and are treated with medications
and forms of psychotherapy.
Etiology and Medical Treatment
While ICDs vary in clinical and biological char- Pyromania
acteristics, shared behaviors include the failure to Pyromania is repetitive and deliberate fire set-
resist the urge to perform a behavior regardless ting without an external reward (such as political
380 Impulse Control Disorder

protest) and typically emerges in adolescents and Kleptomania

in males. Pyromania is distinct from arson because KM involves repetitive and uncontrollable steal-
the criteria includes tension before the fire-setting ing of unnecessary items, which are hoarded or
that is relieved following the act, attraction to discarded. KM differs from stealing for personal
and interest in the fire, and some degree of plea- gain because the primary purpose of stealing
sure seeking or gratification. Prevalence rates are within KM is emotional pleasure or the release
unclear, as this behavior is illegal and often kept of tension. KM contributes to a lowered quality
private; however, it is estimated that approxi- of life (such as poor work performance, arrest/
mately 2 to 3 percent of youth may experience incarceration, or guilt) for the individual and high
pyromania. Fire safety education, CBT, and fam- revenue loss to retailers.
ily therapies are the most common forms of inter- KM is found in pediatric and elder age groups,
vention for fire setting. though typical onset is between 16 and 20 years
of age. Most individuals with KM are believed to
Intermittent Explosive Disorder be women, though epidemiology rates are difficult
Individuals with IED have recurring incidents of to assess because these behaviors have not been
impulsive verbal and/or physical aggression and extensively studied, are under-reported (due to
assaults against people or property out of propor- legal implications), or are often managed through
tion to the stressor or provocation. IED causes the criminal justice system rather than the mental
distress, impaired interpersonal functioning, or health system.
legal/financial consequences and economic loss Although data on the use of psychotropic med-
due to damaged physical property. ications for KM are scant, SSRIs appear to be one
In some regions (such as Japan and South of the most effective pharmaceutical treatments.
Africa), higher education and employment stresses CBTs such as desensitization, aversion therapy,
were indicated as possible environmental triggers, and exposure and response prevention also show
while a history of trauma and exposure to vio- promise. Outside the mainstream perspective,
lence (such as in individuals in South Africa and psychodynamic theorists suggest unconscious
the United States) may also increase the likelihood drives and symbolic interpretations of KM behav-
of IED. Most commonly seen in males, onset is iors (such as sexual gratification and unresolved
typically between 14 and 18 years of age and has conflict) and the stolen objects. Others propose
been found within approximately 3 to 7 percent of these behaviors should be viewed within social,
various populations (such as the United States and economic, and cultural contexts of contemporary
Shenzhen City, China) with lower rates in Asia, excessive consumerism, mass production, and the
the Middle East, and specific countries (Nigeria changing roles of women.
and Romania).
Unexpectedly lower prevalence rates were iden- Trichotillomania
tified in Iraq despite its history of war and con- Individuals with TTM engage in repetitive hair
flict. Variations in prevalence rates may be due to pulling (either with focused or low awareness),
differences in behavioral criteria and cultural fac- most commonly from the scalp and eyebrows,
tors that influence expressions of aggression. For resulting in hair loss and impaired functioning
instance, IED prevalence is lower in Japan than (depression, anxiety, and stress). Immediately
in Western regions, potentially because of their preceding their behavior, some individuals report
tendency to suppress emotion and experience a tension and discomfort, which are alleviated with
negative stigma associated with mental health hair pulling. TTM usually emerges between 11
issues. Though research is limited, drug treat- and 13 years of age and is mostly seen in females.
ments such as antidepressants, mood stabilizers, Though prevalence rates vary depending on crite-
and antipsychotics and CBTs such as cognitive ria, it is estimated that 1 to 13 percent of the U.S.
restructuring, coping skills and relaxation train- population experiences TTM. It is often accom-
ing, group/family therapy, and anger manage- panied by medical complications and feelings of
ment have shown promise in reducing incidents guilt and shame because little is known of this dis-
of anger, rage, and aggression. order within the general public. Individuals with
 Incidence and Prevalence 381

hair loss may avoid intimate and social activities, functional impairments such as the loss of one’s
causing further interpersonal, occupational, or job, reduced job performance, marital stress, or
academic difficulties. While no formalized drug school failure. Much of the existing research is
treatments are available for TTM, CBTs such as from Asia and has prompted early intervention
habit reversal training and stimulus control are strategies and policies to restrict such behaviors in
commonly used for intervention. TTM is now areas such as South Korea and China. Researchers
classified in the DSM-5 under the larger supraor- in nations such as Iran, Taiwan, China, the United
dinate category of Anxiety and Obsessive-Com- States, and Greece have also focused on concern-
pulsive Spectrum Disorder, whereas the ICD-10 ing rates of more generalized problematic Internet
classifies it as a habit and impulse disorder. Cross- use—including preoccupation with the Internet
cultural comparisons of TTM are limited, though that results in withdrawal symptoms and reduced
TTM is studied around the world in the United interpersonal, academic, and occupational func-
States, United Kingdom, Europe, Brazil, and tioning—and its relationship with ICDs.
South Africa.
Ariane Schratter
Pathological Gambling Maryville College
PG is the inability to resist the urge to gamble,
resulting in psychological, economic, and inter- See Also: Cognitive Behavioral Therapy;
personal harm. It is associated with depression, Cross-National Prevalence Estimates; Drug Abuse;
anxiety, and suicide. Typical issues within PG DSM-IV; DSM-5; International Classification of
include committing crimes in order to gamble, Diseases; Internet and Social Media; Obsessive-
losing one’s job or relationships, and spending Compulsive Disorder; Pathological Gambling;
increasingly more time gambling or thinking Serotonin Reuptake Inhibitors.
about gambling. PG affects approximately 1 to
3 percent of the population with consistent rates Further Readings
across various countries including the United Dell’Osso, Bernardo A., Carlo Altamura, Andrea
States, New Zealand, Sweden, Switzerland, Aus- Allen, Donatella Marazziti, and Eric Hollander.
tralia, and Great Britain. While most pathological “Epidemiologic and Clinical Updates on Impulse
gamblers are males, approximately 28 percent are Control Disorders.” European Archives of
women. PG tends to run in families, though the Psychiatry and Clinical Neuroscience, v.256
extent to which genetic and environmental fac- (2006).
tors influence PG are under investigation. Hays, Lon. “A Review of Impulse Control
Like substance abusers, individuals who suf- Disorders.” American Journal on Addictions,
fer from PG become dependent on experiencing a v.18/4 (2009).
state of euphoria with winning (or near winning) Sher, Kenneth J., Rachel Winograd, and Angela
and may use gambling to maladaptively cope with M. Haeny. “Disorders of Impulse Control.”
life stressors. Because the neurological and behav- Handbook of Psychology, v.8 (2013).
ioral underpinnings of PG are similar to drug
addictions, the DSM-5 classifies PG under Addic-
tion and Related Disorders, though it remains
classified as a disorder of impulse control in the
ICD-10. Psychopharmaceutical treatments such Incidence and
as SSRIs have shown promising results, although
treatment efficacy is affected by the presence of Prevalence
other disorders.
Interest in the incidence and prevalence of mental
Internet Gaming Disorder illness is long-standing—with the word incidence
Internet gaming disorder is being investigated for referring to the number of new cases over a partic-
individuals who spend an uncontrollable amount ular period and the word prevalence to the over-
of time gaming on the Internet, which may lead to all number of cases in a given period. Such data
382 Incidence and Prevalence

can aid the planning and organization of service various zones in terms of their social character-
provision as well as support or undermine ideas istics slums toward the center and smarter com-
about its possible causes through the examination muter zones of middle- and upper-class families
of the distribution of cases across a population in toward the periphery.
relation to certain social and environmental fac- In their study, Faris and Dunham examined
tors. The latter was the rationale underpinning new cases of mental illness admitted to pub-
classic epidemiological research by John Snow lic and private mental hospitals in the different
in mid-19th-century London that examined the city zones between 1922 and 1934. While cases
location of cases of cholera in relation to water of manic depression were more or less randomly
supplies—research that supported his view that distributed, those of schizophrenia and alcoholic
the cholera bacillus was transmitted via water. psychoses were concentrated in the poorer, “dete-
Studies of the incidence and prevalence of men- riorated” areas. Whereas manic depression was
tal illness vary enormously, and three key ques- probably largely accounted for by genetic factors,
tions need to be asked of any study: What are schizophrenia and alcoholic psychoses seemed
its objectives? How is mental illness measured? more a product of social factors, such as the social
What definition of mental illness does the mea- isolation and lack of social networks in the poorer
sure incorporate? central zones of the city. Their evidence also indi-
cated that this concentration in the poorer areas
Examining Three Key Questions could not be accounted for by geographical drift
The earliest studies of the distribution of men- consequent on the occurrence of mental illness.
tal illness used inpatient statistics collected by
the private madhouses and asylums for lunatics Social Class
(those with severe disorders considered to have Another classic American study, Social Class and
lost their reason), which were founded from the Mental Illness by psychiatrist A. B. Hollingshead
17th century onward. With the establishment of and sociologist F. C. Redlich, examined the distri-
public asylums in the 19th century, and increased bution of mental illness by social class, prompted
legislative oversight, the collection and consid- by Redlich’s interest in social stratification. The
eration of inmate statistics became a routine study, which examined both incidence and preva-
activity. In Britain, the growth in the number of lence in the early 1950s, extended the range of
asylum inmates over the century—a prevalence cases covered by including those in receipt of any
measure—generated concern as to whether men- form of specialist treatment for a mental health
tal illness was actually increasing. This led to a problem, not just inpatients, incorporating those
report in 1897 by the Commissioners in Lunacy with less severe disorders. Categorizing the sam-
that indicated that insanity was not increasing, ple into five social classes, the authors established
but rather that factors such the availability of asy- that those in the lowest class had far higher rates
lums, a broader view of what required treatment, of mental illness; were more likely to be diag-
and the financial support for inmates were pro- nosed as psychotic, to be referred for treatment
ducing the increase in numbers. The study conse- by nonmedical bodies such as the police and
quently demonstrated that the inpatient statistics social agencies, and to receive some organic ther-
were not a good measure of changes in levels of apy; but were less likely to have some form of
mental illness over time, but instead reflected fac- psychotherapy.
tors such as changes in service provision. However, a limitation of such studies was the
Subsequent studies have often focused on the reliance on statistics from treated cases as the
distribution of mental illness across populations, measure of mental illness because social factors
rather than changes over time. One of the earli- affect whether an individual’s problems come to
est, “Mental Disorders in Urban Areas,” carried attention and are identified as requiring some
out by sociologists Robert Faris and Warren Dun- type of specialist treatment. Hence, subsequent
ham, examined its distribution across Chicago. studies have attempted to generate measures of
Chicago sociologists had been exploring many mental illness of people in the community, inde-
aspects of life in the city and had distinguished pendently of whether they are in treatment. In
 Incidence and Prevalence 383

the United States, the first major study of this was one reason for the difference. Another was
type, Mental Health in the Metropolis, car- that the threshold for pathology was set very low.
ried out in Manhattan in the mid-1950s, again The study was influenced by the prevalent psy-
focused on social and environmental factors. The chodynamic thinking in U.S. psychiatry, which
study, which included a census of treated cases, posited that most individuals had underlying psy-
also had a sample of 1,660 individuals ages 20 to chological conflicts. Third, the responses to ques-
59 who lived in the community and whose men- tions as to the presence of symptoms were not
tal health status was assessed using a structured followed up by any consideration of context. For
interview with 120 items covering psychologi- example, respondents were asked whether they
cal and psychosomatic symptoms. The data did “often worry” about a list of things such as lone-
not allow individuals to be assigned a diagnosis; liness, health, and personal enemies, with no fur-
instead, they were placed on a single dimensional ther questions to determine whether these wor-
scale of mental well-being, with six categories on ries might be appropriate in their particular social
the basis of their responses (and some interviewer circumstances. Consequently, the study highlights
observations). the crucial role played by measurement strate-
Using this scale, only 18.5 percent were judged gies and decisions in assessing levels of mental
“well” and 23 percent “impaired” (Social Class illness. However, it found a marked association
and Mental Illness generated a one-year patient between socioeconomic status (SES) and mental
prevalence rate of around 1 percent). The decision illness, with those in the lowest social groups hav-
to screen for mental disorders in the community ing the worst mental health, with the proportions

Dinner at the Brunos family’s well-kept Boston, Massachusetts, home in July 1973 is documented in the federal government’s
Documerica project (1971–77). During this era, feminism questioned how being a wife, mother, and homemaker impacted a woman’s
mental health. Feminist Betty Friedan asserted that a woman’s discontent with her role could lead to anxiety and depression. Patient
statistics during this era showed that married women’s rates of mental disorders were much higher than rates for married men.
384 Incidence and Prevalence

“impaired” in the lowest group almost double of diagnosis in clinical contexts, which could
those in the highest (a pattern repeated in subse- also be used in community surveys. In Britain,
quent studies), the authors linking this in particu- for example, the Present State Examination was
lar to childhood poverty. introduced in the 1960s, based on descriptions of
mental disorders developed for the International
Gender Classifications of Diseases. It involved a lengthy
In the 1960s and 1970s, influenced by feminist interview schedule, though many questions were
thinking, gender differences became a focus of only asked if an earlier response indicated their
attention. Much of the early debate was about the possible relevance. In the United States, the Men-
impact of women’s marital role on mental health. tal Status Schedule was introduced in 1964, and
In her classic 1963 book, The Feminine Mystique, the Psychiatric Status Schedule in 1970. However,
Betty Friedan talked of “the problem that has no the introduction in 1980 of the third edition of
name”—women’s discontent and dissatisfaction the American Psychiatric Association’s Diagnos-
with their role as housewives, which could lead tic and Statistical Manual of Mental Disorders
to anxiety and depression (many married women (DSM-III) further encouraged the development of
at the time did not have paid employment outside structured diagnostic instruments that could be
the home). Feminists such as Susie Orbach sub- used in community surveys by introducing sepa-
sequently emphasized the psychological impact rate lists of symptom criteria for each disorder,
of women’s nurturing role on their mental health including the minimum number and duration of
and their lack of attention to personal needs. symptoms, rather than simply providing a general
Such ideas were supported by patient statistics, description of each.
which showed that whereas rates of mental disor- Work on the new DSM was led by a group of
der were far higher in married women than mar- biologically oriented psychiatrists who decided to
ried men, the single men’s rates were far higher focus on symptoms to try to enhance diagnostic
than women’s. There was also a marked gender reliability and to exclude etiological claims based
patterning according to the type of mental dis- on psychodynamic understandings that they con-
order, with minimal gender differences in severe sidered highly contentious. These had particularly
disorders such as schizophrenia, a strong female featured in the previous descriptions of the less
predominance in anxiety and mood disorders, severe, more common disorders (the term neuro-
and a marked male predominance in substance sis was also downplayed in the DSM-III). The first
use disorders and those relating to antisocial con- structured diagnostic instrument linked to the
duct. Such differences are not restricted to West- DSM-III was the Diagnostic Interview Schedule
ern countries. (DIS), designed for use in a large survey of men-
A World Health Organization (WHO) study tal disorder, the Epidemiologic Catchment Area
showed that while rates of depression varied (ECA) study, carried out in the early 1980s. The
enormously between countries, the rates for ECA’s first objective was to estimate the preva-
women tended to be double those for men across lence rates of different disorders in the popula-
the countries surveyed, and the reverse held for tion to assist health planners; the second was to
alcohol problems. This patterning suggests a identify groups at high risk of particular disorders
major gender difference in the channeling of emo- with a view to helping identify causal processes.
tions and difficulties, with women tending to Since the DIS was devised to assign specific
internalize their feelings and men to externalize diagnoses based on symptom clusters, it could be
them. It also means that the extent of any gender expected to generate lower incidence and preva-
difference identified in any epidemiological study lence rates than the Midtown Manhattan survey,
depends on precisely which disorders are included with its single dimensional model and low thresh-
in the measure of mental illness. olds of mental ill health. However, since the DSM-
III constructed diagnoses from symptom lists, it
Instruments of Diagnosis was potentially operating with a broader notion of
During this period, a number of new instruments specific disorders than earlier editions because of
were developed to try to standardize the process the reduced consideration to the context in which
 Incidence and Prevalence 385

a symptom arose. For example, with the exception designed for international use, and covered those
of experiencing the death of a loved one, where aged 15 to 54. It also used the diagnostic criteria
a depressed mood could be regarded as a normal from the revised 1987 DSM-III and a narrower
reaction, there was no requirement in the criteria range of disorders concentrating on anxiety, mood,
for major depressive disorder to explore events or and substance-use disorders. The overall one-year
circumstances in the person’s life to assess whether prevalence rate was higher than in the ECA, at
the feelings experienced were normal and reason- 30.2 percent, in part because of the difference in
able. And the minimum duration of symptoms the diagnostic criteria used and the revised order-
was sometimes short (two weeks for major depres- ing of the interview questions. A replication of the
sion). The new DSM also extended the number of NCS roughly 10 years later had a somewhat lower
disorders, partly by subdivision, as in the differen- one-year prevalence rate (26.2 percent for all dis-
tiation of a specific social phobia, partly by adding orders) because it used the DSM criteria from the
new disorders—for instance, a set of sexual dys- fourth, 1994, edition, which added a new “clini-
functions alongside the existing paraphilias. Fur- cal significance” criterion to many disorders, to
ther, the translation of the DSM-III criteria into an enhance their validity and avoid over diagnosis.
interview schedule involved decisions that could Psychiatric morbidity surveys were carried out
lead to important departures from the formal in Britain in 1993, 2000, and 2007 but measured
diagnostic criteria, as with the operationalization specific disorders, or groups of disorders, using a
of the terms intense and recurrent. variety of instruments so that an overall preva-
Using the DIS, the ECA study, which sampled lence rate could not be readily constructed. The
persons older than 18 years, identified 19.5 percent studies showed the oft-noted gender patterning of
as having a disorder in the previous six months and disorders, as well as a marked link with income
21.7 percent the previous year. The lifetime preva- (the only measure of SES) for the psychoses, the
lence was 33 percent, but this figure depends on the common mental disorders, and for drug but not
accuracy of recall and the evidence indicates that alcohol dependence.
this is often poor. The one-month prevalence rates A 2001 to 2003 World Mental Health Survey
for specific groups of disorders showed the typical coordinated by the WHO included 26 countries
gender patterning. The study also incorporated a from Africa, the Americas, Asia, Europe, and the
measure of SES, but analyzed the data separately Middle East and found marked differences in
by the diagnostic categories. However, the data prevalence rates.
reinforced earlier findings that those in the lowest A number of points emerge from this epidemio-
SES group had far higher one-year prevalence rates logical work. First, that each of the varying mea-
than those in the highest, though this did not apply sures used to assess the incidence and prevalence
to affective disorders—a rather surprising finding of mental illness has particular deficiencies. Sec-
in the light of other research that provides evidence ond, that the different measures incorporate vary-
to the contrary, such as Brown and Harris’s clas- ing ideas about what counts as mental pathol-
sic British study in the 1970s, Social Origins of ogy—a problem mainly rooted in and reflecting
Depression. The study also analyzed the data by psychiatry’s changing classifications of mental
ethnic group and found that blacks had the highest illness. This means that comparison of rates of
rates of active disorder, followed by Hispanics, and mental illness over time is very difficult. Third,
then whites, but there was no significant difference despite their varying objectives and despite the
by ethnicity for those under 45, and the authors growing emphasis on neuroscientific understand-
suggested the differences in the older age groups ings of mental illnesses, the studies confirm the
could have resulted from educational differences. importance of social and environmental factors
Nearly a decade later, the ECA study was fol- in fully understanding their causation, just as the
lowed by the National Comorbidity Survey importance of such factors was demonstrated in
(NCA). The focus was on comorbidity, facilitated Snow’s classic work on cholera.
by the DSM-III’s listing of diagnostic criteria for
each disorder. The survey used a variant of the DIS, Joan Busfield
the Composite International Diagnostic Interview, University of Essex, Wivenhooe Park
386 India

See Also: Assessment Issues in Mental Health; DSM- have roots in early Indian medicine and persist in
III; DSM-IV; Measuring Mental Health; Social Class. contemporary times. At the same time, contem-
porary Indian psychiatry continues to struggle
Further Readings with the problem of securing access to treatment.
Busfield, J. “Challenging Claims That Mental Illness Three-quarters of India’s population resides in
Has Been Increasing and Mental Well-Being rural areas with little or no access to modern psy-
Declining.” Social Science and Medicine, v.75 chiatric resources, and mental illness gains little
(2012). recognition in public health efforts. Because of
Regier, D. A., J. H. Boyd, J. D. Burke, et al. “One- this, culturally defined healing and welfare insti-
Month Prevalence of Mental Disorders in the tutions such as temples, local healers, and astrolo-
United States.” Archives of General Psychiatry, gers remain integral to the treatment of mental
v.45 (1988). illnesses throughout India.
Robins, L. N. and L. B. Cottler. “Making a
Structured Psychiatric Diagnostic Interview Ancient Indian Psychiatry
Faithful to Nomenclature.” American Journal of Before the advent of Ayurveda medicine, most
Epidemiology, v.160 (2004). mental illness and psychiatrically based issues
World Health Organization. “Gender Disparities in were primarily considered through magico-
Mental Health” (2010). http://www.who.int/men religious perspectives such as spirit possession,
tal_health/media/en/242.pdf (Accessed June 2013). curses, and karma, a complex concept that con-
siders cosmic retribution for both good and bad
actions from previous lives. Ayurveda, which
means the “science of longevity,” added a natu-
ralistic, empirical element to medicine and heal-
India ing that relies on the longitudinal observation of
symptoms and detailed descriptions of diseases
Indian psychiatry is rooted in both traditional and illnesses. According to this tradition, mental
healing approaches and the vestiges of British illnesses involve mind, body, and nature. Thus,
colonialism. While Western psychiatric medicine all illnesses are seen as having both somatic and
has become common throughout the country, psychiatric symptoms, and health is considered a
many families continue to rely on religious inter- balance of mind, body, and spirit.
ventions, astrology, or trance healing, as well as Ayurveda is one of the world’s oldest tradi-
more established traditional medicines such as tions, beginning well before 1500 b.c.e. It is
Ayurveda, the ubiquitous healing tradition asso- based on several iterations of ancient texts, or
ciated with Hinduism; Unani, an Islamic medi- Vedas. The earliest, written by Caraka, is the first
cal tradition; and Siddha, the healing approach known attempt at creating a written account of
rooted in the Jain religion. Psychiatry in India the prescriptions and disease descriptions that,
is closely related to local cultural traditions and until then, had been passed down orally. This
conventions such as family relations, gender dif- text, known as the Caraka Samhita, contains
ferences, historic caste divisions and roles, and eight mental disorders. Each major subsequent
religious orientation, including the particular text includes more mental disorders than the pre-
god(s) that a family or village worships. These vious version. The Vagbhata describes 18, and
elements define what is normal and what is devi- the Saarangdhara and Artharvada both describe
ant, and influence treatment decisions and cul- 20 mental disorders.
turally sanctioned methods of expressing psychic Mental illnesses are characterized as either
distress. exogenous (the result of something outside
Somatic expressions of psychic distress are the body such as accidents, attacks of deities,
very common in Indian culture; because of this, improper diet, or karma) or endogenous (an
many psychiatric conditions are overlooked when imbalance of the body’s doshas). In Ayurveda, the
patients seek treatment for physical complaints. body has three primary doshas, or constitutions,
Bodily expressions of mental illness or disease which are called pitta, kapha, and vata. When
 India 387

these doshas are imbalanced, the body and mind British government gained control of India, the
experience illness. development and construction of asylums began.
While these texts describe many manifesta- The Indian Lunacy Act of 1858 set guidelines for
tions of mental distress and illness, severe psy- building these asylums and admitting patients.
chosis was described as unmada, which is usu- The creation of asylums throughout India came at
ally translated as “insanity.” Unmada is always the expense of suddenly marginalized Ayurvedic
described as somewhat chronic and is often asso- physicians, mirroring the colonialist elitism of
ciated with endogenous causes. Spiritually based the time. There were often separate wards, if not
mental illness, on the other hand, was thought entire hospitals, for the British mentally ill (and
to be acute, less severe, and associated with an occasionally Indians who emulated the British
event occurring immediately prior to the onset lifestyle) and the Indian mentally ill, with the
of symptoms. According to this tradition, people latter facilities of inferior quality. Originally, the
with a weak will and low mental stamina who do British hospitals and wards were conceptualized
not follow the Vedic prescriptions of proper life- as temporary holding areas until the patient could
style, including diet, are predisposed to mental be sent back to Britain; however, this plan failed
illnesses. These laws of living are described in the because of the lengthy passage to Europe.
Dharmasastras (which place the insane alongside While many asylums were built in India before
thieves and murders as transgressors of moral liv- the 1900s, once Western medical approaches
ing) and the Laws of Manu (which lists insan- began gaining recognition and esteem in the early
ity as a reason for nullifying marriage and other 20th century, there was a rapid increase in both
social contracts). These texts are thought to be the number of facilities and patients. The Indian
linked to contemporary stigmas of people with Lunacy Act was passed in 1912, with the aim
mental illnesses in India. of improving the conditions at asylums, which
Ayurvedic treatments for mental illness depend henceforth were referred to as hospitals. Early
on the determined cause but generally include a asylums and hospitals were staffed by Indians,
combination of exercise (yoga), purgatives, ene- yet the supervisory and senior positions were
mas, procedures (surgery, bone alignment, mas- almost always held by Europeans. This shifted in
sage), nutrition, and medicines. These treatments the wake of World War I, during which Indians
are still practiced in contemporary Ayurvedic took over many of these roles, including super-
clinics for all types of illnesses and maintain close intendent positions, as Europeans were called to
connections with Hinduism. Hindu deities are bring their expertise to the field. After the war, the
often described as having traits associated with Indian supervisors were considered competent,
madness; some are portrayed as chaotic, wild, and local national pride insisted that they remain
and unpredictable. This link between madness in charge of medical and social institutions.
and religion continues to be demonstrated in Although Indian medicine and culture is gen-
holy peoples who live unconventional lives, often erally thought to be 10 years behind Western
rejecting clothing and housing and slipping in and medicine, evidence shows that Indian psychiatry
out of trances. Stories of Hindu gods and god- largely kept up with Western psychiatry. Journals
desses in the major epics—the Ramayana and from the early 1900s reflect the use of interven-
Mahabharata—are still used in contemporary tions similar to those in Western countries. By the
psychotherapy to describe to patients and fami- end of the British reign, Western psychology had
lies the course, cause, prognosis, or treatment of taken root and existed alongside, and often in col-
mental illness. laboration with, traditional healing approaches.

Psychiatry in the Time of British Colonialism Contemporary Indian Psychiatry

British colonialism has heavily influenced Indian The Indian Psychiatric Society and the Indian
life, including medicine and psychiatry. Initially, Journal of Neurology and Psychiatry (later
mental illnesses were not a priority for the British renamed the Indian Journal of Psychiatry) were
in India. However, in the mid-19th century, when both launched in 1949, and in 1954 the All India
the East India Company was dissolved and the Institute of Mental Health was established in
388 India

Bangalore, Karnataka. The latter is still a central of early traditional medical approaches from
training and research center, though the name has Ayurveda, Unani, and Siddha medicine. Physical
been changed to the National Institute of Men- illnesses are much less stigmatizing than psychiat-
tal Health and Neurosciences. In the 1970s, psy- ric ones, a perception that influences the way that
chiatrists developed the Indian Psychiatric Sur- patients approach their physicians. Spirit posses-
vey Schedule, which is based on the biomedical sion and dissociative states are also fairly com-
approach to mental illness and is used to identify mon in India and usually are not associated with
the presence of 124 psychiatric symptoms. physical complaints; however, the spiritual basis
While biomedical psychiatry has a strong pres- for these instances helps deflect the notion that
ence in India, psychiatrists and local healers fre- the person is ill from “bad blood,” which serves
quently collaborate, and many patients navigate to stigmatize the entire family.
both traditional and biomedical facilities for Most Western psychiatric illnesses—as defined
diagnosis and treatment. Since psychiatric hospi- by the American Psychiatric Association’s Diag-
tals are primarily located in major cities, inpa- nostic and Statistical Manual of Mental Disorders
tient care is rarely utilized. Rural families often and the World Health Organization’s (WHO)
exhaust local and religious interventions, such International Classification of Diseases—are
as homeopathy, Ayurveda, or temple prayers present in contemporary India; however, preva-
and visits, before traveling to the nearest urban lence rates are the subject of some controversy.
area for treatment at a Western-style facility. In Some epidemiological research reveals rates com-
India, the family is integral in all health decisions, parable to Western countries, but more recent
including when a person is ill and what types of research suggests that there may be slightly lower
treatments they receive, and is often present dur- rates. This follows the WHO study in which
ing intake interviews and consultations. The pri- schizophrenia was present in nine different cul-
vacy heralded in Western care is absent in Indian tures and that those in developing nations had
systems; people commonly consider the need to better outcomes in terms of psychotic episodes,
discuss or treat in private as an indication of hospitalizations, and severity of symptoms. There
serious illness that may even increase stigmas of is one culture-bound syndrome, dhat, which is
mental illness. characterized by fatigue, palpitations, headaches,
When a person is admitted to a psychiatric hos- anxiety, loss of appetite, depression, and semen
pital, a family member usually lives at the institu- loss. These symptoms mirror those seen in other
tion with them, often at the request of the hospital. culture-bound syndromes of nearby nations, such
This family member, most often a parent, wife, or as shen k’uei in China, prameha in Sri Lanka, and
less frequently a husband, cooks for the ill family jiryan in areas of southeast Asia.
member, ensures that medication is administered As Western psychiatry has become more popu-
as prescribed, and alerts staff to the patient’s needs, lar in India, traditional Indian approaches such
improvements, or regressions. While doctors are as yoga, meditation, and herbal medicine have
often celebrated and admired in Indian culture, become more popular in Western countries.
the family has the final say on when and where Research on the psychiatric and bodily benefits of
to seek treatment and which aspects of treatment these practices is taking place, and Ayurvedic and
to follow. Often, if a person is able to work, he herbal medicines are gaining recognition. Many
or she is deemed healthy, despite the presence of of these approaches have been found beneficial
psychiatric symptoms. to Western patients, and psychiatrists are increas-
Somatic complaints are often presented along- ingly suggesting these ancient techniques as part
side or in place of psychic complaints. Many ill of a treatment package. Physicians are finding that
people visit temples or traditional medical clin- the inclusion of Eastern approaches with Western
ics to rest and recover from a physical complaint, treatments can increase effectiveness and improve
but an underlying psychiatric condition may also overall mental health.
need attention. The combinations of physical and
psychiatric symptoms presented by patients in Jennifer C. Sarrett
present-day India are consistent with the tenets Emory University
 Indonesia 389

See Also: Imperial Psychiatry; Somatization of especially West Papua (West Irian), influenced by
Distress; Spiritual Healing; Treatment. animist traditions.

Further Readings Asylum Building

Agarwal, S. P. and D. S. Goel. Mental Health: An The Dutch, who gradually established the
Indian Perspective, 1946–2003. New Delhi: Netherlands East Indies (now Indonesia) from
Directorate General of Health Services, Ministry of the 17th century, changed their policies after a
Health & Family Welfare, 2004. report in 1862, at which time there were already
Fabrega, Horacio. History of Mental Illness in India: asylums in the Netherlands but none in the East
A Cultural Psychiatric Retrospective. Delhi: Indies. The Dutch government then commis-
Motilal Banarsidass Publishers, 2009. sioned Dr. F. Bauer and Dr. W. Smith to study
Mills, James. “The History of Modern Psychiatry in facilities in Europe, and their report (1868) led
India, 1858–1947.” History of Psychiatry, v.12 to the construction of a krankzinnigengesticht
(2001). (asylum). Located at Buitenzorg (now Bogor), it
opened in 1882 and was known as the Semplak
Insane Asylum.
In 1902, a new facility was built at Lawang.
Both places were chosen because of their rela-
Indonesia tively temperate climates, the former the sum-
mer residence of the governors (from Batavia,
In Javanese history and folklore, there has been now Jakarta), and the latter as the resort for the
a long tradition of epic poetry, and in some of Europeans from Malang. In 1908, there were
these works there are accounts of people suffer- 739 inmates at Buitenzorg (230 European men,
ing from mental problems. This was traditionally 88 European women, 376 Javanese, and 45 Chi-
attributed to the belief that some Javanese (and nese), and there were 921 inmates at Lawang (62
others) suffered from amuk behavior, which is European men, two European women, 772 Java-
often referred to in Javanese as (ng)amuk. It was nese, and 85 Chinese).
felt that this often emerged from the repression of The two asylums were important enough to
emotion, or from attempts to crush political or attract the attention of Emil Kraepelin (1856–
cultural dissent, with the sufferer displaying evi- 1926), a German psychiatrist and one of the major
dence of anxiety and vulnerability. Some of this figures in the development of the ideas of scientific
came from the belief in the semangat, with some psychiatry. He was keen to apply modern Euro-
similarities to the concept of the soul in Christian- pean theories to Asian conditions, and over four
ity. This leaves the body during periods of sleep months in early 1904, he and his brother Karl
and at times of major sickness, its absence some- went to southern Asia and on to Java to make a
times contributing to a trance-like state. study of mental illness in India, and also to what
Mental illnesses are therefore seen to develop was then the Netherlands East Indies. On his
from the lack of presence of the semangat. Many return, Kraepelin concluded that these problems
of these ideas persist, and this has seen a large were similar to the dementia concepts that were
number of conservative Javanese viewing men- emerging in Western Europe during the late 19th
tal illnesses as a spiritual and religious problem century. The system employed at the Buitenzorg
rather than a medical problem. asylum and its counterpart at Lawang was to get
In neighboring Bali, there are similar concepts, inmates involved in relatively simple activities to
with much of Hindu Balinese culture deriving “keep them busy.” These activities involved sim-
from pre-Islamic Javanese traditions. This has ple agricultural work and minor building, renova-
seen research into trances as a part of religious tion, and landscaping work.
culture. Elsewhere in Indonesia, there are a vari- Gradually, other asylums were opened else-
ety of regional variations with coastal areas, espe- where in the Netherlands East Indies, with the
cially ports, influenced by Javanese ideas through third at Magelang completed in 1920. These still
the Bugis, and inland areas of Makassar, and catered to a very small number of the people who
390 Indonesia

suffered from mental illnesses and were heavily The problems facing mental health facilities
slanted toward provision of services for Euro- with stretched resources have caught the atten-
peans. By 1936, there were 15 asylums in the tion of local and foreign journalists. The plight
Netherlands East Indies, some of which were of some patients was captured in the documen-
maintained by religious orders and charities. tary film, Culture and Mental Illness in Indonesia
After independence, the programs increased, and (2010–11), which was directed and produced by
focused on Indonesians because most Europeans psychological anthropologist Robert Lemelson,
had left. However, the overall health service was based on his research throughout Indonesia from
underfunded, and mental health services have 1997 until 2010. It showed how families had tried
only received about 1 percent of the country’s to help members suffering from mental problems
health budget. in Java and Bali. There have been some charitable
organizations and self-help groups established to
Current Situation deal with these problems. The Suryani Institute
There are now 27 government-run and state- in Bali uses a combination of psychiatry, Western
funded mental asylums, with different sources cit- medication, and spiritualism.
ing between six and 21 facilities run by private or With little money available for treating men-
religious organizations. Relative to the population tal illnesses in Indonesia, there are regular stories
of the country, there has actually been a decline in the press of appalling treatment of patients.
in facilities. Overall, there is now a capacity of In October 2012, many newspapers around the
about 7,700 beds in a county that has a popula- world covered the ill-treatment of patients at
tion of 237.4 million (2011 census), with 30,824 Karangasem, Bali. These and similar reports have
people per bed, versus 23,000 people per bed in encouraged foreign psychiatrists to offer their
1992, and 22,800 people per bed around 1910 help, with Professor Chee Ng from the Univer-
and 1911. These figures, however, do not take sity of Melbourne in Australia involved in train-
into account regional variations. Six of Indone- ing Indonesian psychiatrists in the diagnosing and
sia’s 34 provinces have no mental health facilities treatment of patients.
at all; however, there are three times as many beds The parliamentary campaign to improve men-
as the national average, relative to the popula- tal health provisions has been championed by
tion, in Yogyakarta. This situation is dire because Nova Riyanti Yusuf from the ruling Democratic
it has been calculated that there may be as many Party of President Susilo Bambang Yudhoyono,
as 800,000 people suffering from chronic mental after her election to the Indonesian parliament
disorders in Indonesia, with possibly 20 million in 2009. A psychologist by training, in Septem-
others who suffer from emotional problems. ber 2012, she pushed for a working committee
The World Health Organization (WHO) com- to formulate a mental health bill. Issues noted in
missioned a report on mental health in Indone- the subsequent debates were existing provisions
sia that was published in 1968, and the journal to impeach a president if he can be proven to suf-
Djiwa: Madjalah Psikiatri (The Indonesian Psy- fer from mental problems, and the possibility of
chiatric Quarterly) has been published from the mental illness being used as an issue for mitigat-
1970s. The WHO also funded a large number of ing sentences in criminal trials.
studies, including the doctoral thesis of Ernaldi
Bahar, who was able to focus research into those Justin Corfield
suffering from mental illnesses around Palem- Independent Scholar
bang, Sumatra.
It has been calculated that there are some 500 See Also: Asylums; Bangladesh; Kraepelin, Emil;
qualified psychologists in the whole of Indonesia, Thailand.
with a result that many problems remain undi-
agnosed; some of the mentally ill are shackled Further Readings
in centers using the pasung (stocks). This has Agence France-Presse. “Indonesia’s Mentally Ill
resulted in some centers chaining up people over Shackled and Forgotten.” Jakarta Globe (October
sewers to wash away excrement. 10, 2012).
 Inequality 391

Allard, Tom. “The Face of Indonesia’s Sham.” Sydney wealthy in society and those most lacking of the
Morning Herald (June 19, 2010). necessities of optimal life. Three major systems of
Malone, Sloan and Megan Vaughan. Psychiatry and social stratification are typically recognized within
Empire. New York: Palgrave Macmillan, 2007. the field of sociology: the estate system, the caste
Porath, Nathan. “The Naturalization of Psychiatry system, and the class system. In an estate system,
in Indonesia and Its Interaction With Indigenous a ruling elite class is dominant over society and its
Therapeutics.” Bijdragen tot de taal-, land- en resources. This obsolete system was noted during
volkenkunde, v.164/4 (2008). the period of Europe’s Middle Ages. A caste sys-
Sihaloho, Markus Junianto. “Mental Health Bill tem delineates the social standing of an individual
Working Committee to Be Formed.” Jakarta Globe at the time of birth. This location is often fixed
(September 10, 2012). and mostly unchangeable. In a class system, as
in the United States, groups occupy social classes
or strata based on property ownership or wealth,
income, education, or power. Although there is
more fluidity than in either the caste or the estate
Inequality system, there are barriers in a class-based system
for certain groups, such as racial ethnic minorities
Social stratification and social inequality are and women, to easily ascend the social ladder.
important underlying concepts in sociology. Sociologists often recognize social stratifica-
Although often used interchangeably, social tion as fundamental to every society. However,
stratification refers to how goods and services are social inequality, which delineates either if or
distributed in a society. In a stratified system, the how particular social groups receive various
unequal distribution of valued goods and services goods, services, or opportunities, is systemically
provides some members more and others less of patterned. In the U.S. class system, such social
commodities such as money or income, education, inequalities are based on race, class, and gender.
health and health care, food (quantity and qual- Other sociodemographic variables such as reli-
ity), and shelter or quality of housing. In a strati- gion or creed, sexual orientation, age, and region
fied system, select strata or those who occupy one have also been associated with social inequality.
group may benefit from higher or lower social National Centers for Health Statistics data from
status and social standing than others. 2002 demonstrate the importance of gender dif-
The distribution of poverty and wealth dem- ferences in potential life years. In 2003, the life
onstrate social stratification in a society. This can expectancy for women was 79.8 years compared
be examined within a society or across societies. to 74.4 years in men.
The unequal distribution of poverty and wealth is Still, research has shown that although women
increasing worldwide. While poverty refers to the outlive men, women experience more morbidity
lack of a socially acceptable amount of financial than men over the course of their lifetimes and
resources or means of support for basic needs or experience poorer health throughout the life
other material possessions, wealth refers to the course. Life expectancy across race and ethnicity
abundance of goods, services, and other financial demonstrates even wider gaps between men and
resources. Wealth is often measured in terms of women. In 2001, white women, at time of birth,
assets such as home, property, and other financial could expect to live to 80.2 years compared to
savings and resources. African American women, who could expect to
live to age 75.5. In 2001, life expectancy at birth
Three Major Systems of Social Stratification for white men and African American men was 75
Social stratification has been studied at length in years and 68.6 years, respectively.
the various fields of sociology as a contributing
factor to basic social problems including crime, Karl Marx, Max Weber, and the
achievement, and health. In public health and Sociological Foundations of Inequality
medicine, more research has evolved to identify Karl Marx and Max Weber are two of the most
differences in health outcomes between the most notable scholars in the study of social inequality.
392 Inequality

Marx approached the study of social inequality by Prestige refers to the respect provided to someone
examining the role of owners and workers within and power addresses the influence over political
a system of economic production. According to decision making that affects society.
Marx, the system of economic production is the
most important source of inequality in society. Social Stratification and Health Outcomes
Marx focused on the means of production (mate- Social stratification or inequality is critical to
rials, tools, and resources) by which society pro- understanding differentials in population health.
duces and distributes goods and services. Social Because of social inequality, certain groups may
class is thus premised upon one’s social struc- become more vulnerable to conditions, social
tural location within the economy as employer or impacts, or health conditions. Inequality based
owner rather than employee or worker. Marxian on race, gender, income, education, or geographic
theory further emphasizes the struggle between region (such as national or urban versus rural)
the bourgeoisie (ruling class) and the proletariat makes certain population groups more vulner-
(working class) within the means of production. able to certain social and environmental factors,
Marx suggests that class conflict is inevitable and including pollution, community violence, health
will commence with the overthrow of the ruling impacts such as obesity, and other behavioral and
class by the proletariat. mental health outcomes.
Whereas Marx emphasized the economic Social inequality makes some groups more vul-
dimension, Weber approached inequality from nerable to a range of poor health and social out-
the dimensions of class, prestige, and power. comes as a result of their low social status and

Women’s rights advocate Welcome Witboi (center) speaks with women and families in his community in Valhalla Park, South Africa,
about gang violence against women. While South Africa has the largest economy on the African continent, many still live in poverty, and
the gap between rich and poor drives increasing violence. Inequality based on race, gender, income, education, or locale makes certain
population groups more vulnerable to negative social and environmental factors, including behavioral and mental health outcomes.
 Inequality 393

low socioeconomic status. For example, minority the basic necessities or ensuring the distribution
populations are more likely to be susceptible to of these needs as the responsibility of the govern-
a range of social conditions that predict health. ment.
Life expectancy at birth, morbidity and mortality Engels focused on the social causes of health in
rates, and disease-specific mortality rates, when both work and the social environment. He high-
presented by race, class, and gender, suggest large lighted occupational diseases and different types
inequalities between groups. of environmental hazards to which working-class
Differential health outcomes by sociodemo- Germans were exposed in their employment.
graphic classification are reflective of social Engels also emphasized the crowded living condi-
stratification in the United States. Stratifica- tions of the poor, which produced various condi-
tion in America has historically situated groups tions such as tuberculosis and typhus. Engels also
unequally by class status, race, and gender, which looked specifically at the nutrition of the work-
establish minority and majority groups. Accord- ing class. Furthermore, Engels drew connections
ing to the 2000 U.S. Census, minorities comprised from social conditions to nutrition and eventual
32 percent of the U.S. population. The Hispanic disease. His work focused on the cost of food and
population remains the fastest-growing minority the consequent shortage of food supply among
group, comprising approximately 53 percent of urban workers. Engels analyzed various ortho-
the minority population. African Americans only pedic types of disorders that arose from strenu-
represent approximately 13 percent of the total ous physical labor and associated the physical
U.S. population. However, minorities far exceed demands of industrialism to the poor physical
whites in both morbidities and mortalities on health of workers.
nearly every measure. Early 20th-century American studies also sug-
Social inequality leads to health disparities, gested poverty to be a predictor of morbidity and
which are the unequal distribution of diseases mortality. A study by surgeon B. S. Warren and
across social groups. Research indicates that public health statistician Edgar Sydenstricker on
even when class is controlled, health disparities the health of approximately 3,000 New York City
remain between racial ethnic groups so that when garment workers saw poverty as a pathway to
African Americans occupy the same economic poor health outcomes and a way to explain class
groups as whites, African Americans continue to differentials in health. The data compiled by the
fare worse in terms of health. Social and politi- research, based on physical examinations and mul-
cal systems shape health disparities. Several theo- tiple disease screenings of the workers, supported
ries of public health, referred to as theories of the the theory that low wages harmed health. Clas-
social production of disease, explore the social sifications of individuals by income level revealed
economic and political factors that shape health that different health outcomes existed between the
outcomes and the unequal distribution of disease highest paid and poorest people. Infant mortality
in societies. was greater by 9 percent for the poorest families.
A similar study by the U.S. Children’s Bureau
Early Studies of Social Inequality and Health (1912) examined variations in infant mortality
The social causes of adverse health are historically rates by parental employment, occupation, and
grounded in the work of Rudolph Virchow and family income level. The study revealed that infant
Freidrich Engels. Considered the “father of social mortality rates nearly doubled with decreases in
medicine,” Virchow focused on the relationship annual income per 1,000. In the 1920s, scholars
between inequalities and health in Germany. matched death records with tax information from
Although known for work on cellular pathol- a 19th-century census to find that the age-adjusted
ogy, Virchow found multifactorial causes of poor death rate of the wealthy (who could pay taxes)
health. Virchow focused on the way in which was less than one-half of the poorer (nonpaying)
material disadvantage transmitted throughout populations.
communities. Virchow considered factors such as Census data demonstrated the importance of
access to adequate food and housing as preventive race in economic stratification, which historical
measures against disease. Virchow saw providing studies suggest correspond to poorer health quality.
394 Inequality

Inequality and Mental Health Conclusion

Like health in general, epidemiological studies In explaining the poverty and mental health
have associated poverty and low social status to relationship, sociologists consider either social
adverse mental health. Research has noted higher cause or social selection. The causal perspec-
prevalence of certain psychiatric conditions such tive acknowledges the stress and risks of poverty
as substance use, schizophrenia, and depression because of depraved living conditions. Alterna-
in lower social-class groups. tively, the drift perspective suggests that people
began to descend down the social scale prior to
Drug use. Morbidity and mortality linked to the onset of full psychosis.
substance use is a problem among all classes. In
2007, there were nearly 38,000 deaths associ- Raja Staggers-Hakim
ated with drug use. Illegal drug use was higher Eastern Connecticut State University
among African Americans than whites. Recently,
there has been an increase in mortality from pre- See Also: Ageism; Depression; Drug Abuse;
scribed narcotics among whites, especially pre- Economics; Mood Disorders; Race; Race and Ethnic
scription painkillers. Among whites, drug-related Groups, American; Schizophrenia; Social Causation;
overdoses are more common among low-income Social Class; Social Control; Social Isolation; Suicide;
groups. Unemployment; Vulnerability; Welfare.

Schizophrenia. Research has indicated a higher Further Readings

prevalence of schizophrenia among lower-class Adler, N. E., T. Boyce, M. A. Chesney, S. Cohen,
groups. As an explanation for this discrepancy, S. Folkman, R. L. Kahn, and S. L. Syme.
researchers have suggested that for individuals in “Socioeconomic Status and Health: The Challenge
groups already vulnerable to schizophrenia, there of the Gradient.” American Psychologist, v.49
is an impaired sense of reality in the absence of (1994).
resources to deal with the ongoing stress. Further, Bell, C. C. “Pimping the African-American
patients from lower social-class groups are less Community.” Psychiatric Services, v.47 (1996).
likely to receive early interventions for mental ill- Berry, J. W., U. Kim, T. Minde, and D. Mok.
ness because of lack of access and awareness of “Comparative Studies of Acculturative Stress.”
mental health conditions and treatment. International Migration Review, v.21 (1987).
Blazer, D. G., C. F. Hybels, and E. G. Simonsick,
Mood disorders. Mood disorders such as depres- et al. “Marked Differences in Antidepressant
sion are also more common among lower socio- Use by Race in an Elderly Community Sample:
economic groups. Depression is more common 1986–1996.” American Journal of Psychiatry,
in those who occupy a lower social status and v.157 (2000).
among those who experience downward social Bond, C. F., C. G. DiCandia, and J. R. MacKinnon.
mobility. Further, depression and mood disorders “Responses to Violence in a Psychiatric Setting:
have been found in groups with less opportunity The Role of Patient’s Race.” Personality and Social
for upward social mobility such as groups with Psychology Bulletin, v.14 (1988).
low educational levels. Broman, C. L. Mental Health in Black America.
Thousand Oaks, CA: Sage, 1996.
Suicide. Suicide has also been associated with Brown, E. Richard. Racial and Ethnic Disparities in
class disadvantage. Studies have revealed that Access to Health Insurance and Health Care.
many of those who completed suicide faced Los Angeles: UCLA Center for Health Policy
unemployment or were living with a terminal ill- Research, 2000.
ness. Those who attempt suicide are more likely Chen, Jersey, Saif S. Rathore, Martha J. Radford,
to live in depraved conditions. This is also the Yun Wang, and Harlan M. Krumholz. “Racial
case for homicide. Young unemployed men face Differences in the Use of Cardiac Catheterization
the greatest risk of poverty. Drug-related suicide After Acute Myocardial Infarction.” New England
is also common among those living in poverty. Journal of Medicine, v.344/19 (2001).
 Informed Consent 395

Chun, C., K. Enomoto and S. Sue. Handbook of Williams, D. R. and R. Williams-Morris. “Racism
Diversity Issues in Health Psychology. New York: and Mental Health: The African American
Plenum, 1996. Experience.” Ethnicity and Health, v.5 (2000).
Clark, Rodney, Norman B. Anderson, Vernessa
R. Clark, and David R. Williams. “Racism as a
Stressor for African Americans: A Biopsychosocial
Model.” American Psychologist, v.54/10 (1999).
Epstein, A. M. and J. Z. Ayanian. “Racial Disparities Informed Consent
in Medical Care.” New England Journal of
Medicine, v.344 (2001). Informed consent is the permission that a sub-
Exner, D. V., D. L. Dries, M. J. Domanski, and ject of research or recipient of treatment may
J. N. Cohn. “Lesser Response to Angiotensin- give upon gaining a full appreciation of the facts
Converting Enzyme Inhibitor Therapy in Black and implications of a proposed procedure. It is
as Compared With White Patients With Left the responsibility of the researcher or health care
Ventricular Dysfunction.” New England Journal of provider to secure informed consent, whenever
Medicine, v.344 (2001). possible, in accordance with disciplinary and
Giles, W. H., R. F. Anda, and M. L. Casper, L. G. institutional guidelines. When a subject is con-
Escobedo, and H. A. Taylor. “Race And Sex sidered judgmentally impaired and legally inca-
Differences in Rates of Invasive Cardiac Procedures pable of consenting (such as a child or someone
in U.S. Hospitals: Data From the National who is afflicted with serious cognitive disabilities,
Hospital Discharge Survey.” Archives of Internal in a coma, intoxicated, or under severe stress),
Medicine, v.155 (1995). a surrogate decision maker may be authorized
Gorman-Smith, D. and P. Tolan. “The Role to provide or withhold consent on the subject’s
of Exposure to Community Violence and behalf. This is sometimes achieved through the
Developmental Problems Among Inner-City Youth.” use of advance directives or health care proxies,
Development and Psychopathology, v.10 (1998). which specify a person’s wishes concerning their
Herbers, J. The New Heartland: America’s Flight care if they are incapacitated. Even when a per-
Beyond the Suburbs and How It Is Changing Our son’s decision making capacity is believed to be
Future. New York: Crown Books, 1986. compromised, clinicians and researchers should
Hughes, M. and M. E. Thomas. “The Continuing inform him or her about proposed procedures
Significance of Race Revisited: A Study of Race, and seek permission to proceed. In such instances,
Class and Quality of Life in America, 1972–1996.” the subject’s permission is called “assent” rather
American Sociological Review, v.63 (1998). than consent, and permission must still be secured
Jencks, C. and P. E. Peterson, ed. The Urban from a legally appointed conservator.
Underclass. Washington, DC: Brookings Failure to attain adequate informed consent
Institution, 1991. has been a defining feature of human subject
Kessler, R. C., K. D. Mickelson, and D. R. Williams. abuses throughout the 20th century, as exem-
“The Prevalence, Distribution, and Mental plified by the Tuskegee syphilis experiment, the
Health Correlates of Perceived Discrimination in biological experiments of Nazi and Imperial Japa-
the United States.” Journal of Health and Social nese scientists during World War II, and the U.S.
Behavior, v.40 (1999). Central Intelligence Agency’s MKUltra behav-
Krieger, Nancy. “Refiguring ‘Race’: Epidemiology, ioral engineering studies. The Nuremberg Code,
Racialized Biology, and Biological Expressions of which was designed in 1948 to address the crimes
Race Relations.” International Journal of Health of Nazi experimenters, stipulates in its first prin-
Services, v.30/1 (2000). ciple that subjects must be able to exercise choice
LaVeist, Thomas A., C. Diala, and N. C. Jarrett. “without the intervention of any element of force,
Minority Health in America. Baltimore, MD: Johns fraud, deceit, duress, over-reaching, or other ulte-
Hopkins University Press, 2000. rior form of constraint or coercion” and “should
Stolley, P. D. “Race in Epidemiology.” International have sufficient knowledge and comprehension
Journal of Health Services, v.29 (1999). of the elements of the subject matter involved,
396 Informed Consent

as to enable him to make an understanding and associated with involuntary detention. Researchers
enlightened decision.” These two criteria—con- should also consider the multiple axes of vulner-
sent without coercion and with sufficient knowl- ability that shape a subject’s ability to freely con-
edge—present unique challenges in the context of sent. For instance, people who are subordinate to
psychiatric health care and research. others in a formal hierarchy (such as prisoners,
soldiers, students, and employees) may assent to
Ethical and Procedural Norms procedures that they would not under other cir-
While legal requirements vary by jurisdiction, best cumstances. Members of socioeconomically dis-
practices for establishing informed consent have advantaged groups may be motivated to cooper-
been outlined in documents such as the Nurem- ate with professionals in positions of authority in
berg Code, the World Medical Association’s Hel- order to gain access to perceived or actual benefits
sinki Declaration, and the Belmont Report issued or other forms of preferential care. People who suf-
by the U.S. National Commission for the Protec- fer from debilitating conditions that lack standard
tion of Human Subjects of Biomedical and Behav- treatments may be unduly influenced by the hope
ioral Research. Researchers are typically required of cure and may have difficulty assessing the risks
to disclose to subjects the objectives, methods, of a clinical trial. In all such instances, the legal
duration, and potential risks and benefits of their capacity of subjects may not be impaired, but the
investigations; describe how the confidentiality voluntariness of their consent may be in question.
of data will be safeguarded, whom to contact for Research protocols should be designed to strike a
further information, and whether any compensa- balance between respecting the autonomy of con-
tion will be offered; and explain that consent is senting subjects and safeguarding them from forms
voluntary and can be withdrawn without penalty of harm beyond the experimental encounter.
at any time.
For example, an ethnographer who is inter- Issues in Defining Informed Consent
viewing sufferers of post-traumatic stress disorder Some scholars argue that the doctrine of informed
should, in addition to describing the nature and consent relies on ethnocentric assumptions that
purpose of her study, caution interviewees that do not adequately reflect how decisions are made
her questionnaire may elicit distressing emotions, in all societies. For example, members of com-
assure them that they may discontinue participat- munities whose leaders typically negotiate access
ing without consequence, and debrief them after with researchers on everyone’s behalf may feel
data has been collected. Health care providers uncomfortable consenting on an individual basis.
are typically required to inform patients of their Members of groups that have been historically
diagnoses; explain the nature, purpose, risks, and shortchanged by written agreements (such as
benefits of proposed treatments; and describe Native American communities) may have their
alternatives, irrespective of cost or eligibility for own standards for evaluating consent. For these
insurance coverage. For example, a physician reasons, informed consent, whether in research
who recommends a particular drug should offer or health care, should be viewed as an ongoing
a rationale for its use, present it as one of sev- dynamic within a relationship rather than a one-
eral therapeutic options, and explain the drug’s time act or contractual agreement. As bioethicist
known side effects to patients so they can make James DuBois argues, even in transcultural situ-
informed choices about how to manage serious ations involving subjects who do not subscribe
iatrogenic risks (such as weight gain, impulsivity, to the notion of individuated agency, their capac-
or neurological or motor disorders). ity to make informed decisions about their own
Investigators of research projects relating to bodies must nonetheless be respected to whatever
psychiatric health care are sometimes also medi- extent possible.
cal doctors, and they may wish to recruit their Informed consent is said to require subjects to
own patients into their studies. In such contexts, have possession of all facts relevant to a proce-
it is vital for physicians to remember that being dure. In practice, it is rare for subjects to possess
institutionalized compromises patients’ ability to the full range of knowledge needed to appreciate
refuse because of the many tacit forms of coercion the contextual implications of a research program.
 Insanity Defense 397

Current ethical standards do not entitle subjects wrong, disease versus responsibility, and, ulti-
to interdisciplinarily relevant facts such as the mately, treatment versus punishment. The result-
sociohistorical origins of diagnostic frameworks, ing criminal trials further attract attention because
ideological or financial influences on researchers, they often spark contentious battles between law
or the marketing strategies of drug manufactur- and medicine, contemporary society’s two most
ers, all of which may affect their ability to exer- powerful professions. Depending on which lan-
cise consent in an informed manner. guage captures the jury—conceptions of disease
or expectations about responsibility—the defen-
Eugenia Tsao dant will face conviction or acquittal, albeit an
University of Toronto acquittal of a very particular type.

See Also: Clinical Trials; Compulsory Treatment; Insanity and Common Law
Ethical Issues; Human Rights; Malaria Therapy; Although the first recorded common law acquit-
Malpractice; Neurosyphilis; Patient Rights; tal on the grounds of insanity dates to 1505 in
Pharmaceutical Industry; Placebo Effect; England—“the felon was of unsound mind (de
Psychopharmacological Research; Randomized non saine memoire). Wherefore it was decided
Controlled Trial; Right to Refuse Treatment. that he should go free (qu’il ira quite)”—the sig-
nificance of mental impairment for criminal cul-
Further Readings pability can be traced to the late 1200s. Placing
DuBois, James M. Ethics in Mental Health Research: intention at the center of criminal liability, Henri
Principles, Guidance, and Cases. Oxford: Oxford de Bracton, Henry II’s legal scribe, articulated
University Press, 2008. the “will to harm” as the criterion that conferred
National Institutes of Health, Office of History. “The moral and hence criminal culpability to an act.
Nuremberg Code” (1948). http://history.nih.gov Jurors since that time have been charged with fit-
/research/downloads/nuremberg.pdf (Accessed ting various forms of mental distress to the legal
May 2013). criteria regarding insanity in order to assess the
Van Staden, C. W. and C. Kruger. “Incapacity to Give defendant’s blameworthiness. Insanity is therefore
Informed Consent Owing to Mental Disorder.” a finding for the jury to make, not a medical dis-
Journal of Medical Ethics, v.29/1 (February 2003). ease to diagnose. Although there has never been a
shortage of terms associated with madness, none
of these “qualify” as insanity in itself. A diagnosis
begins the inquiry; it does not define the verdict.
An early attempt to define the elements that
Insanity Defense merited an acquittal can be found in judicial
instructions given in 1723. To the extent that the
If criminal responsibility were only a matter of defendant’s reasoning capacity appeared little
committing a physical act, the perpetrator’s state more than that of “an infant, a brute, or a wild
of mind at the time of the crime would likely be beast,” the jury was instructed to acquit. This
raised only as a possible mitigating factor in sen- standard of total insanity was affirmed later in
tencing. Since the 13th century, however, com- the century when the House of Lords was asked
mon law has mandated a requisite level of men- to consider a plea of lunacy proffered by one of
tal competence to accompany a physical act if it its own members. The prosecutor cautioned that
is to be called a crime. Without the purposeful only a total insanity—a total want of reason and
resolve to commit a wrongful deed, a tragic event memory—rose to the level of a legally relevant
may have occurred but not a legal transgression. degree of impairment. The unfortunate defen-
Ever since common law embraced the retention dant, suffering from a transitory and hence not
of mental coherence as critical to ascribing culpa- a complete loss of intellectual powers, was sum-
bility, a lively debate has ensued surrounding the marily convicted and executed.
insanity defense, which necessarily engages a cul- The exacting standard of total insanity would
ture’s most fundamental beliefs about right versus change in 1800 with the acquittal of George III’s
398 Insanity Defense

would-be assassin, James Hadfield. The defen- The Rise of the Forensic-Psychiatric Witness
dant’s attorney had skillfully challenged the law’s Medical witnesses with a special interest in medi-
criterion of total insanity: a person in such a state cal psychology had appeared in court beginning
of mental delirium could hardly be capable of in 1760, but their testimony was unremarkable:
even executing a crime. The attorney introduced with the law’s criterion of total insanity required
delusion as the essence of madness: a circum- to merit an acquittal, only the most florid, mania-
scribed error in belief that precluded an under- cal behavior could qualify. Neighbors and rela-
standing of the nature of an act and therefore an tives of the accused were just as well placed as a
appreciation of its moral consequence. Under the “mad doctor” to provide the jury with accounts of
spell of a religious cult, Hadfield had believed behavioral excess and verbal pandemonium. Not
that his own death at the hands of the state would only was medical participation infrequent, there
mimic Christ’s execution and thereby initiate the was also little in “specialist” testimony to distin-
Second Coming. Actions based on such profound guish the doctor’s opinion from the folk wisdom
confusion, the jury learned, could hardly be seen of the neighbor. Testimony such as “he appeared
as willfully chosen. more like a mad bullock than anything else,” was
The attorney’s persuasiveness was not lost certainly as vivid as any esoteric diagnosis.
on members of Parliament. While the jury was All of this would change with the introduction
deliberating Hadfield’s fate, Parliament rushed of delusion in 1800. The essence of this mental
through the Safe Custody Act (1800), ensuring ailment was its hidden character; disparaging the
that if acquitted, Hadfield—and all future insan- surface impressions of the defendant’s neighbor
ity defendants—would not be set free. (Hereto- or even his intimates, medical men distanced their
fore, an acquittal following a defense of mental experienced-based knowledge from common folk
derangement was recorded simply as “not guilty” wisdom, arguing that they alone knew how to
and the accused was free to leave the court). The probe for the derangement. Throughout the 19th
act provided for a “special verdict”—not guilty century, an era awash in innovative, adventurous
on the grounds of insanity—and that the defen- diagnoses, delusion was invoked more frequently
dant be detained “awaiting the King’s pleasure.” than any other malady. For its part, the courts
Although the Safe Custody Act dictated dis- granted delusion a secure berth in insanity trials
positional consequences for all future insanity because cognitive disarray spoke directly to the
defendants, Hadfield’s significance for common law’s fundamental concern: what the defendant
law cannot be emphasized too strongly. That the had meant to do. An accused mother who believed
defendant had been capable of carrying out an she was wringing a dish towel and not her daugh-
intricately planned maneuver—procuring the fire- ter’s neck could hardly be said to have chosen her
arm and bullets, successfully secreting himself at act. What “will to harm” could ever attend an act
the scene of the crime, methodically choosing the that rested upon profound confusion?
moment for shooting—demonstrated that partial By the mid-1800s, however, medical witnesses
insanity could nonetheless allow for conventional began to chafe at the constricting limits of insan-
behavior, even planning. But at the center of this ity as cognitive derangement, which precluded
seemingly rational behavior sat delusion, preclud- their introducing a newly uncovered form of
ing an understanding of the true nature of the act derangement that focused on emotional upheaval
and its moral wrongfulness. or defects in volition unaccompanied by any
Delusion eventually became the law’s touch- cognitive error. Variously known as manie sans
stone mental illness relevant to criminal responsi- délire, monomania, or moral insanity, this “clear-
bility. It isolated the mental faculty of understand- thinking” madness propelled those afflicted into
ing and hence intention: without the capacity to atrocious acts of violence—often against family
reason effectively, the action could not be seen members or close friends—for no apparent rea-
as willfully chosen. “Delusion” also became the son at all. Moral insanity was thus a derangement
term of preference for medical witnesses who of feeling, of sensibility, of how one ought to feel
were increasingly claiming insight into the nature toward others. This exclusively emotional mad-
of madness. ness entered the London courtroom in 1840 at
 Insanity Defense 399

law. Prosecuted for the murder of a man he mis-

took to be Prime Minister Robert Peel, nine medi-
cal witnesses described the compelling delusion of
political conspiracy that had driven M’Naghten to
destroy Peel: “nothing short of a physical obstruc-
tion would have kept him from his object[ive].”
After his acquittal, the House of Lords charged
the trial judges to articulate instructions for
future juries when weighing the law’s notions of
responsibility against the content of medical testi-
mony. The resulting M’Naghten Rules articulate
the grounds for an insanity acquittal: a defect or
disease of the mind such that the accused did not
know the nature or quality of his act, or if he did,
that he could not distinguish right from wrong.
Under a religious delusion, James Hadfield attempts to shoot Although they neglected to specify which disease
George III at Drury Lane Theatre in London on May 15, 1800. or what defect counted, the rules were explicit in
The standard of total insanity changed after Hadfield’s attorney deleting any mention of moral insanity, suggest-
successfully challenged the law’s criterion of total insanity and ing that they were conceived to restrict future
introduced delusion as the essence of madness. medical witnesses to questions of intellectual, not
emotional impairment.
Medical witnesses bristled at the confining lim-
its placed on their testimony in post-M’Naghten
the trial of Queen Victoria’s would-be assassin, insanity trials, but as they jockeyed in court to
Edward Oxford. Said to be suffering a “lesion of retain an expansive conception of insanity, a
the will,” the defendant shared the jury’s bewil- new cadre of insanity defendants entered the Old
derment that he had shot two pistols at a woman Bailey, prosecuted for acts purportedly commit-
he considered to be “a very nice lady.” Five medi- ted while in unconscious states of being, such as
cal witnesses testified to his state of emotional sleepwalkers, automatons, and persons suffering
derangement yet cognitive coherence. a state of epileptic vertigo. Epileptic vertigo was
The specter of an insanity that left the indi- itself a compelling state. Between two convulsive
vidual’s reasoning capacity intact while being seizures, the patient appeared to regain conscious-
swept away by overpowering emotions or a ness—revealing considerable manual dexterity
“lesion of the will” met stiff opposition. What and a capacity to carry on conversations. Follow-
else was crime but emotions willfully indulged or ing a second convulsion, however, everything that
“irresistible instincts” that were, in fact, simply had transpired between the two episodes was lost.
unresisted? After all, criminal law was designed This was certainly fascinating when recounted in
to condemn such willful deviance; punishment the medical literature, but when epileptic vertigo
had been designed to deter citizens from giving entered the courtroom in the form of a mother
in to such impulses. That moral insanity had fig- who sliced off her daughter’s hand in a period of
ured prominently (and successfully) in a case of “absence,” the court was forced to consider the
attempted regicide was alarming to both the pal- legal status of a defendant in such a state. In the
ace and the court. In less than three years, the end, the jury refused to convict or acquit on the
House of Lords seized upon yet another attempt grounds of insanity, formulating instead a verdict
at political assassination to restrict the insanity of their own in 1876: not guilty on the grounds of
defense to cognitive defect symbolized by delu- unconsciousness.
sion rather than a derangement of feelings or the In addition to an expanding conception of
moral sentiments. mental derangement, the language of the insan-
The case of Daniel M’Naghten (1843) is the ity verdict also underwent a change in the final
most frequently cited insanity trial in common decades of the 19th century: guilty but insane
400 Insanity Defense

replaced an acquittal on the grounds of insanity. diagnosis of psychosis. Regardless of their infre-
Today, it is not uncommon for U.S. jurisdictions quency and likelihood of conviction, cases involv-
to offer the jury both options, with the change in ing an insanity plea attract notoriety for a num-
wording carrying very real significance. If found ber of reasons. The insanity defense often surfaces
guilty but mentally ill, the felon is remanded to in the most atrocious of crimes and captures the
the criminal justice system, not the state’s men- imagination of mental health professionals, legal
tal health apparatus. While in prison, there is no theorists, and the general public. They also serve
guarantee of treatment of any kind. The verdict as an irresistible forum for behavioral scientists
has therefore been interpreted as both retribu- to proffer new understandings of the mysteries of
tive and rehabilitative—a measure with which the brain.
jurors can acknowledge the medical evidence of From phrenologists in the early 1800s to late-
derangement and still make a formal declaration Victorian neurologists asserting states of epi-
of the evil of the wrongdoer. lepsy that produced a form of somnambulism
to today’s neuroscientists attempting to isolate
The Insanity Defense Today the centers in the brain responsible for failing to
The M’Naghten Rules have proven remark- inhibit impulses, claims to have “pierced sanity’s
ably enduring, serving as the basis for instruc- smokescreen” enjoy a rich heritage, not least for
tions in most U.S. states. Various attempts have the confidence with which they are articulated.
been made to develop a “product test”—that the Still, insanity is a legal condition, not a medical
crime was itself the result of the mental illness— one; it will always take a jury of lay people to
or a volitional plank: that the mental illness kept synthesize the claims of science to the community
the defendant from conforming his behavior to sense of right and wrong. Trials that feature an
the expectations of law. Still, the formulation of insanity defense turn on the most enduring and
“knowing right from wrong” has remained the contradictory of cultural sentiments: the desire to
most frequently applied standard, perhaps because protect the sick and the equally strong conviction
it accords with a community sense regarding the that the morally evil deserve punishment.
limits of criminal sanction.
Both before and after the acquittal of John Joel P. Eigen
Hinckley for the attempted assassination attempt Franklin and Marshall College
on President Ronald Reagan in 1981, there was
a flurry of legislative activity at both the state See Also: Competency and Credibility; Courts;
and federal levels aimed at reforming the insan- Dangerousness; Forensic Psychiatry; Hospitals for
ity defense and the disposition of deranged defen- the Criminally Insane; Law and Mental Illness;
dants. Because the legislative process can be noto- Legislation; Moral Insanity; Psychiatry and
riously slow, it is difficult to attribute the changes Neurology; Szasz, Thomas.
to any particular case or a Supreme Court rul-
ing, yet there have been changes in more than Further Readings
half of all states regarding the use of the defense. Moran, Richard. Knowing Right From Wrong: The
These alterations are concerned with who has the Insanity Defense of Daniel McNaughtan. New
burden of proof, what standard of derangement York: Free Press, l981.
should be employed, and how commitment fol- Porter, Roy. Mind Forg’d Manacles: A History of
lowing the verdict is to be monitored. State prac- Madness From the Restoration to the Regency.
tice varies widely on each of these measures. London: Athlone Press, l987.
What has remained consistent is the incidence Schneider, Richard D. The Lunatic and the Lords.
of the plea and its success rate. Fewer than 1 per- Toronto: Irwin Law, 2009.
cent of criminal cases annually feature an insanity Smith, Roger, Trial by Medicine: Insanity and
defense, and only one-quarter of defendants are Responsibility in Victorian Trials. Edinburgh, UK:
likely to be acquitted (or found guilty but men- Edinburgh University Press, l981.
tally ill). The defense has proven to be very dif- Steadman, Henry J., Margaret A. McGreevy, Joseph
ficult to employ successfully without a preexisting P. Morrissey, Lisa A. Callahan, Pamela C. Robbins,
 Insulin Coma Therapy 401

and Carmen Cirioncione. Before and After treatment experienced shakiness, perspiration,
Hinckley: Evaluating Insanity Defense Reform. and drowsiness, followed by a coma. It was
New York: Guilford Press, l993. believed that insulin-induced comas helped jolt or
Walker, Nigel. Crime and Insanity in England. shake patients out of their psychiatric conditions.
Vol. 1, The Historical Perspective. Edinburgh, UK: As a result of ICT, many patients became restless
Edinburgh University Press, l968. and experienced further convulsions and seizures.
In some cases, the insulin-induced coma led to
irreparable brain damage and death.

Origins in Europe
Insulin Coma Therapy Polish psychiatrist Dr. Manfred Sakel developed
ICT in 1927, at the University Neuropsychiat-
Insulin coma therapy (ICT), or insulin shock ther- ric Clinic in Vienna, in order to treat mental ill-
apy, was a psychiatric treatment in which patients nesses with no known cure. Sakel believed that
were injected with enough insulin to induce sei- insulin-induced seizures and comas dramatically
zures and comas. ICT, along with electrocon- changed the mental state of psychiatric patients.
vulsive and cardiazol convulsive therapies, were Specifically, he thought that patients injected
collectively known as shock therapy. ICT was with insulin became less argumentative, aggres-
introduced in the 1930s and was the most widely sive, and hostile, thus enabling greater reductions
used treatment for schizophrenia throughout the in symptomatology. From 1928 to 1931, Sakel
world during the 1940s and 1950s. Beginning used ICT to treat patients suffering from psy-
in 1950, however, questions about the effective- chosis and opiate addition. Sakel’s early success
ness of ICT to treat schizophrenia began to arise, using small doses of insulin to reduce drug with-
and by the 1970s, most countries had abandoned drawal and psychosis symptomatology prompted
their use of ICT to treat schizophrenia with less him to expand the use of insulin to treat other,
invasive and more effective therapeutic interven- previously untreatable conditions, namely schizo-
tions. Even though it was eventually found inef- phrenia. After finding that small doses of insulin
fective and dangerous, ICT opened the door for were successful in treating symptoms, Sakel per-
convulsive therapies and enabled the develop- formed numerous animal experiments to test his
ment of other, possibly more effective convulsive hypothesis that larger amounts of insulin could
treatments, especially electroconvulsive therapy, safely be administered to patients. Sakel theorized
in cultures throughout the world. that larger amounts of insulin would allow for
ICT required treatment from highly trained deeper levels of induced coma and, ultimately, to
doctors and nurses in specialized hospital units. greater reductions in symptomatology. By 1935,
In order to receive ICT, patients had to be diag- Sakel published numerous reports claiming that
nosed with schizophrenia. Most patients who schizophrenic patients undergoing ICT expe-
received ICT were chosen because they could rienced an 88 percent improvement rate. These
withstand physically demanding treatments early publications supporting the effectiveness of
and they suffered from only mild symptomatol- ICT attracted worldwide attention and ultimately
ogy. A standardized treatment protocol for ICT led to ICT’s implementation as the primary treat-
was never developed. Thus, treatment protocols ment for schizophrenia in over 20 nations.
varied across hospitals throughout the world. In 1936, Dr. Isobel Wilson, a medical commis-
Patients were given enough insulin to induce a sioner for the Board of Control for England and
coma; doses were administered in 100-unit inter- Wales, traveled to Vienna in order to study ICT.
vals until the coma was induced. Typically, injec- The Board of Control for England and Wales was
tions were administered six days per week, and in charge of overseeing all psychiatric institutions
the length of treatment varied depending on the and mental health services in Great Britain. After
patient’s response. Once a reduction in symptom- her visit to Vienna, Wilson published a 61-page
atology was reached, doctors reduced the amount booklet titled Hypoglycemic Shock Treatment
of insulin administered. Patients undergoing in Schizophrenia, in which she commended the
402 Insulin Coma Therapy

treatment and urged its adoption in Great Brit- Beginning in December 1936, Sakel traveled to
ain. The highly praised report quickly went out medical centers throughout New York in order
of print, but its influence led ICT to be imple- to teach physicians how to administer the insulin
mented in psychiatric institutions throughout treatment. In 1937, Sakel presented a symposium
England and Wales. In 1938, ICT was utilized at on ICT at the annual meeting of the American Psy-
the Maudsley Hospital, one of London’s leading chiatric Association. This symposium, along with
psychiatric teaching centers. Doctors administer- continued research supporting the effectiveness of
ing ICT at Maudsley Hospital reported immedi- ICT in reducing schizophrenic symptomatology
ate success in treatment and claimed that insulin and enabling significant periods of wellness, estab-
significantly reduced symptomatology in patients lished ICT as the most widely used and accepted
who had not previously responded to therapeutic treatment for schizophrenia in the United States.
interventions. Support for the use of ICT in the In a report examining the use of ICT state by state,
treatment of schizophrenia was also strengthened Deborah Doroshow reported that by 1939, the
by studies conducted by Willy Mayer-Gross at the treatment had been implemented in facilities across
Crichton Royal Hospital in Dumfries, Scotland. most of the United States. However, the signifi-
In his reports, Mayer-Gross claimed that patients cant amount of money and resources required to
who were treated with insulin experienced lower implement the treatment prevented its adoption in
relapse rates than patients who did not receive the poorer states throughout the southwest and west.
treatment or who received an alternate treatment.
Despite its early acceptance and praise, the wide- Decline
spread use of and research on ICT in Great Britain Even though ICT was implemented in medical
was abandoned when World War II began. The facilities throughout the world, questions about its
nurses and doctors who had previously worked in effectiveness and practicality soon emerged, which
insulin units were deployed to army hospitals and led to the development of more effective, less
all medical supplies were concentrated on the war invasive treatments and to the decline of ICT. In
effort, thus halting the practice of ICT in Europe. Europe, support for ICT began to decrease during
World War II because most of the insulin centers
Origins in America throughout England and Wales were abandoned
As a result of the war in Europe, the ICT move- during the war. In Europe and America, reports
ment moved to the United States. The American and studies began to surface in the early 1950s
ICT movement first developed in 1933, when four that called the efficacy of ICT into question. One
physicians traveled to Vienna to study and learn issue that emerged was that the early studies dem-
ICT. Each of the four physicians was prominent onstrating the effectiveness of ICT only contained
within their field, eager to learn and promote new, patients who were thought to have a good prog-
innovative therapeutic techniques, and on staff at nosis, and thus they were not representative of all
major medical institutions throughout New York. patients suffering from schizophrenia. A second
After returning from Vienna in 1935, Josef Wor- issue was that early support for ICT was based
tis, one of the four physicians, set up the first insu- on only a few methodologically weak clinical tri-
lin center at Bellevue Hospital, which became one als. One of the most damaging blows to the ICT
of the most important teaching centers for ICT movement came from Dr. Harold Bourne’s report,
and other similar treatments. By 1937, Bellevue “The Insulin Myth,” which was published in the
had the largest insulin unit, with 26 beds and an Lancet in 1953. In his paper, Bourne called into
extensive medical and administrative staff. Wortis question many of the theories behind ICT, namely,
became the director of the unit, designed a post- that there was no evidence proving that insulin-
graduate course on ICT, and traveled throughout induced comas were sufficient and necessary in
the United States, promoting and teaching ICT reducing schizophrenic symptomology and pre-
techniques to medical professionals. venting the progression of the disease.
The dissemination of ICT to American psychi- In 1957, the Lancet published a randomized
atric hospitals further increased when Manfred controlled trial that examined ICT compared
Sakel immigrated to the United States in 1936. to noninsulin control groups. According to the
 Integration, Social 403

randomized trial, there were no significant dif- This is especially true for individuals who live
ferences in treatment outcome for patients in the alone and/or have a history of institutionaliza-
insulin and noninsulin groups, thus indicating tion, incarceration, or homelessness. Some strate-
that “insulin was not a specific therapeutic agent.” gies and interventions have been helpful in assist-
Additional randomized controlled trials support- ing people with SMI to achieve social integration
ing the ineffectiveness of ICT and the develop- with the general community. Although successful
ment of new therapeutic interventions that were social integration is dependent upon the interac-
more effective, less costly, and less invasive (i.e., tion of individual and neighborhood character-
electroconvulsive therapy and psychopharmacol- istics, one of the primary barriers is the stigma
ogy) caused many within the psychiatric field to attached to mental illness.
question how and why ICT had received global Beginning in the mid-1950s and accelerating
acceptance, despite its lack of empirical support. from the mid-1960s onward, treatment empha-
Even though insulin coma therapy has been criti- sis in the United Sates and elsewhere shifted from
cized as an ineffective and dangerous treatment, long-term psychiatric care in state hospitals to
its adoption and praise by medical professionals more community-based treatment of people with
throughout the world enabled and promoted cul- serious mental illness (SMI), with brief hospital-
tural and scientific unity. izations as needed for psychiatric stabilization.
The overall impact of deinstitutionalization is
JoAnna Elmquist that most people with SMI now spend more of
University of Tennessee, Knoxville their lives in the community rather than in insti-
Andrew Ninnemann tutions. In SMI (e.g., schizophrenia, mood disor-
Lindsay Labrecque ders, severe anxiety disorders, and borderline per-
Brown University sonality disorder), recovery goals include learning
Gregory L. Stuart to live independently in the community, managing
University of Tennessee, Knoxville their illness, and engaging with the rest of society.
Engagement with one’s community has three
See Also: Electroconvulsive Therapy; Schizophrenia; components: physical, psychological, and social.
Treatment. Physical engagement is defined as the extent to
which a person uses community goods and services
Further Readings such as housing, whereas psychological engage-
Jones, Kingsley. “Insulin Coma Therapy in ment is defined as the extent of a person’s sense of
Schizophrenia.” Journal of the Royal Society of belonging in the community. Social integration can
Medicine, v.93 (2000). be defined as the extent of a person’s interactions
Mankad, Mehul V., John L. Beyer, Richard D. and connections with peers and other community
Weiner, and Andrew Krystal. Clinical Manual members. Social integration can be thought of as
of Electroconvulsive Therapy. Arlington, VA: the opposite of social isolation because one cannot
American Psychiatric Publishing, 2010. simultaneously be engaged with a community and
Shorter, Edward and David Healy. Shock Therapy: remain socially isolated. There are several domains
A History of Electroconvulsive Treatment in of social integration, including occupational,
Mental Illness. New Brunswick, NJ: Rutgers interpersonal/leisure, political, religious, and civic
University Press, 2007. engagement with community members. When con-
sidering an individual’s level of social integration,
the size of their social network, the quality of their
social support (including the opportunity for reci-
procity), and the nature of the person’s roles (e.g.,
Integration, Social team member, friend, and coworker) are noted.
The social integration of people with SMI is
For people with severe mental illness (SMI), social lower than that of matched community peers,
integration, the ways in which people interact and and people with SMI tend to have smaller social
connect with others, is challenging and difficult. networks than nonpsychiatrically ill community
404 Integration, Social

members. The social networks of people with SMI nonpatient community members, thereby pro-
are also more likely to consist of family members, viding an opportunity for interactions with non-
other mental health consumers, and mental health disabled peers. It is unclear whether mentally ill
service staff. Often, people with severe mental ill- people residing in specialized community-based
ness experience social isolation. mental health housing are vulnerable to greater
marginalization (i.e., through the inadvertent cre-
Barriers to Social Integration ation of disability ghettos). Some studies report
There are several factors that may render social that SMI residents in community-based mental
integration particularly difficult for a person with health housing are more likely to experience neg-
SMI. Some of these factors are intrapersonal, ative attitudes and less acceptance than mentally
such as the individual’s symptoms (e.g., high ill people who reside in private housing.
suspiciousness or extreme anxiety) and current The custodial and supportive housing alter-
psychiatric status (e.g., acute psychosis and dis- natives are likely to be perceived differently by
organization), their social skills, and their appear- community members than the other, more auton-
ance. Moreover, because of economic depriva- omous housing options, which may not be imme-
tion, people with SMI may be more likely to dress diately recognizable as a residence for people with
more poorly, or they may stand out because of mental illness. However, selection of one’s hous-
medication side effects (e.g., drooling, shuffling ing may depend upon one’s needs for physical
gait, excessive weight gain, facial tics, and overt security, preparedness for the transition from an
trembling); outward physical appearance may institution or homelessness, and/or need for assis-
contribute to the mental illness stigma by mark- tance with medication management.
ing them as different and may make establishing Moreover, some studies reveal that dedicated
and maintaining interpersonal relationships with housing for people with mental illness is helpful
community members more difficult. in terms of providing social support in an accept-
Some of the barriers to social integration may ing, judgment-free environment, where one can
be situational, such as the mentally ill person’s focus on dealing with one’s psychiatric disabil-
housing status, lack of reliable transportation, ity. Regardless of the type of housing the mental
and restricted access to social opportunities. health consumer occupies, residing in neighbor-
There is some controversy regarding whether type hoods in which there is a fair degree of toler-
of housing for people with psychiatric disabilities ance for and acceptance of individual differences
affects their ability to effectively integrate within allows mental health consumers to take part in a
the larger community. There are several different larger range of activities, thereby affording ample
housing options available, including custodial opportunities for interaction with other commu-
housing (e.g., adult foster homes); supportive nity members.
housing, such as staffed group homes or sheltered One major barrier to the successful social
apartments, dedicated rooming houses, one-room integration of people with SMI is stigma. People
apartments, and community-based programs in with psychiatric illness are marginalized in North
private apartments; or autonomous housing. In American and European society. Perceived stigma
the supportive housing options, mental health is negatively associated with social integration;
professionals work to promote community inte- stigma makes it more difficult for mentally ill per-
gration for the mentally ill residents, all of whom sons to feel a sense of belonging within the gen-
live in buildings that are regularly staffed. eral community. Social rejection experiences with
Community-based supported housing pro- employers, landlords, casual acquaintances, and
grams are situations in which housing is provided strangers are typical occurrences for most people
to mental health consumers through mental health with mental illness. Because of social exclusion
agencies, either assertive community treatment or and/or self-imposed seclusion in order to avoid
supportive case management programs. In these anticipated rejection or negative reaction, people
programs, several rental units in each building with SMI have limited opportunities to engage
are allocated to mental health consumers, though with psychiatrically healthy peers. Social distanc-
the units are interspersed, with units rented to ing on the part of the general public makes it
 Intelligence 405

difficult for people with psychiatric disabilities to integrated into the larger community, directly
identify with, and engage in, meaningful recipro- through civic activities, as well as indirectly by
cal interactions with people who are not affected fighting mental illness stigma.
by mental illness.
Diane C. Gooding
Interventions and Strategies to University of Wisconsin, Madison
Increase Social Integration
For people with SMI, studies have indicated an See Also: Marginalization; National Alliance on
association between social isolation and poorer Mental Illness; Social Isolation; Stigma.
psychiatric and functional outcome, such as ear-
lier psychotic relapse. Thus, it is important from Further Readings
a health perspective to provide services to assist Dorvil, H., P. Morin, A. Beaulieu, and D. Robert.
people with psychiatric illnesses to socially engage “Housing as a Social Integration Factor for People
in their communities. This need was highlighted Classified as Mentally Ill.” Housing Studies, v.20
in the 2002 report of the president’s New Free- (2005).
dom Commission on Mental Health. Mandiberg, J. M. “The Failure of Social Inclusion:
Currently, there are several psychological and An Alternative Approach Through Community
psychosocial interventions aimed at helping men- Development.” Psychiatric Services, v.63 (2012).
tally ill individuals learn how to effectively live, Perry, B. L. “The Labeling Paradox: Stigma, the Sick
work, and learn with community members who Role, and Social Networks in Mental Illness.”
do not have mental illness. These services include Journal of Health and Social Behavior, v.52 (2011).
social skills training, assertiveness training, and Ware, N. C., K. Hopper, T. Tugenberg, B. Dickey,
more targeted interventions in the area of social and D. Fisher. “Connectedness and Citizenship:
cognition. All of these interventions are aimed at Redefining Social Integration.” Psychiatric
improving SMI individuals’ interpersonal, com- Services, v.58 (2007).
munication, emotion perception, and perspective-
taking skills to enhance their ability to interact
meaningfully and effectively with others. Occu-
pational therapists are also involved in terms
of providing life skills training, as well as social Intelligence
skills training and occupational therapy interven-
tions for employment and education. For some As stated in an American Psychological Associa-
individuals with SMI, this may include supported tion (APA) report published in 1996, intelligence
employment options. is a concept for which a consensual definition does
Clubhouse models of rehabilitation have been not exist, although most experts agree that intel-
important in terms of reducing mentally ill per- ligence is complex and multifaceted. Particular
sons’ sense of social isolation, by replacing the types of cognitive qualities are frequently delin-
term mental health consumer or patient with the eated by intelligence experts, including abilities
term member. Clubhouses have been successful in “to understand complex ideas, to adapt effectively
terms of increasing the social support networks to the environment, to learn from experience, to
among people with severe mental illness. Social engage in various forms of reasoning, [and] to
activities are planned by and for the members, overcome obstacles by taking thought,” as stated
and employment, whether paid or volunteer, is by Ulric Neisser et al. The various tests that are
emphasized. In this way, each person with SMI is intended to measure intelligence, intelligent quo-
in contact not only with other people with psychi- tient (IQ) tests, measure components of cognitive
atric disabilities but also with members from the ability that are within the domain of the intelli-
larger community. Support groups and advocacy gence concept held by most experts, for instance,
groups (such as the National Alliance on Men- verbal abilities, spatial abilities, memory, and
tal Illness) have also been successful in terms of facility with numbers. However, such tests usu-
helping people with SMI to become more socially ally do not directly measure nonacademic-type
406 Intelligence

abilities that many experts believe are part of are used to make decisions about people, both in
intelligence including social and emotional intel- school systems and in hiring and job placement,
ligence, and practical or “common sense” intel- these group differences in IQ scores produce real
ligence. In short, in the opinion of many experts, impacts on individual people and on the societ-
IQ tests measure part of the intelligence domain, ies in which these group differences exist. Addi-
but also fail to assess many important aspects. tionally, IQ is correlated with prognosis, or prob-
IQ tests are the primary method for measur- able future course, of the serious mental illness of
ing intelligence, both in applied contexts and in schizophrenia.
research studies, and thus are the primary method In the United States, IQ scores differ for dif-
for comparing intelligence across cultures or cul- ferent racial/ethnic groups. Mean IQ scores are
tural groups. In the United States and in other highest for Asian Americans (averaging about
countries, IQ scores differ for individuals of differ- 100, or some say slightly higher) and European
ent racial or ethnic backgrounds, and individuals Americans (averaging about 100). Mean scores
representing different socioeconomic classes. In for African Americans currently average about
the United States, IQ scores usually do not differ 85 or 90. For Hispanic Americans, the mean
between women and men. IQ scores predict real- score lies somewhere between the mean for Afri-
world outcomes fairly well; IQ scores are moder- can Americans and for European Americans and
ately correlated with performance in educational Asian Americans. These group differences in IQ
contexts (especially grades) and job performance generally correspond to group differences in edu-
and attainment. Because IQ tests and similar tests cational and occupational success, with Asian and
European Americans having the highest grades in
school and highest occupational attainment, Afri-
can Americans the lowest, and Hispanic Ameri-
cans somewhere in between.

Race and IQ
In 1994, Richard Herrnstein of Harvard Uni-
versity and Charles Murray from the American
Enterprise Institute created controversy in both
academia and among the general public when they
published their book The Bell Curve, in which
they review research on genetic and environ-
mental determinants of intelligence. Herrnstein
and Murray concluded that intelligence is largely
inherited, that group (race) differences in intelli-
gence are largely inherited, and that these findings
should inform U.S. public policy. They attribute a
wide range of social problems to low intelligence:
according to Herrnstein and Murray, people with
low IQs are the majority of U.S. school dropouts,
unemployed, unmarried parents, and criminals.
Following the publication of The Bell Curve,
the APA convened a task force to respond to Her-
rnstein and Murray’s claims. In their task force
report, published in 1996, the authors cover
much of the territory of interest in a discussion
of intelligence and IQ scores, including general
Alfredo Benet (1857–1911) was a French psychologist who definitions and concepts of intelligence, leading
invented the first usable intelligence test, known at the time as theories of intelligence, IQ tests, the degree to
the Binet test and today referred to as the IQ test. which IQ scores are correlated with important life
 Intelligence 407

outcomes such as grades in school and job per- Racial/ethnic differences in IQ scores also exist
formance, a summary of genetic and environmen- in the United Kingdom and other European coun-
tal determinants of IQ, and group comparisons tries. For instance, in the United Kingdom, whites
(based on sex and race) of IQ test scores. score higher than both blacks and Pakistanis on
The authors, in an attempt to counter some cognitive ability tests. Throughout Europe and
of the social policy positions that Herrnstein in the United States, Ashkenazi Jews (Jews of
and Murray advocate, inform the reader that European origin) score above average on IQ tests.
the gap between black and white IQs appears Ashkenazi Jews typically also earn high grades in
to be decreasing, remind the reader that knowl- school and do very well in occupational attain-
edge of a group’s average IQ says nothing about ment, including earning high salaries. In some
a particular individual’s IQ and that one must studies, racial/ethnic group differences in IQ can
not prejudge an individual based upon race or be partly accounted for by differences in socio-
ethnic background, and inform the reader that economic status (SES) of the groups; people of
many questions still remain about intelligence higher SES have higher IQs on average than peo-
and its measurement. For instance, many intel- ple of lower SES. However, SES differences do not
ligence experts believe that IQ tests fail to mea- account for all IQ differences between groups.
sure important intellectual abilities, and most In the United States, European Americans have
agree that the relative contributions of heredity higher IQ scores than African Americans at each
and environmental factors to IQ remain unde- level of the socioeconomic ladder.
termined. Questions have also been raised about Nigerian American anthropologist John Ogbu
possible cultural biases in the tests. argues that, within a particular country or cul-
Within sociology, a variety of critics have ture, only “caste-like minorities,” but usually not
attacked the methodology and statistical basis other minority groups, obtain relatively low IQ
of Herrnstein and Murray’s work. Inequality by scores and low academic and occupational suc-
Design: Cracking the Bell Curve Myth (1996), cess. A caste-like minority group in the United
written by six Berkeley sociologists, was a par- States is a group of involuntary immigrants,
ticularly influential counterblast and reflected the particularly African Americans, whose ances-
widespread skepticism within the discipline about tors were brought to the United States as slaves.
the quality of the scholarship in The Bell Curve According to Ogbu, many of these African Amer-
and alarm about the political uses to which its icans believe that their opportunities in the United
claims might be put. Scholars nonetheless con- States are heavily restricted and do not wish to
tinue to publish on the controversial issue of the conform to mainstream culture because doing so
degree to which genetics determines IQ and the would mean that they were “acting white.” These
degree to which IQ differences between race/eth- attitudes interfere with their abilities to achieve
nic groups are genetically caused. success in the United States.
Canadian psychology professor Philippe Rush- Minorities who immigrate willingly, by con-
ton and professor emeritus of educational psy- trast, are not handicapped by an aversion to con-
chology Arthur Jensen at the University of Cali- formity and are more likely to believe that hard
fornia, Berkeley, published a review article in the work pays off. Such minority groups, for instance,
journal Psychology, Public Policy and Law in many Asian groups, achieve success in the United
2005, in which they argue for genetic causes of States. Caste-like minority groups exist in other
race differences in IQ. Such views have once again countries, such as the Maori in New Zealand,
been met by fierce criticism. In 2009, for example, non-European Jews in Israel, and “untouchables”
American psychologist Richard Nisbett published in India.
the book Intelligence and How to Get It: Why
Schools and Cultures Count (2009), in which he Schizophrenia and IQ
challenges the interpretations of Herrnstein and IQ is also related to some mental illness out-
Murray and Rushton and Jensen and argues that comes. A review of a large number of studies in
intellectual ability is largely influenced by envi- the United States conducted by Elizabeth Alyard
ronmental factors. and colleagues revealed that IQ is related to an
408 Intelligibility

individual’s prognosis, or likelihood of recovery procedures for making decisions about people in
and degree of recovery, once he or she has been educational and occupational contexts.
diagnosed with schizophrenia. Schizophrenia is a
serious psychiatric illness involving the deteriora- Gretchen M. Reevy
tion of thinking processes and normal emotional California State University, East Bay
responses. Common symptoms include delusions
(unchanging false beliefs, such as a belief that one See Also: Eugenics; Genetics; Race; Race and Ethnic
is being contacted by aliens or that one is a famous Groups, American; Schizophrenia; Social Class.
actor or politician), hallucinations, disorganized
speech, and grossly disorganized behavior. First Further Readings
appearance of schizophrenia most often occurs Alyard, Elizabeth, Elaine Walker, and Barbara Bettes.
between the late teens and mid-30s. The course “Intelligence in Schizophrenia: Meta-Analysis
of schizophrenia varies widely. Some individuals of the Research.” Schizophrenia Bulletin, v.10
suffer an initial psychotic break and continue to (1984).
decline throughout life, usually requiring hospi- Fischer, Claude, Michael Hout, Martin Sanchez
talization for life. Jankowski, Samuel Lucas, Ann Swidler, and Kim
Others are able to cope well or moderately Voss. Inequality by Design: Cracking the Bell
well part of the time and suffer psychotic epi- Curve Myth. Princeton, NJ: Princeton University
sodes regularly, during which time they are Press, 1996.
unable to adequately care for themselves. Others Herrnstein, Richard J. and Charles Murray. The
cope reasonably well most of the time, provided Bell Curve: Intelligence and Class Structure in
they take medication, and can live independently, American Life. New York: Free Press, 1994.
hold down a job, and have a family. About 25 Lynn, Richard and Tatu Vanhanen. IQ and Global
percent or more fully recover from schizophrenia Inequality. Atlanta, GA: Washington Summit,
after a symptomatic phase that lasts anywhere 2006.
from months to years. Individuals diagnosed Neisser, Ulric, et al. “Intelligence: Knowns and
with schizophrenia who have relatively low IQs Unknowns.” American Psychologist, v.51 (1996).
suffer longer hospitalizations, much lower rates Nisbett, Richard E. Intelligence and How to Get It:
of symptom improvement, and more remissions Why Schools and Cultures Count. New York:
than individuals with higher IQ scores. In the Norton, 2009.
United States, schizophrenia diagnoses are higher Ogbu, John. Minority Education and Caste: The
among individuals of lower SES and among American System in Cross-Cultural Perspective.
African American, as compared to European New York: Academic Press, 1978.
Americans.
IQ tests are useful to predict school and job
performance and prognosis once an individual
has been diagnosed with schizophrenia. How-
ever, IQ scores differ by racial/ethnic background Intelligibility
and by SES; thus, when tests are used to make
decisions about people, such as which students The concept of intelligibility has played a key role
will have access to a curriculum designed for the in controversies about the nature of mental ill-
gifted or which individuals will be hired, some ness. The idea that mental illness is characterized
groups of people are disadvantaged. Racial/ethnic by behavior, thoughts, or feelings that fail to make
differences in IQ scores have been used to argue sense in commonsense terms was put forward
that racial/ethnic differences in intelligence are as an alternative to both the orthodox disease
inherited, a view that is politically controversial model of psychiatry and the deviance perspec-
and has been heavily criticized by most sociolo- tive adopted by many of psychiatry’s critics. At
gists. Either the perceived utility of IQ tests will the beginning of the 1960s, psychiatrist Thomas
continue to drive their use or concern about Szasz proposed that only conditions arising from
social effects of their use may lead to alternative a physiological impairment could be regarded as
 Intelligibility 409

illnesses and that since no such impairment had thus intrinsically stigmatizing, even though blame
been found in most psychiatric conditions, mental is removed from the individual in question and
illness was a myth, and that labeling people as placed on the illness. As Michel Foucault and
mentally ill was simply a way of condemning and many others have argued, the rise of the medical
controlling their behavior. model at the beginning of the 19th century (sym-
Many critics of psychiatry in the following bolized by Pinel’s freeing of the inmates of the
two decades accepted this deviance perspective Hôpital Bicêtre from their chains) simply replaced
on mental illness. However, it was challenged by one form of disempowerment and social exclu-
English sociologist David Morgan. Though agree- sion with another.
ing that the disease model lacked empirical sup- How do these sociological, philosophical, and
port, he argued that mad means something quite historical views on intelligibility compare with
different from bad. Psychiatric disorders manifest those of psychiatrists? To a limited extent, recent
themselves in behavior, thoughts, or feelings that editions of the APA’s Diagnostic and Statistical
are unintelligible; that is, they fail to make sense Manual of Mental Disorders (DSM) acknowl-
in terms of an accepted vocabulary of motives and edge the importance of this criterion: a syndrome
goals. Although Morgan was talking about insan- or pattern “must not be merely an expectable
ity, his argument can be extended to less severe response to a particular event, for example, the
types of mental disorder. death of a loved one.” In order to decide whether
a reaction is expectable, a psychiatrist thus has to
Context, Motive, and Code make a judgment about the contextual appropri-
This view was subsequently elaborated by David ateness of a patient’s behavior.
Ingleby, who pointed out that there are three As Allan Horwitz and Jerome Wakefield have
main factors that have to be taken into account pointed out, this has important consequences for
when deciding whether something makes sense in psychiatric epidemiology. Levels of mental ill-
commonsense terms: context, motive, and code ness among populations are usually estimated
(i.e., the underlying framework of meanings). by asking respondents to complete a checklist of
Sociologist Jeff Coulter also analyzed the prac- symptoms. A person scoring above a certain cut-
tice of psychiatric diagnosis through the lens of off point is regarded as probably suffering from
ethnomethodology and Wittgenstein’s philoso- a mental disorder. However, such instruments do
phy of language. In Coulter’s view, the fact that not consider the relation of behavior, thoughts,
psychiatric diagnoses are rooted in commonsense and feelings to their context and are thus incapa-
norms of what makes sense does not make them ble of recognizing “normal reactions to abnormal
subjective or arbitrary. Nevertheless, decisions situations.” In particular, respondents exposed to
about whether behavior is understandable are conditions that provoke high levels of negative
in practice often strongly contested and involve emotions and behavior, such as hardship, oppres-
a choice between value judgments. For exam- sion, and violence, will score higher for mental
ple, prior to 1973, the official standpoint of the illness than they would if proper account were
American Psychiatric Association (APA) implied taken of the context. To complicate matters fur-
that nobody in their right mind could be sexually ther, population estimates based on checklists will
attracted to a person of the same sex. After that also be subject to unpredictable response biases
date, the association ceased to classify homosex- and cultural influences.
uality as a mental disorder. However, debate within the psychiatric profes-
Historically speaking, the intelligibility crite- sion about the criteria for mental disorder, includ-
rion is related to the classical notion that men- ing the role of intelligibility, is limited. Many psy-
tal disorders are an impairment of the faculty of chiatrists are all too painfully aware that theirs is
reason. Although irrationality is not the same as the only medical specialty that is still unable to
immorality, to regard a person’s behavior as “not base diagnoses on the objective results of labora-
making sense” is nevertheless a kind of condem- tory tests. For nonpsychiatrists, it remains unclear
nation, because it implies that the behavior should how the profession is able to distinguish mental
not be taken seriously. To be labeled mentally ill is illness from the normal problems and suffering
410 International Classification of Diseases

that accompany the human condition. Because of states. It is used for reimbursement and resource
this lack of transparency, psychiatry remains as allocation decision making by countries and health
vulnerable to the charge of unnecessary medical- care providers.
ization and pathologization of normal life as it
was when Szasz started writing about the topic. Overview
The ICD is published by the United Nations–spon-
David Ingleby sored WHO. The WHO constitution mandates
University of Amsterdam the production of international classifications
on health to provide a consensual, meaningful,
See Also: American Psychiatric Association; and useful framework facilitating common lan-
Deviance; Diagnosis; Diagnosis in Cross-National guage that can be used by governments, health
Context; Foucault, Michel; Szasz, Thomas. care providers, and consumers. Accordingly,
WHO prepares, and the World Health Assem-
Further Readings bly approves, two groups of classifications on
Horwitz, Allan. “Transforming Normality Into health-related matters, reference classifications,
Pathology: The DSM and the Outcomes of and derived and related classifications as part of
Stressful Social Arrangements.” Journal of Health the Family of International Classifications. Ref-
and Social Behavior, v.48 (2007). erence classifications are main classifications on
Horwitz, Allan and Jerome Wakefield. “The Epidemic basic parameters of health and are prepared and
in Mental Illness: Clinical Fact or Survey Artifact?” approved by the WHO governing body.
Contexts, v.5/1 (2006). The international version of the ICD is one
Ingleby, David. “The Social Construction of Mental of the three reference classifications. The other
Illness.” In The Problem of Medical Knowledge: two classifications in the reference classifica-
Examining the Social Construction of Medicine, tions group are the International Classification of
Andy Treacher and Peter Wright, eds. Edinburgh, Functioning, Disability, and Health (ICF) and the
UK: Edinburgh University Press, 1982. International Classification of Health Interven-
tions (ICHI). The derived and related classifica-
tions, while included in the WHO family of clas-
sifications, may be prepared by the collaborating
groups of specialists or nations and are based
International on the reference classifications. The derived and
related classifications differ in terms of the level
Classification of of adoption of the structure and content of the
Diseases reference classifications.
The national versions of ICD and some disease-
The World Health Organization’s (WHO) Inter- specific expanded versions of ICD come under the
national Classification of Diseases (ICD) is the category of the derived or related versions of ICD.
international standard diagnostic classification WHO defines the objectives of the ICD to permit
for all general epidemiology, health management, the systematic recording, analysis, interpretation,
and clinical purposes, including the analysis of and comparison of mortality and morbidity data
general health situations of population groups. It collected in different locations and times. For
is also used to classify diseases and other health this purpose, the coding procedure of the data
problems recorded on many types of health and is designed to translate health-related informa-
vital records, including death certificates and tion into alphanumeric codes that can be stored,
health records. retrieved, and analyzed easily. To achieve these
In addition to enabling the storage and retrieval objectives, WHO has designated a number of col-
of diagnostic information for clinical, epidemiolog- laborating centers all over the world to partner
ical, and quality purposes, these records also pro- in the development, dissemination, maintenance,
vide the basis for the compilation of national mor- and use of the classifications in national and inter-
tality and morbidity statistics by WHO member national contexts. The classification of mortality
 International Classification of Diseases 411

and morbidity is based on the nomenclature of The ICD-6 was published in 1949 with a new and
the diseases, and WHO also works in collabora- more suitable name, the International Statistical
tion with the member nations on developing a Classification of Diseases, and the three-digit cod-
uniform nomenclature. ing system was introduced for the first time.

Historical Perspective Later Versions

With the work of John Graunt on the London The ICD-7 revision in 1955 was limited to essen-
bills of mortality, attempts at the statistical study tial changes and amendments of errors and incon-
of diseases can be traced back to the 17th cen- sistencies. Although the basic structure of ICD-6
tury. However, François Boissier de Sauvages was left unchanged, the ICD-8 underwent a more
de Lacroix (1706–67), a French physician and radical revision, classifying diseases whenever
botanist, was credited with establishing the first possible according to their etiology rather than a
methodical nosology for diseases in the begin- particular manifestation. During these years, the
ning of the 18th century. During the 18th and applicability of ICD to various health care settings
19th centuries, the nomenclature and statistical and the use of the ICD codes for indexing hospi-
classification of diseases and causes of mortality tal medical records increased rapidly with a rec-
was constantly revised and advanced by pioneers ognized need for providing further detail to code
such as William Farr (1807–83), the first medical hospital and morbidity data. By the time the ninth
statistician appointed by the registrar general of revision took place in 1975, the ICD was being
England and Wales. used for many applications other than as a tool
In 1893, Jacques Bertillon (1851–1922) pre- to compile population data. In spite of enormous
sented the Bertillon Classification of Causes of costs involved in major revisions, provisions had
Death at the International Statistical Congress to be made to meet the growing interest in using
held in Chicago. This was the first classification the ICD system, partly by modifying the classi-
that received universal acceptance and can be seen fication itself and partly by introducing special
as the precursor of the ICD. The Bertillon Clas- coding provisions of optional four- and five-digit
sification represented a synthesis of the French, coding and the “dagger and asterisk” system.
English, Swiss, and German classifications of the This alternative method of classifying diagnostic
causes of death and underwent five revisions at statements was developed to allow users to pro-
approximately 10-year intervals under the aus- duce statistics and indexes oriented toward medi-
pices of the International Statistical Institute, cal care and to include information about both an
expanding the list of causes of death in keeping underlying general disease and a manifestation in
with the medical advances of the time. While par- a particular organ or site.
allel lists of diseases existed in individual countries A number of other technical innovations were
such as Canada, Britain, and the United States to also included in the ninth revision, aimed at
tabulate morbidity, they were little different from increasing its flexibility for use in a variety of sit-
the classification of causes of deaths. uations but also retaining the simple, easy-to-use,
The fifth international conference held in 1938 three-digit coding system to allow users to assess
passed a resolution on the need for a unified list their progress in their health care and control
of causes of mortality and morbidity, and a sub- of disease. While provisions were made for the
committee with representatives from the health users at both ends, retaining enough flexibility in
section of the League of Nations was appointed the use of ICD-9, it became apparent that a revi-
to do the same. The World Health Assembly in sion schedule of every 10 years was unrealistic
1948 endorsed the first comprehensive, integrated and that thorough rethinking of its structure was
version of the Manual of the International Sta- warranted to devise a stable and flexible classifi-
tistical Classification of Diseases, Injuries, and cation that would not need a major revision for
Causes of Death along with its rules of applica- many years.
tion and an international program of cooperation In the 1970s, the importance of internation-
as recommended by the sixth revision conference ally recognized nomenclature of diseases to sup-
under the leadership of the newly formed WHO. port classification was also recognized, and by the
412 International Classification of Diseases

mid-1970s, the preparation of the International ICD-10 and the inclusion and exclusion criteria
Nomenclature of Diseases (IND) had become for using each code is provided in Volume 2.
a joint project of the Council for International The ICD-10, published online and in many
Organizations of Medical Sciences (CIOMS) and languages, was updated regularly from 1996 to
WHO. The IND was intended to complement 2010, mainly correcting and updating the entries
ICD and, wherever possible, the IND terminology as endorsed in the annual October meetings of
received preference in the ICD. Eight volumes of the World Health Assembly. Several derived and
IND were published by 1992 and complemented related classifications were also developed to meet
the terminology used in the ICD-10 that replaced the needs of subject-specific detail and national
the ICD-9. needs. Work on the 11th revision is in progress
and is planned to continue until 2015, with an
The ICD-10 extensive consultation process that is being con-
The ICD-10 was endorsed by the 43rd World ducted for the first time via a Web-based platform.
Health Assembly in May 1990 and came into use
in WHO member states from 1994. The ICD-10 Criticisms
was a significant expansion of the ICD-9 but still The main criticism of the ICD, even with the 10th
remained a variable-axis classification, retaining version, is that although the ICD is suitable for
the basic pattern of the classification structure many different applications, it does not always
that was originally proposed by William Farr. allow inclusion of sufficient detail necessary for
Accordingly, the chapters are grouped into “spe- some specialties. To compensate for this draw-
cial group” chapters and “body system” chapters. back, the concept of the family of disease and
Body system chapters include information on local health-related classifications was developed with
diseases arranged by anatomical site, and special a scope to develop derived and related classifica-
group chapters bring together conditions that are tions. These specialty-based adaptations usually
of wider importance, relevant for epidemiological bring together, in a single compact volume, the
studies. However, all conditions in body system sections and categories that are relevant to and
chapters are included in special group chapters in provide necessary detail for a particular specialty.
some form, and when there is a doubt, the special They are often developed by international groups
group characters take precedence. of specialists.
The ICD-10 is published in three volumes and
alphanumeric coding was introduced for the first International Classifications of
time. Volumes 1 and 3 contain the main classifica- Mental Disorders
tions and the alphabetical index to the classifica- A chapter on mental disorders was first included
tion, while Volume 2 provides guidance on using in the sixth version of the ICD when the classi-
the ICD. Volume 1 has a list of three-character cat- fication included categories on morbidities. The
egories and four-character subcategories. The first ICD-10 Classification of Mental and Behavioral
character of each category is a letter representing Disorders: Clinical Descriptions and Diagnostic
a broad area of classification. The three-character Guidelines provides a description and guidelines
category is the mandatory level of reporting to concerning diagnosis, comments about differ-
the WHO mortality database and comprises the ential diagnosis, and a listing of synonyms and
“core” classification. exclusion terms for each category of Chapter V in
The classification in the ICD-10 itself is divided ICD-10 (Mental and Behavioral Disorders). There
into 21 chapters and generally linked to a letter is scope for using further subdivisions at the fifth-
in the three-character coding, with a few excep- and sixth-digit level to provide more detail. A vol-
tions. The letter “U” is left unused in the ICD-10, ume on diagnostic criteria and a further version
providing scope for assigning provisional codes of the classification for use in primary health care
for new diseases of uncertain etiology and for are also published.
use in special circumstances such as researching The Diagnostic and Statistical Manual of Men-
alternative subclassifications. Extensive guidance tal Disorders (DSM) is another classification of
on morbidity and mortality coding by using the mental disorders that is published by the American
 International Comparisons 413

Psychiatric Association (APA). It is used in the Instruction Manual. (2010). http://www.who.int/

United States and in varying degrees around the classifications/icd/ICD10Volume2_en_2010.pdf
world by clinicians, researchers, psychiatric drug– (Accessed January 2012).
regulation agencies, health insurance companies, World Health Organization (WHO). “The WHO
pharmaceutical companies, and policy makers. Family of International Classifications.” http://
Unlike the ICD, it is copyrighted and generates www.who.int/classifications/en/http://www.who
significant revenue for APA. The latest version is .int/classifications/en (Accessed January 2012).
the DSM-5, which revised the DSM-IV-TR (text
revision) in the spring of 2013.
The DSM and ICD are superficially similar and
use operational definitions of mental disorders and
multiaxial classification systems. However, minor International
differences exist in diagnostic criteria of almost
every category, with additional information in the Comparisons
DSM that could never be expected in the mental
disorders chapter of the ICD. Hence, in spite of Variously termed global mental health, cross-
the ongoing debates on the need for two classifi- cultural psychiatry, ethnopsychiatry, compara-
catory systems, it is likely that the DSM will coex- tive psychiatry, transcultural psychiatry, and
ist or supersede the ICD as an important source of cultural psychiatry, the practice of comparing
information on psychiatric diagnosis. mental illnesses across cultures has a long his-
tory, throughout which alliances were forged
Padmaja Chalasani and lost, discoveries were made, and methodol-
Aneurin Bevan Health Board ogy refined. Culture can influence mental illness
in myriad ways, including defining what is nor-
See Also: American Psychiatric Association; Cross- mal and abnormal; determining which behaviors
National Prevalence Estimates; Diagnosis in Cross- and people are deemed pathological; influencing
National Context; DSM-III; DSM-IV; DSM-5; etiology and clinical presentations and distribu-
Epidemiology; Incidence and Prevalence; Measuring tions of certain mental illnesses; and determin-
Mental Health; World Health Organization. ing how mental illness is recognized, labeled,
treated, and explained. In the field of global
Further Readings mental health, several ongoing debates have
American Psychological Association. “ICD vs. DSM.” influenced the production of international com-
Monitor on Psychology, v.40/9 (October 2009). parisons of mental health, including the univer-
http://www.apa.org/monitor/2009/10/icd-dsm.aspx sality of mental illness, valid research method-
(Accessed January 2012). ologies, and the aim of the field. Current thought
World Health Organization. “History of the in medical anthropology is that major psychoses
Development of the ICD.” http://www.who.int/ and disorders arising from brain disease may be
classifications/icd/en/HistoryOfICD.pdf (Accessed universal; however, clinical presentations vary
January 2012). among cultures. This perspective is considered
World Health Organization. “The ICD-10 the best method to consider mental illness in an
Classification of Mental and Behavioural Disorders: international or cross-cultural context; however,
Clinical Descriptions and Diagnostic Guidelines” the questions on methodology and aim continue
(2010). http://www.who.int/classifications/icd/en/ to challenge the field.
bluebook.pdf (Accessed January 2012).
World Health Organization. “International Early International Interest in Mental Illness
Classification of Diseases (ICD).” http://www.who Interest in mental illness in other nations and
.int/classifications/icd/en (Accessed January 2012). cultures was a by-product of 18th- and 19th-cen-
World Health Organization. “International tury colonialism. Early travelers noted that there
Statistical Classification of Diseases and Related seemed to be very little mental illness among native
Health Problems, 10th Revision.” Volume 2, populations. These reports spurred interest in the
414 International Comparisons

topic, and researchers began traveling to remote, native populations naturally led to the presence
global areas and returned confirming these suspi- of modern mental illnesses. In the 1930s, how-
cions. Soon, a variety of well-known and foun- ever, Franz Boas proposed an alternative perspec-
dational psychiatrists and alienists, such as Jean tive, stating that culture was relative and distinct.
Étienne Dominique Esquirol and Moreau de This notion was quickly accepted by his students
Tours, began to postulate that civilization was the and colleagues, who applied the notion to cul-
reason that native populations had significantly tural aspects as well as concepts such as aggres-
fewer mentally ill members. In other words, Euro- sion and sexual behavior. It was soon thought
pean and other “developed” nations had more that if relativism could be applied to emotions
mental illness because of the general excesses and instinctual human behavior, then it could also
of civilization, such as disordered lives, alcohol, help explain cultural differences in mental illness.
abandonment of simple customs and religious In the aftermath of World War II, during which
values, poverty, self-indulgence, tea, and sexual time returning soldiers showed significant postwar
excess. Mental illness was the price that civilized psychiatric distress (termed shell shock), there was
cultures paid for modernity. a growing interest in global mental health. War-
The next evolution in this research looked at time psychiatrists had become interested in their
instances of unusual and unfamiliar forms of observations of the role of sociocultural environ-
mental illness, such as amok, a condition seen in ment on the mental illnesses they observed while
Malaysia wherein a person goes into an uncon- in the field. As many of the biologically driven
trolled fit of rage. These unusual conditions, called interventions for mental illnesses of the first bio-
culture-bound syndromes in modern psychiatry, logical era of psychiatry were proving ineffectual,
began a field of “psychiatry of the exotic.” At psychiatry was beginning to be seen as a social
this time, there was also a rising interest in the science and a biological or medical science.
presence of more familiar psychiatric conditions Another side effect of this push away from
in native people, which many professionals rea- biology was the popularization of psychoanaly-
soned was the introduction of civilization to these sis, the exact opposite of the failed biological
populations. Alcohol was the most cited cause of approaches. Anthropologists and psychiatrists
mental illness in native populations. began to advocate for an alliance between the
Soon, with the advent of the first biological fields. Anthropologists would help define par-
psychiatry at the turn of the century, psychiatrists ticular cultures and outline the definition and
and researchers became interested in the biologi- recognition of abnormality or deviant behavior
cal reasons for differences in the prevalence of of mentally ill community members. Psychiatrists
mental illness between modern and native popu- could work toward explaining how individuals
lations. Differences in the structure and size of the interact with cultural elements in ways that cre-
brain became a frequently cited reason for psy- ate or exacerbate mental illness.
chiatric and cognitive differences between ethnic This was the first step beyond simply describing
groups. For example, American researchers stated mental illnesses internationally and toward actu-
that “negroes” were thought to have diminished ally understanding and differentiating between
frontal lobes and overall more primitive brains, them. These early disciplinary coalitions resulted
which led to poor smell, sight, bodily sense, and in several findings that are still relevant in con-
self-control. temporary international comparisons of mental
At the end of the 19th century, cultural anthro- illness, such as the importance of the role of native
pologists were increasingly focused on the impor- healers, and how context can change the effec-
tance of temperance, ideas, and the beliefs of tiveness of native healers. They also described
people—in other words, culture. The general how a person’s culture determines his treatment
belief was that culture was universal and similar preference, and that treatment should be modi-
everywhere, but Westerners and modern civiliza- fied to fit a person’s cultural orientation. Finally,
tions were simply more advanced in evolutionary this work revealed that culture can have a nega-
development. This tied in closely with the belief tive or positive influence on a doctor-patient rela-
that providing the amenities of civilization to tionship. During this time period, several journals
 International Comparisons 415

dedicated to global issues of mental health were in the DSM, which had previously been devel-
developed, including Transcultural Psychiatry; oped based on a psychoanalytic perspective of
Culture, Medicine & Psychiatry; and Curare. mental illness.
In many ways, the second biological psychia-
Divisions in the Field try ruined the allegiance between psychiatry
Soon, however, the two disciplines began to and anthropology, but there were other factors
show significant differences. Anthropologists involved. Anthropology had increasingly become
deemed that culture was a protective factor in associated with fieldwork and ethnographic
the course and prognosis of mental illness and, data, making international comparisons of issues
as is the norm for the field, tended to consider such as mental illness somewhat obsolete. Sym-
their work in terms of entire epochs of time. They bolic and phenomenological anthropology were
also tried not to interfere with their subjects, opt- becoming more fashionable in the field, and both
ing for observational distance whenever possible. approaches seemed incompatible with the study
Psychiatrists, on the other hand, saw people as of psychiatric disorders. In addition, because
victims of their culture, noting how specific cul- anthropologists rarely labeled their discoveries
tural elements could exacerbate illness or inter- and the field did not frequently create and dis-
fere with treatment. They also focused on more seminate titled grand or midrange theories, other
acute time periods, usually that of an illness epi- fields did not find their discoveries as theoretically
sode, and avoided professional distance in order important. Psychiatry and psychology, on the
to identify, diagnose, and treat mental illnesses. other hand, had long been in the practice of label-
The term transcultural psychiatry then developed ing theories to be widely applied and used.
two different definitions: for the psychologists, The combination of these divisive factors served
the term described the universality of mental ill- to highlight and enhance the differences between
nesses whereas for anthropologists, it highlighted psychiatry and anthropology, ending interna-
the importance of cultural forms. tional comparisons and investigations of mental
Around the same time, the middle of the 20th illnesses abroad. There were three main areas on
century, the second biological psychiatry was which the fields disagreed. The first was the inter-
beginning. The discovery of psychotropic medica- pretive validity of the opposing field’s methods.
tions for the treatment of severe mental illnesses Psychiatric methods were seen to have little to no
was transforming the field and shifting the focus ecological validity and failed to explain behavior
back toward universalism. The field had shifted in everyday, nonclinical settings. Anthropological
from one extreme, psychoanalysis, which claimed methods, specifically ethnography, was unclear
that all mental illness was externally driven yet in its interpretive methods, and psychologists
had little to no explanations or treatments for assumed that there was no control inherent in
severe mental illness, to biological and genetic these methods.
psychiatry, which described all psychiatric disor- Another area of disagreement was that of the
ders as resulting from internal and predetermined role of culturally specific meanings. Anthropolo-
factors. At this time, the World Health Organiza- gists considered quantitative psychiatric and psy-
tion (WHO) and the American Psychiatric Asso- chological tools, such as diagnostic and assess-
ciation (APA) first attempted to create a universal ment measures, culturally insensitive and claimed
nosological system for psychiatric disorders that that these methods often distorted psychiatric
emphasized biological psychiatry. phenomena. Psychiatrists thought that basing
The ninth edition of the International Classi- research categories on local languages and cul-
fication of Diseases (ICD-9), published in 1978, tural understandings was regressive, and dimin-
and the third edition of the Diagnostic and Sta- ished opportunities to make any generalizations.
tistical Manual of Mental Disorders (DSM-III), Finally, the two fields disagreed on the role of
published in 1980, both attempted to set diag- culture in explaining psychological and psychiat-
nostic criteria based on clinical presentations that ric phenomena. Psychiatrists considered mental
assume universalism in the presentation of men- processes and disorders as outside cultural influ-
tal illnesses. The difference was perhaps starkest ence, arguing that there is an essential human
416 International Comparisons

nature on which culture may influence evalua- better outcomes in developing areas as opposed
tions or displays, but the essential form remained to more modern societies.
the same. Anthropologists took the other extreme Initial findings were that with enough planning
perspective that culture was central to all elements and coordination, it is possible to carry out such
of psychiatric events, noting that mainstream cross-cultural research in psychiatric illness and
psychology was parochial and had little to no that it is possible to design standardized research
explanatory adequacy, particularly when it comes instruments and to train research workers to use
to mental illness in an international context. them appropriately across cultures. This and sub-
These disagreements resulted in vastly dimin- sequent research found that cultural interpreta-
ished funding opportunities for international tions of mental illness influences the ill person
investigations and comparisons of mental ill- and the course of illness. Additionally, the inten-
nesses, putting a stop to this kind of research for sity with which the ill person’s family members
much of the latter half of the 20th century. The respond to a mental health or psychotic epi-
National Institute of Mental Health (NIMH) sode, called expressed emotion, can influence the
sponsored very little of this research in the 1980s; severity of the illness. Cultures that showed low
heavy biomedical tendencies of the field meant expressed emotion had better outcomes in terms
that peer reviewers for grant applications had of fewer hospitalizations and relapses.
little to no experience with anthropological meth- It was also determined that those living in com-
ods and likely considered them ineffectual. There munities dependent on industrial wage labor were
was also a backlash from developing nations that more likely to have more chronic schizophrenia
began to see Western researchers as using differ- than those living in agricultural societies. This
ent cultures as hunting grounds for their work, could be related to the relative poverty of those
who came with a paternalistic attitude and tried with mental illnesses in developed nations. Finally,
to implement Western treatment methods and ser- it was found that the characteristics of the treat-
vices that had questionable value. ment settings can impact chronicity; this is par-
ticularly true of prolonged hospitalization during
World Health Organization which “social breakdown syndrome” can develop
Schizophrenia Study and dependency can be fostered. These are just
However, in the midst of all this dissension and some of the reasons proposed for the poorer out-
reduction of international work in mental illness, comes in Western industrialized nations.
the WHO came out with a landmark study on Soon after the WHO began to publish its
schizophrenia in nine cultures. The study, which work with schizophrenia, medical anthropolo-
came out with several publications in the mid- gist Arthur Kleinman began to reconceptualize
1970s and again in 1992, was called the Inter- the way that cultural investigations of mental
national Pilot Study of Schizophrenia (IPSS) health should be considered. Beginning in the
and began in 1966. It looked at the prevalence, late 1970s, but mainly in the 1980s, Kleinman
course, presentation, and outcomes of people wrote about his research on depression in China
with schizophrenia in Colombia, Czechoslovakia, and, more generally how to research mental ill-
Denmark, India, Nigeria, China, the Soviet Union, ness internationally. His worked stated that
the United Kingdom, and the United States. This mental illnesses may be universal, but what is
was the first large-scale study to look at a spe- more important to consider are the explana-
cific mental illness across cultures using the same tions or explanatory models for mental illnesses,
diagnostic definitions and tools, outcome mea- which are culturally determined. He noted that
sures, follow-up methods, and a consideration of Western psychiatric categories are also culturally
intervening variables in course and outcome. The reliant but are internationally applied as if they
most striking and controversial finding was not were not. Kleinman claimed that the way that
that schizophrenia was found in all nine cultural biological psychiatry reifies the Western noso-
groups but that the course and outcome varied logical system creates a “categorical fallacy”
widely between them. Scholars were surprised at that simply identifies what is universal about a
the finding that people with schizophrenia showed psychiatric diagnosis but fails to consider what
 International Comparisons 417

In the 18th and 19th centuries, the industrialized world’s excesses of alcohol consumption, self-indulgence, and disordered lives, as
opposed to the lifestyle of “native” cultures, were thought to contribute to mental illness, as shown in William Hogarth’s 1751 illustration
Gin Lane (left). Current thought in medical anthropology is that major psychoses and disorders arising from brain disease may be
universal but clinical presentations vary among cultures. At right, a youth named Themba shares his emotional burdens with Isibindi child
and youth care worker Nozuko Ngwalase in February 2013 in South Africa, a violent region with a high stigmatization of mental illness.

does not fit into the parameters put forth by the psychic distress in culturally sanctioned ways. For
diagnostic criteria. He applied this criticism to example, depression in America may be expressed
the WHO work on schizophrenia. through symptoms of fatigue, listlessness, and loss
of appetite, whereas in South Korea this type of
Current Work: Findings and Debates psychic distress may be expressed through soma-
By the end of the 20th century, psychiatric tization, or bodily pain.
anthropology was on the rise. Other notable Another major result from recent work on
work on mental illness abroad includes Byron J. international comparisons of mental illness comes
Good’s work on psychosis and mental illness in out of the culture-bound syndrome research.
Java, Indonesia; Nancy Scheper-Hughes’s work Researchers have begun to identify and accept
on schizophrenia in Ireland and maternal bond- that certain psychiatric diagnoses in Western soci-
ing in Brazil; Lawrence Kirmayer’s work on men- eties can be considered culture-bound syndromes.
tal health of immigrants and suicidal behavior One example is anorexia, which is prevalent in
in Inuit and other aboriginal communities; and many Western societies, yet does not seem to be
Thomas J. Csordas’s work on religious healing inherent in many collectivist societies. Research
among Catholic charismatics in North America. has also shown that the introduction of Western
One major finding from these works is the concept idioms of distress, such as anorexia, can actually
of “idioms of distress.” Coined by sociocultural create these conditions in new cultural environ-
anthropologist Mark Nichter, this term describes ments. Research in China has demonstrated that
the ways individuals express and communicate before the introduction of Western-style anorexia,
418 Internet and Social Media

food refusal was rare and primarily somatic, such influx of transnational collaboration is leading to
that sufferers refused food because of bodily sen- broader understandings of how human behavior,
sations preventing eating. However, recently the the mind, and the social world interact and how to
term anorexia and its Western definition have best intervene on the individual and cultural level
become more well known, and food refusal as a to lessen psychic distress. Research is beginning
result of body dissatisfaction, a key diagnostic cri- to understand the delicate balance between biol-
teria for Western anorexia, is on the rise. ogy and culture as international aid efforts and
There are still some major debates in the field of increasingly diverse communities regularly bring
global mental health. Some professionals see the professionals in contact with issues of cultural
primary aim as using local knowledge and prac- difference and mental health. While the issues of
tices to provide care for everyone, and for others the field are not yet solved, international compari-
the aim of the field is to regulate the exportation sons continue to illuminate some of psychiatry’s
of Western mental health concepts and categories most important issues.
that work to replace or supplement local struc-
tures. There remains a split between Western, Jennifer C. Sarrett
developed nations (the global north) and non- Emory University
industrialized areas (the global south) such that
the flow of information and concepts is one way, See Also: Anthropology; Cultural Prevalence;
traveling from north to south, instead of collab- Diagnosis; Diagnosis in Cross-National Context;
orative and supportive relationship. While some DSM-III; Globalization; World Health Organization.
scholars focus on this asymmetry, others, such as
Dr. Vikram Patel, see the main drive of the field as Further Readings
related to human rights and diminishing abuses of Bains, Janitor. “Race, Culture and Psychiatry: A
mentally ill individuals around the world. History of Transcultural Psychiatry.” History of
Two of the historic debates continue among Psychiatry, v.16 (2005).
professionals in the field of global mental health: Good, Byron J. “Studying Mental Illness in Context:
that of methodological and analytical validity Local, Global, or Universal?” Ethos, v.25/2 (1997).
and the universality of mental illness. There is, Kleinman, Arthur. Rethinking Psychiatry: From
however, a shift in emphasis from the need for Cultural Category to Personal Experience. New
randomized controlled trials to a more qualita- York: Free Press, 1988.
tive and pluralistic approach to research. Addi- Miller, Joan. “The Interdependence of Interpretive
tionally, many scholars now agree there are some Ethnographic and Quantitative Psychological
underlying biological markers or etiologies of Methodologies in Cultural Psychology.” Ethos,
major mental illnesses, while also realizing that v.25/2 (1997).
psychiatry must rely on patient accounts and rec-
ognize that these accounts can and do vary across
cultures and must be considered within that con-
text. Regardless, the field reflects varied notions of
the nature of mental illness and how to best treat Internet and
mental health issues across the globe. While many
agree that mental health needs to be a higher pri- Social Media
ority, and perhaps integrated into primary health
systems, the amount of medical pluralism and the Every new technology brings with it support-
role of the traditional healer remains contested. ers and detractors, celebrating or fearing the
There is a general feel in the field that there impact that it will have on the fabric of society.
needs to be more attention paid to the issues rel- This was true of Guttenberg’s press and remains
evant to transcultural psychiatry. Globalization is true of online social networks like Facebook and
bringing divergent cultures into contact with each Twitter. With the advent of the Internet, and the
other, and cross-cultural psychiatry is bringing popularization of social contacts within social
researchers from around the world together. This media platforms, there has been an impact on
 Internet and Social Media 419

global mental well-being. The use and prolifera- Some research has found that Internet access has
tion of smart phones and wireless Internet access enabled a subset of individuals who otherwise
have propelled even previously underdeveloped would not have regularly engaged in these behav-
regions into contact with members of the globe iors to do so. The impact of addictive Internet
far removed from their geographic location. At use is a concern for mental health practitioners,
the same time, much of the world’s written and although there remains no consensus for what a
visual record of wellness and illness has been formal diagnostic category should entail. In its
catalogued and made searchable by anyone with May 2013 debut, the fifth edition of the Diagnos-
an Internet interface and connection. The impact tic and Statistical Manual of Mental Disorders
that Internet and social media have had on global (DSM-5) included Internet use disorder in section
mental illness is both positive and negative in III of the manual. The category concerns Internet
that information and communication has been gaming and the degree to which it intrudes on
made more accessible, while interactions within the normal activities and relationships previously
virtual spaces can both create and highlight isola- held by the individual.
tion experienced within real-world communities. There has been sizable evidence from cognitive
Research has confirmed this paradoxical effect, science and neuroscience that Internet and social
while illustrating the benefits of the Internet and media use affect neural functioning. Research
social media to society. has revealed the stimulus/reward cycle that can
Access to the Internet increases globally each affect individuals who frequently access online
year, as does participation in commercial, finan- social networks. Research has also demonstrated
cial, government, entertainment, and social that attention can be altered through use of the
forums delivered via the Internet. At the same Internet and social media, although consensus
time, there are stated and observed concerns about with this finding has not been obtained. In some
digital divides within communities and between research, individuals asked to pay attention or
developed and developing countries. Communi- perform memory tasks while using the Internet
ties with faster and less expensive Internet access perform poorly, while other research highlights
often have health and economic advantages for the cognitive flexibility and attentional gains
their populations, even for members who do not made possible from practice with multitasking
actively use the technology, than communities and Internet use. Imaging studies have revealed
with slower or more expensive access. Similarly, the areas of the brain that can be activated when
those within a community with access that are users view or interact within social networks.
disenfranchised because of lack of computer or Some have questioned the degree to which youth
technology device access, lack of knowledge or may be more affected by the neural changes asso-
Internet literacy, or lack of disability-accessible ciated with Internet and social media use. Along
interfaces for the technology have lower health with this, questions have risen as to the impact
and well-being than members of the community on identity that results when individuals, par-
not disconnected from the technology. Despite ticularly children or adolescents whose identity
these findings, there have been concerns about the development is still under way, participate in
mental effects of Internet and social media use. online social networks.
There has been a consistent increase in online
gambling and pornography use since the Inter- Positive Effects of the Internet
net’s inception. Globally, it is estimated that more and Social Networks
than $20 billion in revenue annually is generated Along with concerns about neural plasticity,
through online gambling. Online pornography social alienation, and addictive behavior pat-
sales are estimated at just under $3 billion annu- terns, there have also been consistent findings that
ally in the United States, where 90 percent of social connectedness, information sharing, and
the pornography is generated and over half of wellness literacy has been positively impacted by
consumers reside. A subset of those who gamble Internet technology and social networking. When
online or consume pornographic material engage an individual encounters an illness that no one
in compulsive behavior labeled “addictive.” else in their physical community has encountered,
420 Internet and Social Media

the Internet and social networking community Internet and social media have also been useful
extends their access to individuals who may have in outreach to those who may benefit from men-
similar experiences. This has been shown in indi- tal health supports. Facebook offers information
viduals seeking organ or tissue donation, where about suicide prevention, enables users to alert
their chance of a match was increased through them if they believe a user is in danger of harming
social media outreach. Individuals who utilize the themselves, and offers users ways to enter a com-
technology to expand their circle of support often plaint if they feel that another user is endangering
report on the tangible benefits of accessing virtual the Facebook community. In New Zealand, the
world supports. National Health Service has instituted a country-
Social supports that benefit individuals are wide text message service that allows teens at risk
not just relegated to contacts that only exist in of suicide a chance to receive instant mental health
the virtual environment. There is a mixed set of support. Also in New Zealand, the Internet has
findings about online social networks and social been used to deliver self-directed treatment mod-
experiences in the physical world. Some research ules for depression targeted to teens and adults.
has identified that those with fewer or greater
than 150 friends on Facebook were equally dis- The Darker Side of Social Media,
advantaged when compared with those around the Internet, and Mental Illness
150 friends in terms of their perceived satisfac- While there have been many positive and help-
tion with their real-world friendships. Similarly, ful uses of social media and the Internet, and in
research has suggested that increases in virtual- many ways more information has been shared to
world contact do not always translate into sup- increase awareness, decrease stigma, and improve
port in real-world relationships. When investi- treatment access for mental illness since the incep-
gating benefits of social supports for those with tion of these technologies, some of these efforts to
depression, studies have found that those with improve access and outreach only arose follow-
depression using social networks often attend ing tragedies associated with their use. In Great
less to illustrations of support offered through Britain and the United States, adolescent suicides
the social network. For those who might seek from 2006 to 2011 were connected with the
support explicitly in their postings in social online social network experience of the children
networks, research has found that negatively who took their lives. In some cases, children were
phrased postings often elicit fewer responses of picked on or bullied within both their real-world
support or approval. school environment and within the social network,
A consistent positive effect of Internet and whereas in other cases the social network arose
social network use has been on decreasing stigma as a bullying pulpit against them. Communities
and increasing information about mental illness. began enacting legislation to stop online bullying
Over 60 percent of individuals who use Internet behavior and to articulate a chain of accountabil-
technology report using it for conducting personal ity if it were identified. Internet technology and
health searches. Because of the wide variety of Web broadcasting was also cited as a factor in the
information sources and quality, there is a need to 2009 suicide of Tyler Clementi, whose freshman
increase the information literacy of individuals so college roommate was accused of surreptitiously
that they can best utilize the information that they Webcasting Clementi and a male friend kissing in
find when conducting such searches. Those with his dorm room.
severe and persistent mental illnesses like bipolar It is unclear to what degree an individual may
disorder have found social networks to be use- have been vulnerable to mental illness or sui-
ful in connecting them with others who also have cidal behavior, but these examples show that
the illness or in allowing them to communicate there are real impacts from social network and
with members of their real-world social network, Internet technology. Although not responsible
regardless of their current symptom presentation for suicide, online social networks have raised
(a person can wish their aunt “Happy birthday!” concern when users see an indication of suicidal
even though they may not be up to attending the action but do not respond. Two examples of this
family party held in her honor). include the death by suicide in 2010 of Great
 Interpersonal Dynamics 421

Britain’s Simone Back (42 years old) and in The concept of the self involves the interplay
2012 of China’s Claire Lin (31 years old). Both between the conscious and unconscious mind
women indicated on their Facebook wall that and is developed as a direct result of interper-
they were in the act of killing themselves, Back sonal interaction. In other words, an individual’s
by overdosing and Lin by inhaling fumes from a self-concept is the way that people make sense of
charcoal fire. Researchers seeking to understand their human experience in relation to others. The
the lack of response for these messages, despite development of the consciousness of self is con-
between 30 and 180 witnesses, return to long- structed as individuals become aware that the self
standing findings within social psychological rarely moves out of view and is always with them,
research that underlines that the number of wit- and the characteristics that are ascribed to oneself
nesses is inversely related to the speed of inter- are in relation to interactions with others (e.g.,
vention (bystander effect). Even with increased being “good,” “bad,” or “practical”).
knowledge and literacy, Internet technology and Therefore, as one’s self-concept develops, indi-
access to social networks have not resolved the viduals learn that the self is biologically differenti-
human dilemma of knowing when and how best ated from the world around them and from oth-
to respond to the needs of others. ers. For example, a child learns that slapping his
or her leg is different than slapping someone else’s
Loretta L. C. Brady leg. As individuals develop a concept of self, they
Saint Anselm College realize that certain acts produce specific reactions
from others (e.g., a smile may mean that some-
See Also: DSM-5; Help-Seeking Behavior; Social thing good is going to happen, such as being fed).
Isolation; Suicide; Suicide: Patient’s View. Therefore, the process of learning and engaging
in interpersonal dynamics begins. As learning
Further Readings continues, ideas of the self become more complex
Bell, Vaughan. “Online Information, Extreme and diverse as individuals learn what is expected,
Communities and Internet Therapy: Is the Internet appropriate, or right in specific situations, as well
Good for Our Mental Health?” Journal of Mental as the resultant emotional benefits. Hence, indi-
Health, v.16/4 (2007). viduals learn what is best to display in differential
Christensen, Helen and Kathleen Griffiths. “The situations based on interpersonal dynamics.
Internet and Mental Health.” Australian and New
Zealand Journal of Psychiatry, v.34/6 (2000). Affect and Communication
Ybarra, Michele L. and William W. Eaton. “Internet- An individual’s experience of affect, or their feel-
Based Mental Health Interventions.” Mental ings, and the social rules that an individual is taught
Health Services Research, v.7/2 (2005). about displaying affect, plays a driving force in the
development of interpersonal dynamics. As the
self develops, individuals achieve a sense that they
are one person and have diverse affects, such as
interest, joy, surprise, fear, distress, anger, disgust,
Interpersonal Dynamics shame, love, boredom, guilt, hope, and hate. The
capacity to feel and regulate affect, especially in
Interpersonal dynamics refers to the interactions interpersonal interactions, is a fundamental part
and connections that exist or occur between indi- of the human interpersonal experience. An indi-
viduals. The interpersonal dynamics that form vidual’s ability to contain and regulate their affect
between individuals are developed and shaped in interpersonal situations may determine their
because of many factors, such as an individual’s concept of how a sense of well-being can be main-
concept of self and self in relation to others, tained and how affective pain can be avoided, giv-
experience of affect, nonverbal and verbal com- ing shape to interpersonal dynamics.
munication, defense mechanisms, interpersonal Communication, verbal and nonverbal, is a key
conflict, boundaries, transference, and cultural variable in interpersonal dynamics, and how indi-
worldviews. viduals communicate delineates the individual’s
422 Interpersonal Dynamics

concept of self and others. Individuals have a per- individual’s desire for quiet while in the same
ceived self, or how they see themselves truthfully room, will likely cause interpersonal conflict. Per-
as a whole, which is likely different or edited than ceived scarce rewards also create conflict because
what they communicate or present to others in individuals believe that there may not be enough
interpersonal relationships. For example, indi- of something for one or more individuals (e.g.,
viduals may maintain a specific front when they space, love, or monetary rewards). The interper-
want to impress others, which may be quite dif- sonal dynamics of conflict are also based on the
ferent than when alone in front of a bathroom fact that individuals are interdependent, however
mirror. Verbal and nonverbal communication that much at odds they are with another individual;
is expressed also shapes the nuances of interper- the well-being and satisfaction of each individual
sonal dynamics. To expand, individuals use dif- depends on another person’s actions. Individuals
ferent methods of communication such as body handle conflict in different styles, such as avoid-
language, eye contact, sounds, gestures, verbal ance, accommodation, competition, aggression,
language, and intonations that all affect the inter- compromise, and collaboration. These patterns
personal dynamics that are experienced. and relational styles of interacting during conflict
all have a part in shaping interpersonal dynamics.
Defense Mechanisms and Conflict
A thorough exploration of interpersonal dynam- Boundaries and Transference
ics encompasses a description of defense mecha- The existence of boundaries in interpersonal
nisms, which are the ways that people develop dynamics can be physical (e.g., personal space),
a personal shield of defenses against distressing psychological (e.g., how much attention to
affects such as anxiety, rage, fear, shame, envy, give someone), sociological (e.g., social group
guilt, and grief. As individuals define for them- norms), and temporal (e.g., time constraints in
selves what is good and bad, or acceptable and interpersonal interaction). An understanding of
unacceptable, they experience impulses or affects the boundaries between individuals or between
that threaten the sense of self. groups is fundamental to cohesion or discord in
Such impulses may be shameful because they interpersonal dynamics.
do not fit into the concept of the self in accor- When in a relationship with others, individual
dance with what is “acceptable or unacceptable,” awareness of the boundaries of that relationship
as defined by the interpersonal world in which or group defines how the interpersonal dynam-
they live. Hence, individuals develop these per- ics will take shape. For example, a person who
sonal defense mechanisms that may prevent the comes into a store, ignores the long line to the
offensive ideas or impulses from being active and checkout counter, and cuts in front of everyone
affecting interpersonal relationships. Hence, these to pay for his coffee will get a different reaction
defenses impact the dynamics of interpersonal from the group than an individual who recognizes
relationships. For instance, an individual who is the line to wait to checkout, respects that others
disturbed by his aggressive impulses may become will get mad if he breaks in front of others, and
overly friendly and kind to others in order to pre- gets in the back of the line to wait his turn. Hence,
vent those threatening impulses from occurring boundaries are an essential component of how
and causing a threat to the self. interpersonal dynamics are structured.
The experience of conflict in interpersonal Interpersonal dynamics are also shaped by
dynamics is a natural occurrence in everyday the experience of transference: the feelings, per-
interpersonal life. Conflict breaks down to an ceptions, and reactions that an individual has
expressed struggle between an individual or indi- toward another individual as a result of overgen-
viduals who perceive incompatible goals, scarce eralizing previous learning to present situations.
rewards, and interference from the other indi- For example, a university professor is about to
vidual or individuals in attaining personal goals. start her first freshman class in sociology, and
Hence, the dynamics of differential goals between new students already start to transfer their per-
two individuals, such as one individual’s desire sonal expectations from other authority figures
to listen to music while they study and another they have had in their lives to this new professor.
 Iran 423

Hence, for example, some may admire or reject Schultz, Duane P. and Sydney Ellen Schultz. Theories
the professor based on previous good or bad of Personality. Belmont, CA: Wadsworth/Thomson
experiences with a mother or high school teacher. Learning, 2001.
Transference reactions are everyday occurrences, Teyber, Edward. Interpersonal Process in Therapy:
and many are reality based; however, the more An Integrative Model. Belmont, CA: Brooks/Cole,
conflict one has experienced, the more inaccurate 2011.
transference reactions may occur. Transference
is also more hypothetical in situations that are
more emotionally laden, such as when people are
falling in love.
Cultural background and an individual’s world- Iran
view greatly influence the way that individuals
interact, express emotions, and interpret other peo- Iran is a Middle Eastern country with an area
ple’s emotions, intentions, and verbal/nonverbal of 636,373 square miles (1.64 million square
communication, tailoring interpersonal dynamics. kilometers) and a population estimated at 75
Interpersonal dynamics are fundamentally shaped million in 2012. Thirty percent of the popula-
by the intricacies of a cultural makeup such as age, tion are younger than 18, 5 percent are age 60
any developmental or acquired disabilities, family or older, and life expectancy at birth is 74 years
of origin, religion, ethnicity, socioeconomic status, for women and 70 years for men. According to
sexual orientation, indigenous heritage, national the World Bank, Iran is an upper-middle-income
origin, and gender. country with a per capita gross domestic prod-
For example, familial rules about how to deal uct (GDP) in 2011 of $12,200. It is classified as
with conflict may form whether an individual having high human development (the second-
avoids conflict or confronts it and may even deter- highest category) by the United Nations Devel-
mine what an individual feels they can talk about opment Programme. Total expenditure on health
outside the family unit; one’s gender and the is 5.5 percent of GDP, and per capita government
experienced sociocultural construction of gender expenditure on health was $344 in 2006. Neu-
may delineate that an individual feels they either ropsychiatric disorders contribute an estimated
have to be assertive or submissive, sculpting the 16.6 percent to Iran’s global burden of disease,
interpersonal dynamics. Accordingly, culture is an and mental health expenditures constitute 3.6
integral part of the composition of interpersonal percent of the total health budget, with 16.7 per-
dynamics. cent of the total mental health budget going to
mental hospitals.
Erika Carr
Memphis VA Medical Center Mental Health Services
Iran’s mental health policy and program was
See Also: Emotions and Rationality; Identity; created in 1986 and revised in 2004. It includes
Integration, Social; Social Support. funding allocation, integration of mental health
services into primary care, shifting of mental
Further Readings health services to community facilities, and a
Adler, Ronald, B., Lawrence B. Rosenfeld, and timeline for implementation of these changes.
Russell F. Proctor II. Interplay: The Process of Government expenditures for mental health are
Interpersonal Communication. New York: Oxford part of the general government expenditures for
University Press, 2009. health care, and no specific information is avail-
Hays, Pamela. Addressing Cultural Complexities in able about the amount of expenditure on mental
Practice, Second Edition: Assessment, Diagnosis, health care. Primary health care physicians are
and Therapy. Washington, DC: American allowed to prescribe psychotherapeutic medica-
Psychological Association, 2007. tions, but primary health care nurses are not nor
McWilliams, Nancy. Psychoanalytic Case are they allowed to independently diagnose and
Formulation. New York: Guilford Press, 1999. treat mental health conditions. Official manuals
424 Iran

for the treatment of mental patients exist, as do and mental disorders are covered in Iran’s social
official procedures to refer patients from pri- insurance schemes.
mary to secondary and tertiary care, but most
primary health care physicians and nurses have Epidemiology
not received official in-service training on mental The suicide rate in Iran is 0.3 per 100,000 for
health care within the past five years. About 40 to males and 0.1 per 100,000 for females. In mental
50 percent have received this type of training at hospitals, the most common disorders treated are
some point in their careers. mood disorders (65 percent), followed by schizo-
Iran has 855 outpatient mental health facili- phrenia (17 percent) and neurotic disorders (7
ties (948 per 100,000), of which 40 are reserved percent). In inpatient mental health units, schizo-
for children and adolescents. The country has 31 phrenia is most common (24 percent), followed
day-treatment facilities (2.78 per 100,000), 46 by mood disorders (21 percent), other disorders
community residential facilities, and 33 mental (20 percent), and personality disorders (19 per-
health hospitals (7.9 per 100,000). The coun- cent). In outpatient mental health facilities, the
try has 1,366 psychiatric beds in general hospi- most common diagnoses are neurotic disorders
tals (2.02 per 100,000, of which 3 percent are and mood disorders (both 34 percent). However,
reserved for children and adolescents, and 5,350 access to mental health care is unequal across the
beds in mental hospitals (7.9 per 100,000), 3.4 population; for instance, most mental health beds
percent of which are reserved for children and are located in large cities rather than rural areas.
adolescents. Mental health status is also related to income:
In 2011, the rate of treatment in outpatient men- Esmaeil Morasae and colleagues found that, in
tal health care facilities was 1,048.35 per 100,000 Teheran, mental health disorders were primarily
population, of which 55 percent were female and concentrated among the poor.
25 percent under age 18. The rate of admission to
mental hospitals was 118 per 100,000, with 46 Sarah Boslaugh
percent of those admitted female and 4 percent Kennesaw State University
under age 18; most (94 percent) of mental hospi-
tal patients were in the hospital for less than one See Also: Inequality; Iraq; Social Class; Urban Versus
year. The rate of admission to psychiatric beds in Rural; Violence; Women.
general hospitals was 36.6 per 100,000, with 28
percent female and 20 percent under age 18. For Further Readings
treatment in mental health day-treatment facili- Gakhari, Ali, Mehdi Tabatabavakili, Yousef Sayah
ties, the rate was 7.2 per 100,000 (60 percent Javid, and Sara Farhang. “Family Violence
female and 11 percent under age 18). At year’s Influences Mental Health of School Girls in Iran:
end, the rate of people in community residential Results of a Preliminary Study.” Asian Journal of
facilities was 8.11 per 100,000, with 60 percent Psychiatry, v.5 (2012).
of those female. Morasae, Esmaeil Khedmati, Ameneh Setareh
In 2011, Iran had 1.5 psychiatrists per 100,000 Forouzan, Mohsen Asadi-Lari, and Reza Majzadeh.
population and 2.2 psychologists per 100,000. In “Revealing Mental Health Status in Iran’s Capital:
addition, the workforce in the mental health sec- Putting Equity and Efficient Together.” Social
tor included physicians not specialized in psychia- Science and Medicine, v.75 (2012).
try (11.4 per 100,000), nurses (7.5 per 100,000), World Health Organization. “Mental Health Atlas
social workers (0.7 per 100,000), occupational 2011. Country Profiles: Iran, Islamic Republic of.”
therapists (0.6 per 100,000), and other health http://www.who.int/mental_health/evidence/atlas/
workers (40.9 per 100,000). About one in 10 pri- profiles/en/index.html (Accessed April 2013).
mary and secondary schools have a counselor, and World Health Organization Country Office in the
about one-quarter have school-based activities to Islamic Republic of Iran. “WHO-AIMS Report
promote mental health. About half (53 percent) on Mental Health System in the Islamic Republic
of the country has subsidized (at least 80 percent) of Iran.” Tehran: World Health Organization
or fee access to essential psychotropic medicines, Country Office in the Islamic Republic of Iran,
 Iraq 425

2006. http://www.who.int/mental_health/evidence/ Iraq has 34 mental health facilities, for a rate

who_aims_report_iran.pdf (Accessed April 2013). of 0.108 per 100,000 population; five of these
World Health Organization (WHO) Regional Office are reserved for children and adolescents (0.016
for the Eastern Mediterranean Region. “Mental per 100,000). Iraq has one day-treatment facil-
Health Systems in the Eastern Mediterranean ity (0.003 per 100,000), three mental hospitals
Region: Report Based on the WHO Assessment (0.010 per 100,000), 350 psychiatric beds in
Instrument for Mental Health Systems.” general hospitals (1.112 per 100,000), and 1,340
Cairo: WHO, Regional Office for the Eastern beds in mental hospitals (4.258 per 100,000).
Mediterranean, 2010. http://applications.emro The rate of treatment in mental health outpa-
.who.int/dsaf/dsa1219.pdf (Accessed April 2013). tient facilities in 2011 was 223.54 per 100,000
(25 percent female, 17 percent under age 18). The
rate of admissions to mental hospitals was 12.71
per 100,000 (33 percent female, 6 percent under
age 18) and the rate of admissions to psychiatric
Iraq beds in general hospitals was 4.93 per 100,000
(37 percent female, 36 percent under age 18). Iraq
Iraq is a Middle Eastern Country with an area had 0.27 psychiatrists per 100,000 working in the
of 169,235 square miles (438,317 square kilome- mental health sector, along with 0.89 nurses per
ters) and a July 2012 population estimated at 31.1 100,000 and 0.15 psychologists per 100,000.
million, with 66 percent of the population living In 2009, the international medical organiza-
in urban areas. Almost half (46 percent) of the tion Médecins Sans Frontières (MSF, or Doctors
population are under age 18, and 3 percent are
over age 60. Life expectancy at birth is 72 years
for females and 63 years for males. According to
the World Bank, Iraq is a lower-middle-income
country, with a 2011 estimated per capita gross
domestic product (GDP) of $3,900. According
to the United Nations Development Programme,
Iraq is also a country with medium human devel-
opment (second-lowest of four categories).
Iraq spends 3.9 percent of its GDP on health,
with a per capita government expenditure on
health of $114. Neuropsychiatric disorders con-
tributed an estimated 6.1 percent to Iraq’s global
burden of disease, with mental health disorders
as the fourth leading cause of ill health in Iraqis
older than age 5.

Current Mental Health Services

Iraq does not have an official mental health policy,
but does have a mental health plan, most recently
revised in 2008. This plan includes the integra-
tion of mental health services into primary care,
a shift of resources from hospitals to community
mental health facilities, funding, and a timetable
to implement the plan. Physicians are allowed
to prescribe psychotherapeutic medications, but An Iraqi girl from the Janabi village waits in line with her father
nurses are not; most primary care physicians and at a doctor’s office in Yusufiyah, Iraq, March 2, 2008. Iraq has 34
nurses have not received in-service training on mental health facilities (a rate of 0.108 per 100,000 population);
mental health in the last five years. five of these are reserved for children and adolescents.
426 Italy

Without Borders) began to collaborate with the disorders (4 percent), and severe depression (2.2
Iraqi Ministry of Health (IMoH) to improve percent). The 12-month prevalence rate for all
access to psychological counseling. Between 2009 disorders was higher in urban (11.7 percent) than
and 2012, this project provided over 25,000 in rural (10 percent) areas, and was higher in
counseling sessions in Baghdad and Fallujah, Kurdistan (14.1 percent) than in the south-central
using teams of counselors trained by the MSF and region (10.5 percent) or the country as a whole
IMoH. MSF also created a program of education (11.1 percent). The 30-day prevalence of mental
and outreach to raise awareness in the population disorders was 7.1 percent, with a higher rate for
about mental health and the availability of care women (10.3 percent) than for men (4 percent),
services. and for urban (7.8 percent) than for rural (6 per-
cent) areas, and for Kurdistan (9.6 percent) com-
Epidemiology pared to the south-central region (6.7 percent)
Iraq has suffered from years of warfare, includ- and the country as a whole (7.1 percent).
ing the Iran–Iraq War (1980–88), the Persian Gulf
War (1990–91), and the Iraq War (2003–11). The Sarah Boslaugh
country remains in social turmoil, with high rates Kennesaw State University
of violence affecting many civilians (over 116,000
violent civilian deaths were recorded between See Also: Community Mental Health Centers; Shell
2003 and 2011). Surveys have found high lev- Shock; Stress; Violence; War.
els of post-traumatic stress disorder (PTSD) and
other mental health disorders in the Iraqi popu- Further Readings
lation; for instance, in a 2006 study, PTSD rates Médecins Sans Frontières. Healing Iraqis: The
of 14 to 36 percent were found in children and Challenges of Providing Mental Health in Iraq.
adolescents (the rate depended on location). A Geneva: Médecins Sans Frontières, 2013. http://
2007 household survey found that over 35 per- www.msf.org/sites/msf.org/files/english_iraq
cent of household members were suffering from _mental_health_final_report.pdf (Accessed May
psychological distress, including 3.5 percent who 2013).
had considered ending their life. World Health Organization. “Mental Health Atlas
Iraq conducted its first national mental health 2011. Country Profiles: Iraq.” http://www.who.int/
survey from 2006 to 2007 and found high levels mental_health/evidence/atlas/profiles/en/index.html
of psychological distress in the population, with (Accessed January 2013).
a 19.4 percent lifetime prevalence for women World Health Organization Regional Office for the
and 13.7 percent incidents among men. The most Eastern Mediterranean. “Iraq: Mental Health and
common problems reported were anxiety disor- Substance Abuse.” http://www.emro.who.int/irq/
ders (11.6 percent lifetime prevalence), followed programmes/mental-health-and-substance-abuse
by affective disorders (7.8 percent), specific pho- .html (Accessed May 2013).
bias (5.4 percent), PTSD (3.6 percent), and severe World Health Organization (WHO) Regional Office
depression (3.5 percent), while substance abuse for the Eastern Mediterranean. “Iraq Mental Health
was quite low at 0.9 percent. Lifetime prevalence Survey 2006/7.” Geneva: WHO, 2009. http://
of mental disorders was higher in urban (17.7 applications.emro.who.int/dsaf/EMRPUB_2009_
percent) than in rural (14.5 percent) areas, and EN_1367.pdf (Accessed May 2013).
Kurdistan had a higher rate (21.1 percent) than
the south-central region (15.7 percent) or the
country as a whole (16.6 percent).
The 12-month prevalence of mental disor-
ders found in the survey was 11.1 percent, with Italy
a higher rate for females (13.4 percent) than for
males (8.8 percent). Overall, the most common The Italian Republic, or Repubblica Italiana, is
disorders were specific anxiety disorders (8.6 the official name of country of Italy. It is a dem-
percent), specific phobias (4.6 percent), affective ocratic republic in south-central Europe and
 Italy 427

occupies a peninsula that projects into the Medi- and his newly developed National Fascist Party
terranean Sea. The current population of Italy is began a reign of dictatorship with the support
59,570,581 (2011 census), with over 92 percent of King Victor Emmanuel III. In the late 1930s,
of the population originating from the Italian Mussolini and his party joined forces with Nazi
ethnic group. Italy spans 116,217 square miles Germany and the Empire of Japan, and even-
(301,000 square kilometers), including a number tually joined World War II in 1940, on the side
of islands. The capital, Rome, is the most densely of the Axis powers. The collapse of the Fascist
populated city in Italy, with Milan and Naples party and Mussolini began in 1943, when the
following in population rates. It is surrounded by Allies invaded Italy. Conflict ended in 1945, leav-
the Alps Mountains to the north, and vast bodies ing Italy economically and emotionally crushed.
of water including the Adriatic Sea, Ionian Sea, After war and turmoil, the Italian Republic was
Tyrrhenian Sea, and Mediterranean Sea. Italy is created on June 2, 1946, with Alcide De Gasperi
currently led by President Giorgio Napolitano as its first president.
and Prime Minister Mario Monti. The currency
is the euro, and the estimated 2012 gross domes- Culture
tic product per capita is slightly above $30,000. Italy encompasses a wide array of ethnic groups
Italian is the official language, and although Italy and cultures, mostly based on historical geo-
does not have an official religion, the country has graphic settlement. The Etruscans settled in Tus-
an overwhelmingly large Catholic population. cany, Greeks occupied the southern region, and
Romans inhabited most of west Italy. Since the
History Middle Ages, these dynamics have changed, but
The etymology of the name Italia is thought to many traditions and heritage from these locations
stem through the Greek, from the Oscan language, remain evident in modern Italy. In recent years,
meaning “land of the cattle (calf).” Ancient Rome immigrants from Asia, north Africa, and all parts
was founded around the 8th century b.c.e., and of Europe have migrated to Italy for growing
the Roman Empire eventually grew to encom- opportunities in urban settings. Demographically,
pass the entire Mediterranean Sea region when rural areas are in decline because many Italians
the Greek and Roman civilizations united. The are moving toward more industrial urban centers.
Romans greatly influenced modern law, govern- Although many inhabitants are drawn toward cit-
ment, politics, philosophy, architecture, and the ies, the Italian rural areas are still great epicenters
arts. In the 5th century c.e., the Roman Empire for vineyards, orchards, and tourist attractions
fell to a succession of barbarian invasions, which such as skiing.
eventually seized portions of Italy. During the Education and literacy are of much importance
Middle Ages, various tribes and regimes fought for the Italian people. Education is free from ages
for control of the territory that comprises mod- 6 to 16. In addition, the country holds a wide
ern Italy. Commerce and trade were re-emerging array of universities and colleges. One of the old-
in regions such as Florence and Sicily by the est universities, University of Bologna, started in
beginning of the 14th century, but the arrival of the 11th century. Strong fields of study include
the plague brought a sharp decline in economic science, technology, and business.
activity because the huge mortality from the Italian cuisine has been greatly influenced by
Black Death, here as elsewhere in Europe, had Etruscans, Greeks, Jews, and Romans. Many of
devastating effects. Subsequently, powerful city- the staple foods traditionally thought of as Italian
states emerged in Italy, and trade and economic are derived from produce and products from the
growth resumed, leading to the flowering of art, New World. Tomatoes, peppers, potatoes, and
literature, architecture, philosophy, and science corn were not abundant in Italy until the 18th
known as the Italian Renaissance. century. Cheese, ham, wine, and coffee are inte-
Following its political unification in the 19th gral pieces of historical and present Italian cuisine.
century, Italy played a significant role in world The arts are also an important facet of Ital-
politics and warfare, especially in the early to ian culture and existence. Italy produced many
mid-20th century. In the 1920s, Benito Mussolini of the world’s most influential painters, such as
428 Italy

Michelangelo and Leonardo da Vinci. Da Vinci’s care, self-care promotions, and interpersonal
Mona Lisa painting is one of the most famous skills training.
pieces of art, believed to be painted sometime in In recent years, health care in Italy has been
the 16th century. moving toward an integrated model, where indi-
viduals receive care through what is meant to be a
Mental Health system of health, social, economic, and vocational
As in most of Europe and North America, the resources. In Italy, primary care is regarded as
19th century saw different regions in Italy adopt the first and most frequent type of health care for
the asylum as the primary response to serious individuals in both rural and urban communities.
mental illness, and Italian mental hospitals rapidly However, in many urban areas, primary care phy-
grew in size and increasingly became custodial. sicians are also collaborating with mental health
Deinstitutionalization appeared later in Italy than professionals in a shared care process to deliver a
in the United States and the United Kingdom; its greater quality of overall health care.
most charismatic proponent was the left-wing Ital- In 2002, there were over 30,000 mental health
ian psychiatrist Franco Bassaglia, who crusaded personnel in Italy, including 5,094 psychiatrists
for the closing of mental hospitals and the return and 1,785 psychologists. In addition, a wide
of mental patients to the community. By 1978, array of facilities comprise the mental health sec-
efforts were under way to close all mental health tor, including private psychiatric clinics, univer-
hospitals throughout the country. New legislation sity psychiatric departments, and day hospitals.
stated that no new admissions to existing mental Coordinating resources across different sectors
hospitals were allowed, integrated community- remains the goal, though the implementation of
based clinics would provide full mental health this model remains far from perfect.
needs to the community, and mandatory psychiat-
ric admissions were an exception and time limited. Jay Trambadia
As happened elsewhere, the necessary community Christopher Edwards
infrastructure was slow to appear. Abigail Keys
A national plan was announced in 1994 that Duke University
sought to put into effect a broad network of
mental health services in the country. This plan See Also: Asylums; Deinstitutionalization;
attempted to enhance health care by creating men- International Comparisons.
tal health departments that would provide citizens
with rehabilitation and crisis interventions. Further Readings
Currently, multidisciplinary mental health Donnelly, Michael. The Politics of Mental Health in
departments consist of psychiatrists, psycholo- Italy. New York: Routledge, 1992.
gists, nurses, social workers, therapists, and psy- Fruggeri, Laura, Umberta Telfner, Anna Castellucci,
chosocial rehabilitation specialists. These depart- Maurizio Marzari, and Massimo Matteini. New
ments include community mental health centers, Systemic Ideas From the Italian Mental Health
general hospital inpatient wards, semiresidential Movement. London: Karnac Books, 1992.
facilities, and residential facilities. The locations Scalzo, A. L., A. Donatini, L. Orzella, A. C. S. Profili,
provide a variety of interventions, such as crisis and A. Maresso. “Italy: Health System Review.”
intervention, diagnostic evaluations, outpatient Health Systems in Transition, v.11/6 (2009).
 J
Jails and Prisons department. In a few states, jails and prisons are
operated by one authority, the department of cor-
In the late 1840s and early 1850s, Dorothea Dix rections; this is the exception, however, not the
traveled around the United States, exposing the rule. There are more than 3,000 separate jail sys-
parlous state of the mentally ill in the community tems in the United States. There are 51 separate
and urging state politicians to construct asylums prison systems in the United States, one for each
where they could be treated. She frequently visited state and one operated by the federal government.
jails where, in the absence of specialized mental Jails hold approximately one-third of all incarcer-
hospitals, many of the mentally ill were confined. ated people. They have a huge turnover in their
By the 1980s, the problem had reoccurred: population. For each person held in a jail, there
jails and prisons were holding a disproportionate are 20 times as many bookings during the course
number of prisoners with mental illness. While of the year.
some prisoners with mental illness belonged in Each booking could represent a new person or a
jails and prisons, others seemed to be incarcer- “repeat customer.” Some inmates are booked 100
ated instead of being placed into a psychiatric times during the course of a year. Jails house peo-
facility. The problem of using jails and prisons as ple who have just been arrested, people who are
psychiatric hospitals in the 1980s was not new. It awaiting trial, people who have been convicted of
was simply a reoccurrence of a system that had a misdemeanor and are serving a sentence, people
existed in the early 19th century. To completely who have been convicted of a felony and who are
understand this issue, several smaller issues must awaiting transfer to prison, people who belong
be explored: the definition of and difference in prison but for whom a bed has been rented in
between jails and prisons; psychiatric hospitals jail, federal prisoners, and illegal aliens. Prisons,
and deinstitutionalization; and the legal proce- on the other hand, house two-thirds of all pris-
dures associated with placement in a jail, prison, oners in the United States. They receive prisoners
or psychiatric hospital. and spend many weeks classifying them. Prisons
The terms jail and prison are used interchange- have far less turnover. Inmates may have the same
ably by many people. Jails and prisons are com- cell for years. If the prisoner has a specific health
pletely different places, even though both places problem, prisons tend to know about it and can
incarcerate people. In most states, jails are oper- send the person to a specific prison facility for
ated at the local (county/city) level by the sheriff’s treatment.

429
430 Jails and Prisons

Psychiatric Hospitals and involuntarily placed into a psychiatric hospital,

Deinstitutionalization a person must be evaluated by a mental health
Psychiatric hospitalization has changed greatly professional who in most jurisdictions can now
since the 1950s. The number of psychiatric hospi- have the person admitted to a psychiatric facility
tal beds decreased 90 percent between the 1950s for only 72 hours (not including weekends and
and the 1980s. In addition, the average length of holidays) before a hearing must be held before a
stay decreased from six months (in the 1950s) to judge. When people have problems in the com-
less than two weeks currently. Whereas psychi- munity, they are more likely to encounter the
atric hospitalization used to take place entirely police rather than mental health personnel. Once
in public institutions, many psychiatric hospi- they have made an arrest, police officers often
talizations now take place in general hospitals find it easier to take someone to jail rather than
and private hospitals. The large, state psychiatric to a hospital. Hospital intakes often take longer
hospitals have closed or reduced their numbers than jail intakes, and some officers report that
to the point that large sections of some hospitals jails have more ability to maintain custody of the
have been closed, and many hospitals have been individual for a longer period of time than hos-
entirely closed. The huge decrease in the psychiat- pitals. For these reasons, it is often easier to take
ric hospital population was the result of deinsti- a person with mental illness who acts out to jail
tutionalization. than to take them to a hospital. Jails, therefore,
Deinstitutionalization took place for several often become the path of least resistance for a
reasons: the development of psychotropic medi- society trying to control a person exhibiting devi-
cations that helped control psychiatric symp- ant behavior.
toms, the heavy tax burden of psychiatric hos-
pitalization, and increasing civil rights concerns Jails and Mental Health Treatment
that those hospitalized in psychiatric institutions Jails are open all day, year-round, and must accept
were placed there without due process (and pro- nearly everyone that police bring to them. While
tection under the law), and that the psychiatric jails are often not pleasant, they know how to deal
institutions were inhumane places in which to with difficult people, are warm, feed people, and
live. In the 1950s, new drugs were developed can hold a person for a period of time. Jails have
that, although they did not cure mental illness, become psychiatric hospitals in some locations.
decreased a person’s symptoms to the point where
the individual could return to the community. As
is the case with prisons today, psychiatric hospi-
talization represented a significant financial bur-
den on state governments. Decreasing psychiatric
populations held out the promise of a reduced
tax burden (although governments would soon
find that many of these costs had simply shifted
to other groups like local government to pay for
police and jail space). Finally, there were concerns
that those hospitalized may have been placed
there for the convenience of others rather than for
the treatment of their mental illness.
In order for someone to be placed into prison,
they have to have been sent to a jail, must have
pled guilty, and been convicted following a trial;
or in the case of a parolee, they must have at least
been given a hearing concerning an alleged parole In most states, jails are operated at the local level (as by the city
violation. To be placed into a jail, one needs only or county) by the sheriff’s department, which is the case with
to be arrested for a misdemeanor such as dis- this jail in Lake County, Ohio. Jails must accept all comers; some
turbing the peace or public intoxication. To be jails screen well for mental illness while others do not.
 Jails and Prisons 431

Research suggests that persons with mental ill- Network. With this system, jailers who operate
ness spend longer in jail for the same crime than a rural jails (with no mental health resources) can
non–mentally ill person. Persons with mental ill- call a nurse and describe the detainees’ symptoms.
ness tend to cause more problems for corrections This triage system allows jailers to receive advice
officers and take more of their time. about handling difficult inmates and to make
While jails hold persons with mental illness, some rough distinctions between the mentally ill
they often do not treat, or they inefficiently treat, and others.
persons with mental illness. While some jails have
medical staff, others contract an outside company Prisons and Mental Health Treatment
or individual doctors on a case-by-case basis. Prisons constitute a very different set of institu-
Some jails screen well for mental illness, while tions and manage a less heterogeneous popula-
others do not. Jails tend to be more concerned tion. When people come into the prison system,
with the threat of suicide than with mental illness they typically spend time in a classification center
in general. Jails have a suicide rate 450 percent that is designed to detect and note whatever prob-
greater than the general U.S. population, control- lems (e.g., mental, cognitive, physical) a prisoner
ling for race, gender, and age. Many of these sui- might have. Once at the prison, the prisoner may
cides occur within 48 hours of booking, and many spend many years or even the rest of his life there,
of the people who kill themselves have a history and these initial assessments have administra-
of mental illness. Corrections officers, therefore, tive and other consequences for their placement
concern themselves with decreasing suicide but within the prison hierarchy. Prisons provide acute
do not always exhibit the same level of concern and long-term care for persons with mental ill-
about underlying mental illness. Many persons ness. Some prison systems reserve certain facilities
with mental illness thus stay in jail for long peri- for people with health problems (e.g., Lexington
ods of time without adequate treatment. Federal Medical Center), while other people are
There have been some attempts to divert treated for their mental illness in regular prisons.
offenders with mental illness to a hospital set- In Kentucky, each prison provides mental health
ting in lieu of taking them to jail. The Memphis, services; over 5,000 inmates are provided regu-
Tennessee, police department did this as part of lar mental health treatment. Each mental health
its Crisis Intervention Team. In the late 1980s, program has a licensed psychologist who oper-
Memphis developed a program to train officers ates mental health services, provides assessments
in how to deal with offenders with mental illness. for prison authorities, and offers some counsel-
One component of the program was a situation ing and psychotherapy and crisis intervention. As
where officers could take an arrestee to a hospital with the provision of medical services of a more
and drop him/her off into the custody of another general nature, resources are scarce, and for many
officer there. This was beneficial because one of inmates, drug treatments are the primary form of
the complaints made by officers was that hospital intervention, leading to criticism that mentally ill
intake took a great deal of time. The arrestee was inmates are simply chemically restrained rather
then able to receive medical treatment instead of than effectively treated.
sitting in jail.
While many small jails must rely on commu- Daniel W. Phillips III
nity resources (e.g., private practice physicians, Lindsey Wilson College
community mental health centers, and indepen-
dent pharmacies), larger jail systems (e.g., Cook See Also: Courts; Deinstitutionalization; Mental
County, Chicago, Illinois) provide inmates with Institutions, History of; Prison Psychiatry; Violence.
mental illness with acute care treatment (with
mental health care staff), inpatient treatment Further Readings
(with an over-100-bed facility), talk therapy, med- Milligan, Connie and Ray Sabbatine. Reducing
ication, and rehabilitation. For rural jails, there Risk and Responding to Mental Health Needs:
are even phone triage systems such as those oper- Kentucky’s New System of Care. Washington, DC:
ated by the Kentucky Jails Mental Health Crisis American Corrections Association, 2006.
432 Japan

Palermo, George, M. Smith, and Frank Liska. “Jails sites to eventually meet up and execute a planned
Versus Mental Hospitals: A Social Dilemma.” group suicide together.
International Journal of Offender Therapy and One factor that differentiates the psychiatric
Comparative Criminology, v.35/2 (1991). care system in Japan seems to be the predominant
Parry, Manon. “Dorothea Dix (1802–1887).” focus on institutionalization of the mentally ill.
American Journal of Public Health, v.96/4 (2006). As of 2010, Japan has had the greatest number of
available psychiatric beds (352,721), as well as the
highest ratio of beds per capita worldwide (2.8).
Low hospitalization costs and low staffing levels in
psychiatric hospitals contribute to this enhanced
Japan hospital-based locus of care. In addition, 80 per-
cent of Japanese hospitals are privately run, and
The mental health system in Japan poses many incentives exist to keep patients hospitalized for
challenges for its citizens. It has been estimated long periods of time. Consequently, Japan’s men-
that of the 128 million people in Japan, more tal health care system has little economic incen-
than 3 million suffer from mental illness and tive to transition to a more community-based
receive psychiatric care. Around one-third of these care, although a community-based care system
patients have sought treatment for mood disor- has been raised as an alternative model for the
ders, which represent the most prevalent psychi- future among some recent Japanese mental health
atric disorders in Japan to date. According to the care researchers.
Japanese Ministry of Health, Labor, and Welfare,
the number of Japanese individuals seeking treat- Public Attitude Toward the Mentally Ill
ment for mood disorders more than doubled from The attitude toward Japan’s mentally ill reflects
1996 to 2005. both its system of psychiatric health care as
Furthermore, suicide rates are high: the sec- well as cultural values. A recent study examined
ond-highest among the G8 nations, after Rus- stigma associated with schizophrenia in 17 differ-
sia, and the leading cause of death among youth ent countries. In 16 of these countries, including
under 30 years of age. Other related disorders, Japan, there was a marked preference for psy-
such as schizophrenia and dementia, are also chosocial explanations over biogenetic causes of
commonly seen within Japan’s mental health schizophrenia. Of the 1,211 respondents surveyed
system. Suicides among middle-aged men can be in Japan, 64.8 percent believed that schizophrenia
directly attributed to the downturn of the econ- is caused by problems in interpersonal relation-
omy because they have taken for granted the life- ships. Approximately 40.3 percent of those sur-
time employment system and do not know what veyed attributed schizophrenia to nervousness,
alternatives exist when they are let go from their and 30.2 percent took a biogenetic approach,
companies. stating that schizophrenia was a cranial nerve
In contrast, many of the teenage suicides are disorder. Thus, the majority of Japanese viewed
reported to be motivated by existential suffering mental illness largely as the failure to socially
associated with a need for “affiliative belonging” learn appropriate behaviors.
that is not met. This includes the need for con- Furthermore, in a 2005 study, Japanese par-
nectedness, the fear of social rejection, and the ticipants were asked for their mental image
need to be needed by others. In fact, even when associated with schizophrenia, and 69.9 percent
many of them commit suicide, they tend to seek of respondents replied that schizophrenia is an
out others to die with them as a last resort to feel unstable disease in which the condition is good
connected with others. This kind of despair, com- at times, and poor at other times. At the same
bined with a desperate yearning to connect with time, only 33 percent of Japanese respondents
others one last time, has led to a surge in Inter- viewed schizophrenia as treatable. Furthermore,
net group suicides. In such groups, suicidal indi- a 2006 study comparing Australian and Japanese
viduals network with each other through Internet attitudes toward depression and schizophrenia
group suicide Web sites and other social network illustrated that a significantly higher percentage
 Japan 433

of Japanese respondents relative to Australian cultural dropouts. In addition to the 1,830,000

respondents endorsed the following statements: young people (6.4 percent of Japanese youth)
the [mentally ill] person can snap out of the prob- labeled “freeters” who do irregular, nonstandard
lem; the problem is a sign of personal weakness; work and have virtually no prospects of even-
the problem is not a real medical illness and the tually securing a full-time job, there are an esti-
problem should not be shared with anyone. When mated 800,000 young people (2.8 percent of Jap-
answering questions on a perceived stigma scale, anese youth) who fall into the not in employment,
Japanese respondents stated that most people education, or training (NEET) category, as well
would not employ someone with this problem, as 1,293,704 young individuals (4.6 percent Japa-
and most people would not vote for a politician nese youth) who are hikikomori. A hikikomori is
with this problem. Only 11.1 to 25.2 percent of someone who chronically and acutely withdraws
Australians stated that they were unwilling to from any kind of social or occupational par-
socially interact with a schizophrenic or depressed ticipation from six months to even decades at a
individual who lives next door, while 77.6 to 89.2 time. According to psychiatric researcher Asuka
percent of Japanese stated the same. Koyama, the majority of these marginalized
Such pervasive attitudes about keeping the youth are perceived as having “a psychopathol-
mentally ill outside participation in society seems ogy characterized by impaired motivation,” yet
to stem from the value of conformity to consen- they do not meet any diagnostic criteria for a psy-
sual standards of excellence, fulfilling one’s inter- chological disorder, according to standard manu-
personal obligations, and being sensitive enough als of psychological disorders used in the United
to pick up on subtle interpersonal communication States or internationally.
cues within the context of a relatively homoge- Marginalized youth categories such as hikiko-
nous population. Since the mentally ill are per- mori have been increasing in incidence over
ceived to be particularly deficient in these areas, time and have recently been classified as cul-
the chronic institutionalization, marginalization, ture-bound syndromes, although there is some
and relatively poor prognosis of the mentally ill evidence of hikikomori also diagnosed outside
are likely to be sustained, to some extent, by such Japan. Some Japanese mental health research-
public attitudes. ers, such as Takashiro Kato, have tried to clas-
sify these youth phenomena as a “modern-type
Marginalization of Youth in depression,” which is characterized by a shift
Postindustrial Japan in values from collectivism to individualism, a
The fact that those who are mentally ill in Japan reluctance to accept social norms, a vague sense
are more likely to be dismissed by others and are of omnipotence, and an avoidance of effort and
therefore less likely to fully participate in society strenuous work. However, others have argued
stems not so much from the fact that they are men- that these phenomena overstate the individual
tally ill per se but more from the fact that they are pathology aspects, while understating the social
perceived to deviate from normative standards of origins and culture-boundedness aspects of these
behavior. Thus, it is not only those with known phenomena.
mental illnesses who are prone to becoming mar- Given that these youth phenomena are rela-
ginalized in Japanese society. Anyone who simply tively recent, the role that globalization pressures
deviates from a relatively narrow range of cultur- play in Japanese cultural context has to be con-
ally prescribed behaviors, especially in interper- sidered. Japanese sociologists and cultural psy-
sonal contexts, may find themselves marginalized chologists have argued that these youth-related,
and even pathologized. culture-bound syndromes are the result of youth
There is an easily identifiable and growing being increasingly marginalized because of glo-
population of Japanese teens and young adults balization pressures exerted on Japanese society
(ages 15 to 34), cutting across all social classes, to reinvent itself in the midst of transitioning
who are living lifestyles that significantly deviate from an industrialized society to a postindustrial-
from collectivistic norms predominant in Japa- ized society. The increasing marginalization and
nese society. Many of them can be described as the decreasing appeal to conform to culturally
434 Jung, Carl Gustav

prescribed behaviors and norms among many Koyama, Asuka, Yuko Miyake, Norito Kawakami,
Japanese youth today appear to be stemming Masao Tsuchiya, Hisateru Tachimori, and Tadashi
from institutional resistance to such globalization Takeshima. “Lifetime Prevalence, Psychiatric
pressures to move away from a seniority system Comorbidity, and Demographic Correlates of
to a meritocracy system, for example. ‘Hikikomori’ in a Community Population in
This institutional resistance comes at the Japan.” Psychiatry Research, v.176 (2010).
cost of decreased competitiveness in the global Norasakkunkit, Vinai, Yukiko Uchida, and Tuukka
marketplace and, consequently, greater barri- Toivonen. “Caught Between Culture, Society,
ers to obtaining stable, long-term employment and Globalization: Youth Marginalization in
for mostly younger individuals. Thus, there is a Post-Industrial Japan.” Social and Personality
cost associated with institutional resistance to Psychology Compass, v.6/5 (2012).
the pressure to make structural and ideological Toivonen, Tuukka, Vinai Norasakkunkit, and Yukiko
adjustments that are diametrically opposed to a Uchida. “Unable to Conform, Unwilling to Rebel?
collectivistic, hierarchical social system already Youth, Culture and Motivation in Globalizing
in place in most large, established Japanese orga- Japan.” Frontiers in Cultural Psychology, v.2/207
nizations. This cost is largely borne out by the (2011).
youth population in Japan, whose lack of oppor- Yamawaki, Niwako, Craig Pulsipher, Jamie Moses,
tunities in the labor force ensures that senior Kyler Rasmuse, and Kyle Ringger. “Predictors of
elites continue to enjoy lifelong employment in Negative Attitudes Toward Mental Health Services:
an institutional bubble that protects traditional A General Population Study in Japan.” European
values and practices. Journal of Psychiatry, v.25/2 (2011).
The mostly young individuals who either have
been or anticipate being excluded from the long-
term labor markets forgo the intensive and long
process of workplace socialization that core labor-
ers are subjected to while they are faced with few, Jung, Carl Gustav
if any, alternative paths to success. Moreover, the
incongruence between the behavioral tendencies Swiss psychiatrist Carl Gustav Jung’s analytical
of the marginalized individual and those who are psychology, a broad psychological theory that
dominant in Japanese society should only serve was partly influenced by Sigmund Freud’s psy-
to exacerbate their marginalized status, and in a choanalysis, differed from Freud’s psychology in
vicious cycle, some of them will continue retreat- that it incorporated both Western and Eastern
ing from participating in society until it feels like cultural ideas. Although Jung’s formal higher
there is no turning back. This process may result educational training was in medicine, he was also
in the chronic marginalization and withdrawal an earnest student of Western and Eastern phi-
that is characteristic of hikikomori and modern- losophies and religion. The early part of Jung’s
type depression. career was devoted to treating and understanding
the seriously mentally ill, particularly those suf-
Vinai Norasakkunkit fering from schizophrenia. Jung’s views of mental
Natasha Gulati illness, for the time period during which he lived
Gonzaga University and worked, likely incorporated more cross-cul-
turally relevant ideas than the views of many of
See Also: Depression; Identity; Social Isolation; his European contemporaries. Additionally, Jung
Stigma; Suicide. outlined a theory of cause of mental illness, which
included the idea that mental illness has multiple
Further Readings determinants.
Kato, Takashiro, et al. “Introducing the Concept of Carl Gustav Jung was born near Basel, Swit-
Modern Depression in Japan: An International zerland, in 1875. His father, the Reverend Dr.
Case Vignette Survey.” Journal of Affective Paul Jung, was a pastor of the Swiss Reformed
Disorders, v.135/1–3 (2011). Church, an occupation that he chose after failing
 Jung, Carl Gustav 435

to become a university professor of Oriental lan- with the unconscious.” This period lasted about
guages. Jung’s mother, Emilie, a housewife, was six years, during which he conceived of (or, as
a complicated person, often warm and maternal, he would say, discovered) the collective uncon-
and other times eccentric. Jung’s relationship with scious. The collective unconscious is a deep
both of his parents was complex. Jung was a good layer of unconsciousness beneath the personal
student, and in 1895, he began to study medicine unconscious (which Freud discussed and simply
at the University of Basel. During his education at called the “unconscious”) and is one’s individual
Basel, he read extensively in Western and Eastern repressed memories, impulses, and fantasies. The
philosophies and theologies. collective unconscious is inherited, common to all
In 1900, Jung moved to Zurich and began work people, and contains archetypes, which are uni-
at the Burghölzli mental hospital as an assistant versal images and inherited behavioral tendencies
physician. He remained at Burghölzli until 1909. (instincts).
During these years, he also studied psychopathol- According to Jung, humans know that arche-
ogy at the Salpêtrière in Paris (1902–03), worked types exist because of the common motifs found
as a lecturer at the University of Zurich (1905– across cultures in myths and fairy tales. For
13), and married Emma Rauschenbach, with instance, the hero story possesses similar features
whom he later had five children. across cultures; the hero is one example of an
archetype. Other archetypes include the shadow
Friendship and Split With Sigmund Freud (one’s “dark half”), the anima (femininity), the
In 1907, Jung published a groundbreaking book animus (masculinity), and the mother. Archetypes
on schizophrenia, The Psychology of Dementia are expressed in myth-making but also in dreams,
Praecox (dementia praecox was a term used in fantasies, artistic expressions, delirium, and delu-
the late 1800s and early 1900s for schizophre- sions of the mentally ill. As Jung was discover-
nia). Schizophrenia is a serious psychiatric con- ing and understanding the collective unconscious,
dition that involves the breakdown of thought he began to modify and elaborate his view of
processes and ordinary emotional reactions. schizophrenia.
Common symptoms include delusions, hallucina- He had stated earlier that the schizophrenic’s
tions, disorganized speech, and severely disorga- hallucinations and delusions are individually cre-
nized behavior. In Jung’s book, he presented his ated; however, he also noted that some content
view that schizophrenia may have psychological of these schizophrenic experiences is transper-
causes. The prevailing view at the time was that sonal in nature, in other words, archetypal. He
schizophrenia was biologically caused. He held described a case of a patient with a vision of the
that the delusions and hallucinations of schizo- sun with a phallus hanging down from it, through
phrenia are not random or arbitrary; they are which a stream of wind blows. A few years after
created by the patient. In later writings about meeting the patient, Jung read a book by the Ger-
schizophrenia, Jung explained that the grandeur man religious scholar Albrecht Dieterich that
of paranoia, a common delusional system among described a similar image that was part of a ritual
schizophrenics, is in some sense understandable of the ancient Mithraic Greek religious cult. Jung
because it is the patient’s attempt to seem impor- concluded that the patient could not have known
tant. As Jung described, the schizophrenic patient about the ancient cult’s vision, and that the vision
feels unimportant or insignificant in the real world that the young patient had did not come from his
and is compelled to be important somewhere else, personal unconscious but rather from the collec-
particularly in his or her fantasy world. Jung sent tive unconscious that all humans possess.
his 1907 book to Sigmund Freud, inaugurating After 1909, Jung worked primarily in private
their collaboration and friendship. Their relation- practice. In the 1920s and 1930s, he traveled
ship ended bitterly in 1913. internationally, including to Algeria, Tunisia,
Jung was 38 when his break with Freud Kenya, Uganda, the Nile, and India. He traveled
occurred. At this time, he entered an unusual to the United States several times in his lifetime.
period of his life, one of introversion, turmoil, Following his initial publication on the collec-
and creativity, which he called the “confrontation tive unconscious, the majority of his publications
436 Jung, Carl Gustav

focused on general personality and development. usually necessary. He made this claim because
For instance, he published his theory of person- most of the mentally ill are not constantly symp-
ality types (extraversion and introversion, and tomatic but rather may function normally, then
other traits) and wrote extensively about the have a “breakdown” after experiencing stress.
adult personality development process, which he
called individuation. He published a final paper Gretchen M. Reevy
about schizophrenia in 1958. He was working on California State University, East Bay
writing his autobiography, Memories, Dreams,
Reflections, when he died in Kussnacht, Switzer- See Also: Dementia Praecox; Freud, Sigmund;
land, in 1961. Schizophrenia.
Jung’s very notion of the collective unconscious,
whether valid or not, was based to some degree Further Readings
upon his cross-cultural studies. His eventual view Jung, Carl Gustav. Memories, Dreams, Reflections.
of schizophrenia integrated his collective uncon- New York: Random House, 1989.
scious concept. For his time, Jung was a multi- Noll, Richard. American Madness: The Rise and Fall
culturalist. Jung believed that mental illness had of Dementia Praecox. Cambridge, MA: Harvard
multiple causes. As he explained, an early cause, University Press, 2011.
perhaps a biological one, may lay the groundwork Storr, Anthony, ed. The Essential Jung. Princeton, NJ:
for mental illness, but a precipitating cause is also Princeton University Press, 1983.
 K
Kenya a biological etiology such as marijuana abuse or
malaria for acute psychosis and schizophrenia,
Among the 42 tribes in Kenya, cultural beliefs as well as a supernatural etiology for schizophre-
about the etiology of mental illness vary widely nia, acute psychosis, and epilepsy. Furthermore,
and include the following: mental illness is caused this study indicated that participants frequently
by gods and evil spirits, individuals develop men- sought to understand why an illness occurred but
tal illness to atone for sins committed by their not how (e.g., the idea that because a bride price
clan against ancestors, and those who develop had not been not paid for a wife, the children
mental illness have been bewitched. However, were liable to suffer from mental illness).
because of cultural changes and increasing West- Public perception of the types of healers avail-
ernization, some suggest that such traditional able for those who experience mental illness
cultural beliefs are of declining importance, and include modern health care workers, religious
there is increasing acceptance of the medical healers, and traditional healers. Research indi-
model of mental disease. cates, however, that more individuals still believe
Mental health research in Kenya provides some in the superior ability of religious healers or tra-
data on the prevalence of psychiatric morbidity: ditional healers to treat mental illness. Research
In 1987, 44.8 percent of patients attending a pri- indicates that individual likelihood to first seek
mary care facility had a psychiatric presentation; in modern health services varies with the type of
1988, there was a 22 percent psychiatric morbidity psychological symptom. Individual reporting is
rate among inpatients admitted to medical wards highest for those seeking modern health services
in a hospital in Nairobi; and in 1991, there was for problems such as insomnia or convulsions
a 75 and 36 percent psychiatric morbidity rate, and somewhat less for excitement and “strange
respectively, among human immunodeficiency behavior.” However, for problems in which some-
virus (HIV)-positive and HIV-negative patients one seemed “possessed,” most individuals report
who presented to an outpatient clinic in Nairobi. that they would seek alternative healers first, and
A Kenyan study completed in 2007 indicated only 30 percent of people indicated they would
that participants identified issues such as poverty, seek treatment from a modern health worker.
major life events, social problems, and “think- Additionally, although many people report they
ing too much” as the causes for neurosis and would seek modern services first for some symp-
depression. Furthermore, respondents indicated toms, when pressed to elaborate further, they

437
438 Kleptomania

indicated that they would seek medication for with the World Federation for Schizophrenia
initial active symptoms and would later seek out and Allied Disorders. Another notable nongov-
an alternative treatment when symptoms sub- ernmental organization called Basic Needs has a
sided, both to aid in diagnosis and for more sub- pilot project in Nairobi and two in the Rift Val-
stantive treatment. ley province aimed at improving the provision of
Evaluation of Kenya’s mental health services psychiatric services.
indicate that the country’s system for provid-
ing mental health care is profoundly resource Erika Carr
restricted with respect to infrastructure, man- Memphis VA Medical Center
power, and finances. Reports in 2010 indicated
that Kenya has 23 psychiatrists in public service See Also: Cultural Prevalence; Primary Care;
and approximately 500 psychiatric nurses (of Religiously Based Therapies.
which only half work in mental health services),
breaking down to about one psychiatric nurse Further Readings
per district of 150,000 people. Furthermore, Jenkins, Rachel. “Integration of Mental Health Into
there are a total of 1,114 hospital beds for a pop- Primary Care and Community Health Working
ulation of over 38 million people. Estimates on in Kenya: Context, Rationale, Coverage, and
global prevalence of mental illness indicate that Sustainability.” Mental Health Family Medicine,
of 150,000 people, 1,500 individuals will have v.7 (2010).
psychosis and 15,000 people will have some type Kiima, David and Rachel Jenkins. “Mental Health
of mental illness; therefore, there is a great gap Policy in Kenya—An Integrated Approach to
between access to a psychiatric clinician and the Scaling Up Equitable Care for Poor Populations.”
levels of need in Kenya. Journal of Mental Health Systems, v.4 (2010).
Because of these mental health disparities, Kiima, David, Frank G. Njenga, Max M. O.
mental health care was identified as Kenya’s ninth Okonji, and Pius A. Kigamwa. “Kenya Mental
essential element of primary health care in 1982. Health Country Profile.” International Review of
Following this recommendation, mental health Psychiatry, v.16 (2004).
services have been integrated into the primary Muga, Florence A. and Rachel Jenkins. “Public
care setting at the district level, and community Perceptions, Explanatory Models, and Service
mental health services are provided alongside pri- Utilization Regarding Mental Illness and Mental
mary health care services. Because many people Health Care in Kenya.” Social Psychiatry and
are more likely to go to a primary health care Psychiatric Epidemiology, v.43 (2008).
provider than a mental health care setting, this
method of providing access is of particular impor-
tance. Traditional health practitioners have been
identified and have received training in the provi-
sion of mental health services, but they have not Kleptomania
received detailed training in diagnosis and treat-
ment, multiaxial assessment of mental illness, and Kleptomania is characterized by the fourth edi-
in-service training or supervision of mental health tion of the Diagnostic and Statistics Manual for
services. Though primary care staff diagnose and Mental Disorders (DSM-IV) as a recurrent fail-
treat individuals with psychosis, other disorders ure to resist impulses to steal objects that are not
such as anxiety and depression are rarely diag- needed for personal use or for their monetary
nosed or adequately treated because they may not value. Many of those diagnosed with this disor-
be as easily detected by a provider who does not der carelessly throw away or abandon the stolen
have more extensive training in mental health. objects, while other individuals may hoard them
There are groups emerging in Kenya with the compulsively into piles in their homes. Patients
goal of advocating for the public’s mental health generally describe an increasing sense of tension
needs. One group, called the Schizophrenia Fel- immediately before committing the theft, followed
lowship of Kenya, is growing and is associated by pleasure, gratification, or relief at the time of
 Kleptomania 439

Kleptomania is the recurrent failure to resist impulses to steal objects, but not for personal use or monetary value. Several wealthy
public figures have been arrested for shoplifting theft: Winona Ryder (left) was convicted in 2002 for a shoplifting spree in Saks Fifth
Avenue in Beverly Hills. In 2012, it was reported that Lindsay Lohan (right) had, over time, stolen items such as a friend’s Rolex, a mink
coat from a nightclub, and a $2,500 necklace from a jewelry store, as well as cash, four pairs of sunglasses, an iPod, and car keys.

committing the act. The stealing is not committed men. In a study by Marcus Goldman published in
to express feelings of anger or vengeance toward 1992, 70 to 80 percent of diagnosed cases of klep-
others and is not in response to a psychotic delu- tomania were documented in women. Kleptoma-
sion or hallucination. The stealing behavior is not nia is often diagnosed comorbidly with affective
better accounted for by a diagnosis of conduct disorders such as mood and anxiety disorders,
disorder, a manic episode, or antisocial person- eating disorders, and substance abuse disorders.
ality disorder. Within the current classification Silvio Presta and colleagues described some of
system, kleptomania is grouped with intermittent the difficulties in thoroughly characterizing this
explosive disorder, pyromania, pathological gam- diagnostic category. They note that individuals
bling, and trichotillomania. The course of klep- with this condition are generally unlikely to seek
tomania, as described in the DSM-IV-TR (text treatment because of the shameful nature of the
revision), is thought to follow one of three paths. symptoms. Thus, patients may not present to a
These courses include sporadic with long periods mental health professional unless he or she has
of remission, episodic with long periods of steal- been mandated to seek treatment by the courts
ing and remission, and chronic with some vari- after an arrest or has developed another psycho-
ability in the frequency of stealing behavior. logical condition for which treatment is sought
Kleptomania is thought to exist across the life­ (e.g., depression, anxiety, or substance abuse).
span; however, this disorder is most commonly Kleptomania was first characterized in the early
diagnosed after years of theft. Women are more 1800s. The disorder was given the name klope-
likely to be diagnosed with kleptomania than are manie by the Swiss physician Andre Matthey in
440 Kraepelin, Emil

1816. The name came from the Greek meaning behavioral strategies to assist patients in control-
“to steal” and “insanity.” Then, in 1838, Jean- ling their impulsive urges.
Etienne Esquirol and C. C. Marc modified the
term to kleptomanie and characterized the con- Katherine L. Applegate
dition as a set of involuntary and irresistible Duke University Medical Center
behaviors rather than moral deficiency. In 1896, Abigail Keys
the Frenchman Alexandre Lacassagne expanded Jay Trambadia
the description of this condition to include three Duke University
categories. These groupings included hoard-
ers who stole objects with no apparent need for See Also: Law and Mental Illness; Obsessive-
them, impulsive individuals who were unable to Compulsive Disorder; Women.
resist the urge to steal, and psychiatric patients
who displayed kleptomania as one symptom of a Further Readings
larger disorder. August Wimmer, in 1921, concep- Campbell, Duncan. “Winona Ryder Escapes Jail for
tualized the stealing behavior observed in klep- Theft.” The Guardian (December 6, 2002). http://
tomania as sexually motivated, suggesting that www.guardian.co.uk/world/2002/dec/07/usa.film
individuals experience intense orgasmic pleasure news (Accessed June 2013).
during the theft. Durst, R., G. Katz, A. Teitelbaum, J. Zislin, and P.
Later theorists provided less moralistic perspec- Dannon. “Kleptomania: Diagnosis and Treatment
tives on kleptomania. For example, Paul Eugen Options.” CNS Drugs, v.15 (2001).
Bleuler, in 1924, emphasized that individuals with Goldman, M. J. “Kleptomania: An Overview.”
this condition generally report distress associated Psychiatric Annals, v.22 (1992).
with their irresistible urge to steal. Also, clini- Grant, J. and D. Kim. “Kleptomania.” In Mental
cians made the observation that patients diag- Disorders of the New Millennium. T. Plante, ed.
nosed with kleptomania generally did not exhibit Westport, CT: Praeger, 2006.
immoral behaviors in any other area of their lives. Presta, S., D. Marazziti, L. Dell’Osso, C. Pfanner, S.
Rimona Durst and associates have suggested that Pallanti, and G. Cassano. “Kleptomania: Clinical
the repetitive intrusive thoughts associated with Features and Morbidity in an Italian Sample.”
kleptomania may indicate that this condition Comprehensive Psychiatry, v.43 (2002).
actually falls along the obsessive-compulsive dis- Sieczkowski, Cavan. “Lindsay Lohan $100,000
order spectrum. Patients with kleptomania gen- Jewelry Theft: A Timeline of the Actress’ Latest
erally understand that the stealing behavior is Legal Woe.” Huffington Post (August 28, 2012).
morally wrong and illegal. However, they appear http://www.huffingtonpost.com/2012/08/28/
unable to tolerate the impulse to steal without lindsay-lohan-jewelry-theft-100000-heist-sam
carrying out the behavior, despite the likely penal- -magid_n_1837654.html (Accessed June 2013).
ties associated with discovery of the theft. Thus,
it is believed that the primary motivation to com-
mit these acts is to relieve psychogenic tension
that the patients experience prior to the thievery.
Kleptomaniacs also generally conduct these acts Kraepelin, Emil
alone and report a reduction in tension and anxi-
ety afterward. Seen as the “father of modern psychiatry” by many
Therapeutic approaches to the treatment of in the mental health field, the German psychiatrist
kleptomania have greatly expanded in the past Emil Kraepelin (1856–1926) was the first to pro-
century, as noted and described by Rimona Durst duce a classification system of mental disease that
and colleagues. Although the condition was origi- could be used in daily practice. Between 1883 and
nally treated with psychodynamic techniques to 1927, his highly popular Lehrbuch der Psychiat-
expose the unconscious motivation for stealing, rie (Textbook of Psychiatry) went through nine
more recent interventions have focused on treat- editions, in the process isolating distinct forms
ments with psychotropic medication and cognitive of psychosis, including schizophrenia and manic
 Kraepelin, Emil 441

depression. Though his somatic approach to men- Kraepelin and his contemporaries as organic “dis-
tal pathology was eventually replaced for a time eases of the brain” involving real, discrete entities,
in American psychiatry by a system based on Sig- it was theorized that each mental disease could
mund Freud’s psychodynamic theory, Kraepelin’s be detected and properly defined through careful
conceptualization of different mental illnesses observation, recording, and analysis of the behav-
as discrete pathological entities has been highly ior of mental patients over time.
influential on the construction of recent editions
of the Diagnostic and Statistical Manual and Comprehensive Nosology
Mental Disorders (DSM). Following attempts by his contemporary, Karl
Trained in medicine and specializing in the areas Kahlbaum, Kraepelin recognized that psychiatry
of neuropathology and psychology at the univer- needed a comprehensive nosology—a classifica-
sities of Leipzig and Würzburg, Kraepelin was tion and descriptive system for disease—to inform
quick to note the chaotic state of contemporary and guide the profession. With a critical mass of
psychiatric knowledge on mental disease. Among information, psychiatrists would eventually be
his colleagues there were large disparities in their able to accurately define each mental disease, give
approaches to pathologies of the mind and a general the likely course of the illness, offer a prognosis,
lack of guiding principles to their work. Inspired and recommend appropriate treatment.
by the progress reported by internal medicine in During residencies in Munich and Heidel-
identifying pathologies of the body through the sci- berg, Germany, Kraepelin developed a zahlkarten
entific method of empirical observation, Kraepelin (numbered card) system through the meticulous
acknowledged that his profession similarly needed recording of the life histories and observed behav-
a knowledge base that could be acquired system- ior of patients in the asylum. The resulting index
atically and subsequently verified through scien- system involved over 1,000 patients, from which
tific measurement and testing. Conceptualized by Kraepelin performed his nosological identification
and separation by numbering and systematically
grouping the cards into different major groups
and subgroups of mental disease. On the basis of
this empirical work, he produced his Lehrbuch
der Psychiatrie, later recognized as the founda-
tional document of psychiatric nosology.
Subsequent editions revised and updated his
disease classifications and description of symp-
toms and eventually led the psychiatrist to dis-
tinguish between dementia praecox (later rela-
beled and reworked by the Swiss psychiatrist
Eugen Bleuler as schizophrenia), which Kraepelin
claimed involved cognitive or thought disorders,
and manic-depressive illness, seen as a disease
associated more with disorders in mood. This
separation became known as the Kraepelinian
dichotomy and continues to be debated within
psychiatry today.
Despite Kraepelin’s concern for scientific
rigor, his research was criticized for a lack of
independent measures of reliability, where other
researchers could analyze his zahlkarten system
to see whether they came to the same conclu-
Using the dominant scientific paradigm, Emil Kraepelin sions on the nature, symptoms, and course of dif-
(1856–1926) was the first to produce a classification system of ferent mental pathologies. Other commentators
mental disease that could be used in daily practice. were critical of Kraepelin’s overriding focus on
442 Kraepelin, Emil

individual symptoms in the establishment of dif- again on somatic lists of symptomologies—with

ferent pathologies, rather than on groups of symp- the publication of the DSM III, a document that
toms or the general course of the illness. Overall, has since been dubbed neo-Kraepelinian. Simi-
there was a concern that Kraepelin’s focus could lar to the development of Kraepelin’s Lehr­buch,
lead to “nosologomania,” the overdiagnosing of subsequent editions of the DSM have served to
people as having a mental illness. Critical schol- justify psychiatry’s continued expertise through
ars such as Gary Greenberg and Christopher Lane the language and practice of science, yet as criti-
have noted that Kraepelin was well known for his cal researchers such as Stuart Kirk and Herb
highly narrow view of normality and was prone Kutchins have demonstrated, the reliability of
to the swift pathologization of his patients. diagnostic classifications remains poor, leaving
A more sustained critique—one that contin- the continued validity of mental illness (and thus,
ues in the debate between somatic and dynamic psychiatry’s vocation) in doubt.
psychiatrists—is based on Kraepelin’s belief in Arguably, Kraepelin’s main achievement was
the biological etiology of mental disease. This to rescue the psychiatric profession from poten-
approach led him to fixate on symptomologies tial obscurity by utilizing the methods of science.
while ignoring any personal understandings of In the sociology of mental health, the continued
his patients. He also offered little in the way use of Kraepelin’s nosology demonstrates how
of a potential cure, and he eventually gave his the turn to the dominant scientific paradigm
support to the burgeoning eugenics movement, can successfully legitimate professional power,
deploring the “degeneration” of the German race knowledge, and practice within a branch of
that he believed was evidenced by the increased medicine.
prevalence of mental illness within German soci-
ety. His approach was eventually overshadowed Bruce Macfarlane Zarnovich Cohen
by Sigmund Freud’s dynamic psychiatry, which University of Auckland
theorized that all human mental states could
be placed on a neurosis-psychosis continuum. See Also: Biological Psychiatry; Dementia Praecox;
Freud’s experiential and empathetic approach Freud, Sigmund; Medicalization, History of; Neo-
offered a radical alternative to the determinism Kraepelinian Psychiatry.
of Kraepelin’s scientific psychiatry, as well as the
possibility of cure. Further Readings
Kraepelin’s ideas reemerged with the develop- Kirk, Stuart A. and Herb Kutchins. Making Us Crazy:
ment of psychopharmacology in the 1950s, once DSM: The Psychiatric Bible and the Creation of
it appeared that distinct forms of mental illness, Mental Disorders. New York: Free Press, 1997.
such as schizophrenia, could be effectively treated Kraepelin, Emil. Lectures on Clinical Psychiatry.
by specific chemical compounds. By 1980, the psy- London: Bailliere, Tindall & Cox, 1904.
chiatric profession had fully reinstated Kraepelin’s Shepherd, Michael. “Two Faces of Emil Kraepelin.”
notions of discrete disease entities—focused once British Journal of Psychiatry, v.167 (1995).
 L
Labeling Goffman also elaborates on individual behavior
but acknowledges how labels can be stigmatizing,
The labeling concept can be found rooted in ide- that is, discrediting to the individual in public situ-
ologies first established by Herbert Mead and ations. Goffman elaborates that stigma is a “deeply
Charles Cooley; Mead’s notion of the “general- discrediting attribute,” and that individuals can be
ized other” and Cooley’s notion of the “look- categorized into two groups: the discredited and
ing-glass self” both reflect the idea of others’ the discreditable; one that has a visible stigma, and
perceptions of individual behavior and appear- one that has an attribute that could be stigmatized
ance. Both also acknowledged that emotions and but takes great pains to hide such from the public.
self-appraisals were essential in forming identi- Stigma, for Goffman, has many effects on the
ties and that these were largely shaped by public individual, and building on these ideas, labeling
views and attitudes. Labeling builds on this by theory and empirical research within the field has
acknowledging public reactions and labels that focused on three main areas: societal reactions,
construct identity. Various individuals are associ- social and psychological consequences of receiv-
ated with labeling theory, most notably Howard ing a label, and the self-fulfilling prophecy. These
Becker with his work on “outsiders” and Erving tenets have informed a number of applications in
Goffman and his work on “stigma.” labeling theory, including the sociology of devi-
Becker outlines how individual behavior can be ance, mental illness, and education. More modern
constructed as deviant (or out of the norm), and conceptions of labeling have included a modified
this definition is then used to categorize individu- labeling approach and self-labeling.
als and provide social sanctions. For example,
Becker uses various groups to demonstrate the Tenets of Labeling Theory: Reaction,
effects of public labeling on individual behavior, Consequences, and Self-Fulfilling Prophecy
with his most infamous example being marijuana The first area of focus within labeling research
users. In his elaboration of all of these labeled and is on societal reactions to deviant behaviors; this
deviant groups, Becker also introduces the con- was largely because some sociologists, at the time,
cept of the moral entrepreneur, in which various were concerned with the social construction of
groups in society arrogate to themselves the task labels and deviant behavior. For example, Edwin
of categorizing individuals who do not meet the Lemert was one of the first to observe societal
moral code of society. reactions to children with stuttering problems

443
444 Labeling

and to people with schizophrenia. He was espe- and psychological consequences of being labeled
cially intrigued by the two means by which soci- and stigmatized. Research in this area is extensive
etal reaction occurred: informally and through and highlights how labeled individuals can often
formal agencies. Others have criticized Lemert suffer from increased depression and resentment,
for not being more empirical and operational in which can then lead to various forms of secondary
these definitions, and have also commented that deviance. Secondary deviance refers to the devi-
the association of Lemert to societal reactions is ant behaviors the individual engages in as a result
more of an honorary notation. Others have used of being labeled and stigmatized. This can lead to
his ideas and elaborated that societal reactions further stigmatization such as reduced social and
are key to experiencing stigma. employment opportunities.
Informal labels given by peers and the general However, researchers have also found that there
society can often defame and humiliate individ- can be increased access to opportunities, such as
uals who behave against the norm, which can in education. As a result of the short-term social
lead to the labeled individual’s feeling rejected and psychological consequences, researchers have
and worthless. On the other hand, societal reac- elaborated a third research area, that of the self-
tions can be positive, resulting in sympathy and fulfilling prophecy. Here, the long-term outcomes
a willingness to exempt labeled individuals from are elaborated, focusing on the decreased overall
their normal social roles. As a result, research has self-worth of individuals and lowered self-esteem.
probed into a secondary area, that of the social But like the previous two research areas, others
have argued that individuals can also gradually
come to view their label as a positive experience.
Both Becker and Goffman contributed in this area
by looking at the lifelong careers of criminal and
psychiatric patients.

Areas of Research
Lemert was one of the first to acknowledge devi-
ant behaviors and reactions to such; as a result,
labeling theory first emerged within the sociology
of deviance. Lemert elaborated on reactions once
acknowledged by Cooley, such as shame, fear, and
disgust, but also highlighted, much like Becker,
that these labels and reactions were socially con-
structed. Notions of primary and secondary devi-
ance emerged and were elaborated upon by Wal-
ter Gove. Gove was highly critical of the labeling
perspective, arguing that the effects of labeling
were exaggerated and that the pathological fea-
tures of the deviant were more important. Much
of the research in this area has centered on how
labels prompt secondary deviance to occur and
the social limitations that criminals face as a result
of receiving the official criminal label: reduced
employment opportunities, increased public stig-
matization, and increased recidivism.
Isaac, a 10-year-old boy with Down syndrome, uses a Vantage The mechanism by which labeling prompts this
Light communication device from Oklahoma’s Assistive secondary deviance is still unclear, but much of
Technology Act Program at the Mary K. Chapman Center in the literature points to the effect that internaliza-
Tulsa, Oklahoma, November 2011. Being able to communicate tion of labels has on an individual’s behavior, with
effectively helps the mentally disabled to deflect societal labels. the emphasis placed on social and psychological
 Lacan, Jacques 445

consequences. As labeling gained in popularity, mental health and education has focused on the
Thomas Scheff began to elaborate on its appli- effects that societal and more informal labeling
cation within the mental illness/health setting. agents have on individuals. For example, much
A staunch advocate for labeling effects, he con- like Link and his colleagues, Peggy Thoits argues it
tended that their impact provided a better expla- is also essential to understand how individuals can
nation of the origins of mental illness than the engage in self-labeling behavior. This refers to how
medical model proposed by psychiatrists. As a individuals will voluntarily commit to treatment,
result of their opposing views of labeling theory and Thoits argues that many in labeling theory
and its effects, Gove and Scheff entered into a have overlooked this component.
public debate that spanned multiple publications.
Ultimately, labeling theory took on a rather dif- Christina DeRoche
ferent form; Bruce Link and his colleagues devel- McMaster University
oped what they called modified labeling theory.
They argued that the individual’s reaction played See Also: Deviance; “Normal”: Definitions and
an integral role in the social and psychological Controversies; Public Education Campaigns;
effects of labeling activity. As a result of their Stereotypes; Stigma; Stigma: Patient’s View.
work, many conclude that the individual’s aware-
ness of the label, the public conceptions of such, Further Readings
and the individual’s subsequent self-perceptions Link, Bruce. G., Francis T. Cullen, Elmer Struening,
are all necessary in understanding the process of Patrick E. Shrout, and Bruce P. Dohrenwend. “A
labeling. Because of the popularity of labeling Modified Labeling Theory Approach to Mental
theory in deviance and mental health, research- Disorders: An Empirical Assessment.” American
ers became increasingly concerned with the label- Sociological Review, v.54/3 (1989).
ing occurring in educational settings for much the Link, Bruce. G. and J. C. Phelan. “Labeling and
same reasons: reactions, social and psychologi- Stigma.” In The Handbook of the Sociology of
cal consequences, and the self-fulfilling effects of Mental Health, C. S. Aneshensel and J. C. Phelan,
such. Ray Rist was one of the first to elaborate eds. New York: Springer, 1999.
on the application of labeling within educational Rist, Ray C. “On Understanding the Processes of
settings, outlining that children are segregated Schooling: The Contributions of Labeling Theory.”
according to levels of abilities and, as a result, can In Exploring Education: An Introduction to the
suffer a number of mental health consequences. Foundations of Education, A. R. Sadovnik, P. W.
As research has progressed in this area, many have Cookson, and S. F. Semel, eds. New York: Allyn
found that peer and teacher expectations of and and Bacon, 2001.
reactions to labeled children have a direct conse- Scheff, Thomas J. Being Mentally Ill: A Sociological
quence on their self-perceptions and self-esteem. Theory. Chicago: Aldine, 1966.
Wellford, Charles F. and Ruth A. Triplett. “The Future
Criticisms of and Future Work in of Labeling Theory: Foundations and Promises.”
Labeling Theory In Advances in Criminological Theory: New
Many have criticized labeling theory for its inabil- Directions in Criminological Theory, F. Adler, W.
ity to measure the perceived effects of labeling on Laufer, R. Clarke, and M. Felson, eds. Piscataway,
an individual’s self-concepts and perceptions. It has NJ: Transaction Publishers, 1990.
been difficult to differentiate between the effects of
primary and secondary deviance in labeling theory,
and it is also hard to operationalize and measure.
Gove was the first to elaborate on these problems,
and his objections have convinced many. Oth- Lacan, Jacques
ers, however, have continued to see merits in the
labeling approach. Much research has focused on Among the most controversial figures in his field,
formal labeling agencies in deviance and mental French psychoanalyst and psychiatrist Jacques
health literature. However, more research within Lacan (1901–81) continues to influence scholars
446 Lacan, Jacques

in numerous fields of study. In the development of reflection, the infant recognizes him or herself
his work, Lacan readily sought insight from fields to be a coherent, coordinated being for the first
such as structural linguistics, surrealism, biology, time. Further, infants view in this image of them-
anthropology, philosophy, and mathematics in selves what has been the object of their caregiver’s
addition to his specialty of psychiatry. One of his desire. Lacan’s assumptions regarding the mirror
most influential theories is also among his most stage developed into his conceptualization of the
challenging to understand: that of “the imaginary, imaginary, the symbolic, and the real.
the symbolic, and the real,” each of which rep-
resents some aspect (or lack thereof) of internal The Imaginary, the Symbolic, and the Real
psychological being. Lacan also spoke extensively Lacan’s concepts of the imaginary, the symbolic,
on the concept of desire, the object of which he and the real each represent some aspect of psy-
described as impossible to know. chological experience (and/or lack of experience).
Clinically, Lacan utilized sessions of variable Lacan believed the mirror stage to have played
length (versus the typical 50-minute session of a key role in the development of the imaginary,
classical psychoanalysis), believing that important which can roughly be described as one’s sense of
clinical material was more easily uncovered when self as a somewhat unique, coherent being in the
the client was interrupted at some key point. Over world, worthy of desire.
time, Lacan’s ideas took new, evolving forms, Following the development of the imaginary,
making his work that much more difficult to com- the symbolic begins to evolve. Following World
prehend. Further, Lacan’s ideas come largely from War II, much of his work involved an intense
accounts of his students and colleagues because rereading of Freud’s original works, in which
he produced very little published work. Nonethe- Lacan placed specific focus on Freud’s refer-
less, Lacan’s early work, in which he examined ences to the function of language. For example,
the case of a paranoid French woman, foreshad- Lacan believed that an understanding of others,
ows many of the concepts that he continued to the world, and the self is shaped in part by the
revisit throughout his career. language used. Lacan also believed that con-
Lacan began his studies in medicine and psy- sciousness and unconsciousness were structured
chiatry in the 1920s in Paris, where he became in a manner similar to language. That is, just as
acquainted with members of the surrealist move- words conjure different meanings when spoken
ment. These included influential figures such as alone versus spoken along with other words in
James Joyce, Salvador Dali, and Pablo Picasso. any number of potential sequences, so do experi-
For his thesis, Lacan examined the case of Aimée, ences of the internal self (e.g., a feeling leads to a
a woman who attempted to murder a Parisian memory, which leads to a sense, which leads to a
actress. Lacan wrote that the actress whom she particular thought).
attempted to murder represented the person who The third aspect of psychological experience
Aimée had hoped to be, her ideal image of her- described by Lacan was the real, which seem-
self. Lacan described Aimée’s persecutory ideas, ingly paradoxically refers to that which cannot be
which led to the attempted murder as a paranoid made conscious.
phenomenon by suggesting that Aimée’s attempt Lacan’s work is largely ignored in the field
to murder the actress actually represented an of psychiatry; however, an ongoing academic
attempt to hurt her (nonexistent) ideal self. The conversation about Lacan’s work and ideas
case of Aimée is a reflection of much of Lacan’s continues among philosophers. Lacan’s work
career, wherein he continued to focus on such has influenced the development of critical the-
concepts as the ideal and the development of ory, literary theory, sociology, feminist theory,
identity within a social context. and clinical psychoanalysis. Some have argued
Lacan’s description of the mirror stage also that his rejection by psychiatrists and others is
stands among his most important and lasting because of the somewhat obscure nature of his
contributions. Lacan described the infant as hav- ideas, such that it may be difficult for nonphi-
ing no sense of unique self until viewing a reflec- losophers to fully understand. Some have sug-
tion of him- or herself (e.g., in a mirror). In that gested that this obscurity may in part be because
 Laing, Ronald David 447

of the fact that much of what is written about fundamental assumption that mental illness had
Lacan’s ideas come from others’ accounts of his biological causes. Instead, he shifted the focus to
lectures and/or conversations. Further, it is dif- social, cultural, and particularly family influences,
ficult to interpret discrepancies in his work with- suggesting that mental illness develops as a result
out knowing whether they represent an organic of difficult social interactions. He also challenged
change in thought or simply the perceptions of the validity of psychiatric diagnosis and its related
whoever wrote those specific accounts. Finally, therapies. Laing argued that there was a logical
an understanding of Lacan’s ideas requires the disconnect between an illness diagnosed on the
understanding of a complex Lacanian vocabu- basis of behavior and conduct but then treated
lary. Thus, although his work was meant to pro- with drugs. He instead advocated drug-free psy-
vide clinicians with a framework from which to chotherapy, arguing that drugs hindered the abil-
understand the individual, it lingers primarily ity to think and develop insight, thereby interfer-
in the realm of philosophy, in some other areas ing with the recovery process. Laing developed
of the humanities, and among a much smaller what he termed an existential-phenomenological
group of sociologists and social scientists. foundation for a science of persons. Laing’s writ-
ings attempted to make “madness” intelligible to
Hope Brasfield lay audiences and thus played a crucial role in the
Heather Zucosky popularizing of psychology.
Sarah Mauck Laing was influenced by phenomenological and
Gregory L. Stuart existential philosophies, which focused on mean-
University of Tennessee, Knoxville ing making, subjective individual experience, and
the notion of authenticity (i.e., being true to one-
See Also: Clinical Psychology; Critical Theory; self). The self is developed through experience
Identity; Interpersonal Dynamics; Psychoanalysis, and in relation to others. Individuals’ actions
History and Sociology of; Psychoanalytic Treatment. either conceal or disclose the self, thus the exis-
tential analysis of action can serve as a means to
Further Readings understand another. Laing introduced the notion
Bailly, L. Lacan: A Beginner’s Guide. Oxford, UK: of ontological security to describe the sense of
Oneworld Publications, 2009. existing for others, who also exist for us. This
Lacan, J. Ecrits: The First Complete Edition in facilitates authentic self-disclosure whereas onto-
English. New York: W. W. Norton, 1966. logical insecurity can generate a false self, which
Payne, M. Reading Theory: An Introduction to over time becomes detached from the real self.
Lacan, Derrida, and Kristeva. Cambridge, MA: Laing’s views were also heavily influenced by
Blackwell, 1993. the work of anthropologists such as Gregory
Žižek, S. Looking Awry: An Introduction to Jacques Bateson, who had put forward a theory of the
Lacan Through Popular Culture. Cambridge, MA: double bind. This involves the receipt of two or
MIT Press, 1991. more conflicting messages, creating a situation
where it is impossible to respond successfully to
both. This is compounded because the situation
is unavoidable, that is, the individual can neither
resolve it nor opt out. This leads to a lose-lose
Laing, Ronald David situation, which can generate immense psycho-
logical distress. Laing expanded the notion of
Laing was a British psychiatrist who challenged the double bind into the “incompatible knot”
the psychiatric orthodoxy of his day. Although to acknowledge the inextricable complexity and
associated with the antipsychiatry movement, he inescapability of certain situations.
rejected this label, having never denied either the In Laing’s view, the family acts as the primary
existence of mental illness or the value in treat- instrument that fashions the developing self. It
ing it. However, he challenged the core values of also constitutes an ongoing relationship to which
psychiatry, rejecting the medical model with its individuals are committed and from which they
448 Law and Mental Illness

cannot easily escape. Laing put forward the of responsibility is thus placed on the therapist in
notion of a family nexus, a common viewpoint, terms of effortful engagement and the maintenance
of both the family and the external world, which of active listening, conducted in a spirit of empa-
is held and reinforced by family members. Fam- thy and openness. Laing’s desire to place value on
ily members will, individually and collectively, psychotic behavior and speech was revolutionary
have vested interests in maintaining this com- and required a more humane engagement with
mon viewpoint and will seek to oppress and the mentally ill than had previously been seen. To
exclude conflicting viewpoints. The family nexus facilitate this, Laing cofounded the Philadelphia
can therefore become a mechanism for persecut- Association, which established a therapeutic com-
ing an individual who holds other views. Lack- munity at Kingsley Hall, London. This operated
ing the power to challenge the common view can on less confrontational principles than those seen
generate profound and lasting distress, particu- in other psychiatric settings, intending to allow
larly when the individual in conflict is a vulner- the mentally ill to live free from unwanted inter-
able child. In Laing’s view, psychotic episodes ference and offer real asylum.
can be seen as a crisis in experience of the family Although many of Laing’s specific ideas have
nexus. However, Laing did not intend to blame been discredited, his work has had a lasting
the family for an individual’s mental illness. The impact, particularly in family therapy, which con-
impossible position created for an individual by siders the system of interactions between family
the family nexus is by definition unperceivable to members as crucial for mental health. The Phila-
other family members. Mental illness constitutes delphia Association also continues its work, with
a possible outcome of a problematic organization Kingsley Hall merely the first of 20 therapeutic
of the nexus rather than inevitability. communities.
Laing felt that psychiatry incorrectly stigma-
tizes mental illness as something that is wrong Vivienne Brunsden
and requires fixing. While this may at face value Nottingham Trent University
be understandable because mental illness does not
conform to social norms, Laing suggested that the See Also: Anthropology; Antipsychiatry; Asylums;
acceptance of particular social norms as appro- Family Support.
priate (e.g., those within the family nexus) might
need reconsideration. Rather than stigmatize Further Readings
mental illness, Laing suggested that mental illness Laing, R. D. The Divided Self: An Existential Study
should be viewed as a cathartic and transforma- in Sanity and Madness. Harmondsworth, UK:
tive experience that carries the potential to lead to Penguin, 1960.
personal insights. The feelings expressed during Laing, R. D. and A. Esterson. Sanity, Madness and the
episodes of mental illness should not be treated Family. London: Tavistock, 1964.
merely as symptoms of an underlying or separate Szasz, T. Insanity: The Idea and Its Consequences.
disorder but instead as valid descriptions arising New York: John Wiley & Sons, 1987.
from lived experiences.
Mental illness can therefore be seen both as an
expression of distress and as an attempt to return
to a healthy natural state. Psychotic episodes
can be viewed as efforts to communicate and to Law and Mental Illness
express a valid and understandable distress. Laing
acknowledged that these communicative efforts Mental health law has struggled to establish a
can be difficult for others to comprehend. This is consistent set of legal principles satisfactory to
because they use a language wrapped in personal both legal experts and medical professionals.
symbolism that is meaningful only from within. While substantial progress has been made, con-
For those external to the symbolic system, a seri- sistency is still an elusive goal because the law
ous effort to understand is needed if they wish to is built around different and sometimes clash-
effectively interpret these expressions. A burden ing definitions of mental illness, which has been
 Law and Mental Illness 449

described variously as insanity, disease, or dis- not distinguish between right and wrong behav-
ability. The development of these ideas and their iors. While antecedents of the definition can be
ramifications can be traced throughout history; found in early modern legal writings and decision
in some areas today, mental health law remains a making, its formal explication and application is
hodgepodge of ideas rather than a consistent set traced to the 1840s.
of principles. Mental health courts may provide a The British case In re M’Naghten (1843) is the
forum through which the differences in philoso- landmark decision establishing a legal definition
phy can be reconciled. for insanity. Criminal law must be understood
within the framework of classical criminology,
Laws Prior to the Nineteenth Century which regarded the wrongdoer as a rational being
The courts had no consistent guidelines for han- who chose to commit an offense. Mental illness
dling mentally ill persons prior to the 1840s. Some presented a problem for courts inasmuch as the
individuals benefited from compassionate treat- offender’s behavior could not be considered inten-
ment under the law. Care for the mentally ill was tional because impaired cognition or poor emo-
primarily the responsibility of family members or tion management had clouded the accused’s judg-
the immediate community, and if necessary the ment. The M’Naghten (or MacNaughton) Rule
doctrine of parens patriae permitted the interven- defined legal insanity in terms of one’s inability
tion of the monarch or government if other help to know or cognitively understand the implica-
was not forthcoming. At times, jurists recognized tions of one’s actions, and some jurisdictions later
the inequity of punishing people whose actions accepted an expansion of the concept of legal
were driven by “madness” and might release a insanity to recognize that irresistible, emotional
guilty party if a disorder created a mitigating cir- impulses could override cognition.
cumstance. English common law included a prec- In re Oakes (1845) applied a legal concep-
edent that the accused should be mentally compe- tion of insanity to involuntary civil commitment.
tent to stand trial. Here the concept was not about the cause of past
Others were subjected to harsh or cruel treat- actions, as was the case in criminal law, but a con-
ment. As modernization unraveled interpersonal cern about future actions where the insane person
mechanisms of social assistance, governments might be dangerous to oneself and others. Con-
started in the 16th century to use their powers siderable discretion was also granted to medical
of intervention to treat the mentally ill as soci- professionals to determine the need and type of
etal pariahs deserving institutionalization just like treatment on the grounds that the mentally ill per-
criminals and the poor. Even when the presence of son was incapable of using one’s own judgment.
a disorder was recognized, a judge might sentence One area in which the formal implementation
a mentally ill person to imprisonment if a reason- of the insanity concept was delayed regarded the
able alternative were not readily available, and issue of whether a mentally ill person was com-
popular superstitions in the Middle Ages could petent to stand trial. This lack of progress may
even lead to charging the mentally ill with prac- have reflected the willingness of courts to accept
ticing witchcraft. the common-law tradition. Competency to stand
trial was finally established as a constitutional
Mental Illness as Insanity doctrine on the appellate level in Youtsey v.
During the 19th century, the law began to develop United States (1899), though the U.S. Supreme
consistent standards for handling mentally ill Court did not rule definitely on the matter until
defendants and may have actually moved faster Dusky v. United States (1960).
than the medical community in shedding the These early criminal and civil applications of
unwarranted stereotypes of the past. While the the concept of insanity shared a lack of precision.
medical community accepted the cruel condi- Criminal courts were caught in debates trying to
tions of the asylum as a best practice, the judicial determine the accused’s state of mind. Although
system concluded that the mentally ill had to be the notion of intent implies understanding of a
handled differently and created a legal definition person’s state of mind, state of mind is normally
of insanity to deal with individuals who could established by examining objective behaviors
450 Law and Mental Illness

indicating purposiveness; the insanity defense’s surrogates for prisons. Starting with Rouse v.
requirements to establish what a person knew Cameron (1966), the Supreme Court forwarded a
or felt were too difficult to achieve objectively. new position in which the denial of medical treat-
Civil proceedings, which did not require proof ment, including psychiatric treatment, violated
of mental incapacity beyond a reasonable doubt, the Eighth Amendment prohibition against “cruel
resulted in the commitment of many people who and unusual punishment.”
did not require it. The medicalization of mental Parallel to the development of the right to
illness provided the opportunity to correct these treatment was the insistence that individuals be
deficits in the justice system. served in the least restrictive environment. The
concept has its origins in a series of legal deci-
Mental Illness as a Disease sions during the 1960s and 1970s, rulings that
The rise of psychiatry resulted in an understanding reflected the confidence of courts in the use of
of mental illness couched in medical and scientific psychotropic drugs and the development of out-
language and raised the promise of objective stan- patient treatment programs under the auspices of
dards for disorders under the law. The mentally ill the Community Health Act of 1963. These deci-
person was now conceived as a patient who could sions hastened the pace of deinstitutionalization;
be treated with medication. The results of this for example, a medical professional could not
philosophical change were obvious: admissions consign a patient to a psychiatric hospital if the
to psychiatric hospitals declined as more mentally person could live safely in the community while
ill individuals were released into the community taking prescribed medication.
with the hope that prescribed drugs would enable Patient confidentiality was established along
the normalization of their behaviors. two lines. The first was the confidentiality of
Labeling mental illness as a disease resulted in therapist-patient communication. All states came
major shifts in legal decision making in two ways. to recognize this privilege in some form, and the
First, on the matter of declaring a person to be argument for it is rooted in common sense: a
insane, the court now deferred to the opinion of person cannot be expected to seek mental health
mental health professionals because of the latter’s treatment if there is no guarantee that conversa-
expertise in diagnosis and treatment. The legal tions will be held in confidence. Second, the pri-
foundations for the medicalization of the insan- vacy of patient records was granted under the
ity defense were established through Durham v. Health Insurance Portability and Accountability
United States (1954) and the American Law Insti- Act (HIPAA). While mental health confidentiality
tute’s issuance of the Model Penal Code in 1962. policies now have the support of the courts, they
With regard to civil commitment, states intro- are not absolute. The confidentiality of therapist-
duced changes to make the process easier based patient communication is owned by the patient,
on certification of psychiatric need. not the therapist, making the privilege very differ-
At the same time, the discretionary power ent from religious confessions, where the privilege
of medical professionals was circumscribed by is owned by the priest. However, confidentiality
new patient rights such as the right to treatment, can be overridden by a “duty to warn” if there
the requirement that care by offered in the least is a belief that the patient may put someone in
restrictive environment, and the establishment imminent danger. (A similar standard also applies
of patient confidentiality. All of these rights were to attorney-client privilege in criminal cases.)
extensions of ideas put in place in the medical Since the rise of disease as an image of men-
arena and extended to cover mental health issues. tal illness, some changes brought about by medi-
The right to treatment established the obligation calization have been reversed, particularly with
of the state to ensure the granting of medically regard to the definitions of insanity. Judges found
necessary procedures, including care for men- the scientific details too technical and resisted the
tal disorders. The initial concern was that the incursion of medical professionals in their decision
ordering of medical confinement did not guar- making, especially after it became apparent that
antee that the person would receive therapeutic professionals could legitimately disagree about an
treatment, thus turning psychiatric hospitals into individual’s diagnosis and treatment. Moreover,
 Law and Mental Illness 451

U.S. Representative Carolyn McCarthy (D-New York) introduces a bill to ban high-capacity ammunition magazines for guns, January
18, 2011, in Washington, D.C. In 1993, McCarthy’s husband was killed and her son seriously wounded on the Long Island Railroad
by a gunman she refers to as “a madman.” Other gun-control measures related to mental health are also controversial, such as
background checks to screen for mental illness, which would require violating patient confidentiality under HIPAA laws.

in criminal cases, society’s demand for retribution was expanded to apply to educational institutions
was not satisfied when mental illness resulted in a in their support of special education and disabled
less severe sentence. In criminal law, the setback students through the passage of the Individuals
became apparent after John Hinckley’s successful with Disabilities Education Act (IDEA) in 1990.
insanity defense in his trial the attempted assas- In the same year, the passage of the Americans
sination of Ronald Reagan; many states rolled with Disabilities Act (ADA) in 1990 enshrined
back medical definitions of criminal insanity and this perspective through prohibitions against dis-
reverted to the M’Naghten and irresistible impulse crimination and demanded “reasonable accom-
standards of an earlier era. modation” when mental illness did not interfere
with major components of a job, such as atten-
Mental Illness as a Disability dance, punctuality, interaction with others, and
The designation of mental illness as a disability performance.
marks a distinct change in perspectives on mental Concomitant to legislative action was the
health. Rather than focusing on the shortcomings development of the doctrine of informed consent,
of the mentally ill, as is the case with the con- established in the mental health arena through
cepts of insanity and disease, the disability per- Zinermon v. Burch (1990). Informed consent
spective places the onus on society at large to finalized a shift in decision-making authority from
limit discrimination and remove barriers causing the doctor or psychiatrist to the patient. Previ-
exclusion. This new set of rights is about placing ously, medical professions provided patients with
the mentally ill person within the societal main- a minimum of information about a procedure
stream, not the conditions under which the per- because professionals had the discretionary power
son may be contained. to assess medical necessity and the risks of treat-
Two pieces of federal legislation signed in 1990 ment. The doctrine of informed consent required
elevated the status of the disability perspective. that the mentally ill be given proper information
The concept of least restrictive environment, ini- to make decisions about their own mental health
tially seen as an extension of the right to treatment, care, thus undermining professional discretion.
452 Law and Mental Illness

Current State of Affairs public employees even when they have failed to
The ideas of insanity, disease, and disability follow the advice of mental health professionals.
accompany the demise of the cruel treatment to Mental health courts offer a promising avenue
which the mentally ill were once subject. All of to reconcile differences. Now about 350 in num-
the perspectives insist that mental illness creates ber across the United States, they create situations
a special situation under the law and that the in which mental health professionals work as part
routine ways to handle problematic and criminal of the courtroom work groups. When success-
behavior do not apply when mental health is a fully implemented, the arrangement has fostered
mitigating factor. However, much work remains circumstances in which judges and lawyers have
to craft a set of consistent policies. more understanding of how the medical commu-
Several situations illustrate the way in which nity, social workers, and counselors form their
the different understandings of mental health opinions. At the same time, mental health pro-
clash. Even though mental health professionals fessionals gain insight into the logic of the legal
must give their patients adequate knowledge of processes.
the treatments they can receive so they can choose
to accept or refuse those treatments, informed Richard L. Rogers
consent is undermined in cases of serious mental Youngstown State University
illness because the individual may not have the
capacity to understand the situation. The right See Also: Commitment Laws; Competency and
to treatment has a corollary—the right to refuse Credibility; Compulsory Treatment; Courts;
treatment—but how a person whose judgment is Deinstitutionalization; Human Rights; Informed
clouded can refuse treatment becomes a compli- Consent; Insanity Defense; Medicalization, History
cated question that the courts have not resolved. of; Mental Institutions, History of; Therapeutics,
Courts also have been inconsistent with regard to History of; Voluntary Commitment.
whether there is a duty to warn because predicting
behavior is difficult, and sometimes people just Further Readings
“snap.” The current gun-control debate also illus- Bucky, Steven F., Joanne E. Callan, and George
trates the problem: thorough background checks Sticker. Ethical and Legal Issues for Mental
screening for mental illness would require violat- Health Professionals. Binghamton, NY: Haworth
ing patient confidentiality under HIPAA laws. Maltreatment and Trauma Press, 2005.
The roots of the problem are different expecta- Durham v. United States, 214 F. 2d 852 (1954).
tions of the courts and mental health profession- Dusky v. United States, 362 US 402 (1960).
als with regard to the imprecision of mental health Marty, Douglas A. and Rosemary Chapin. “Ethics in
diagnosis and treatment. Courts want to establish Community Mental Health Care: The Legislative
legal principles applicable to all cases. However, Tenets of Client’s Right to Treatment in the Least
this logic does not work well with the realities of Restrictive Environment and Freedom From
the mental health arena: how to handle the diag- Harm: Implications for Community Providers.”
nosis and treatment of an individual can vary from Community Mental Health Journal, v.36 (2000).
one mental health professional to the next, and Melton, Gary B., John Petrila, Norman G. Poythress,
the determination of whether a person will turn and Christopher Slobogin. Psychological
dangerous is a question of statistical probability, Evaluations for the Courts: A Handbook for
not objective certainty. To deal with these fluid Mental Health Professionals and Lawyers. 3rd ed.
situations, mental health professionals operate New York: Guilford Press, 2007.
under the assumption that the doctor or therapist Meyer, Robert G. and Christopher M. Weaver. Law
is allowed to utilize discretion to create a custom- and Mental Health: A Case-Based Approach. New
ized response suitable to the patient. The courts, York: Guilford Press, 2006.
viewing cases with the wisdom of hindsight, have Milner, Neal. “Models of Rationality and Mental
shown little recognition of this professional dis- Health Rights.” International Journal of Law and
cretion, though ironically the courts have granted Psychiatry, v.4 (1981).
qualified immunity to law enforcement officials as Rouse v. Cameron, 383 F. 2d 451, D.C. Cir. (1966).
 Lay Conception of Illness 453

Schultz, Elizabeth G. “Sell-ing Your Soul to the those of the body. At the end of the 18th century,
Courts: Forced Medication to Achieve Trial Rene Descartes’ theory of mind-body dualism—
Competency in the Wake of Sell v. United States.” the idea that the mind and the body are sepa-
Akron Law Review, v.38 (2005). rate—heavily influenced individuals in the health
Youtsey v. United States, 97 F 937, 6th Cir. (1899). care professions who then endorsed the idea that
Zinermon v. Burch, 494 U.S. 113 (1990). these entities produced discrete diseases. Such a
distinction still exists today in most cultures and
perpetuates the belief that mental illness is distinct
from physical illness. This may be explained by
the fact that some forms of illness are manifested
Lay Conception of Illness as physical lesions or symptoms, while psycho-
logical manifestations of illness may be less easily
Cultural definitions of normality in a given soci- recognized. Although some mental health profes-
ety directly influence that society’s perception of sionals believe in the interaction between mind
what constitutes an illness. Controversies arise and body, stigma experienced by individuals with
when seeking a uniform definition of normal- mental versus physical illness may be informed by
ity both within and across cultural delineations. mind-body dualism, suggesting that individuals
Cultural standards are important as they influ- have greater ability to control mental over physi-
ence the extent to which someone assumes an cal distress.
internal or external source of control over illness, Mental health has received increased attention,
perceptions of certain treatments, and the way as neuropsychiatric disorders are the leading cause
in which individuals are expected to cope with of disability in the United States and Canada. The
psychological or physical distress. Lay concep- World Health Organization reports that, among
tion of illness—the manner in which the general the neuropsychiatric disorders, unipolar depres-
public perceives the development and severity of sion diagnoses account for more than one-third
different forms of illness—has enormous implica- of disability. Neuropsychiatric disorders include
tions for the management of disorders. Although alcohol use disorders, Alzheimer’s and dementia,
health care providers commonly adhere to estab- drug use disorders, schizophrenia, and bipolar
lished criteria in defining diseases or disorders, disorder, among others. The National Alliance on
the public’s conception of illness is influenced by Mental Illness reports that mental illness results
philosophical theories, popular media, and values in $100 billion in lost productivity in the United
inherent in personal belief systems. States annually. Such losses have led to changes in
insurance coverage, with many states calling for
Mental Illness health packages that provide greater coverage for
Controversies exist regarding how to define men- mental illness similar to that provided for physi-
tal illness. There is debate as to whether mental cal diseases.
health professionals are simply treating normal
variations in human behavior as illness or treat- Cultural Stigma
ing human behaviors that fall outside the bounds Stigma remains a crucial deterrent to help-seeking
of normal variation. Normality in mental health behavior of individuals with mental illness. To
suggests that an individual does not vary much help reduce stigma, many pharmaceutical com-
from certain biological and behavioral standards. panies and health care providers have advertised
Illness is diagnosed as deviations from these bio- major depressive disorder (MDD) as a chemical
logical and behavioral norms. In other words, imbalance to be remedied by the use of antide-
many forms of illness are diagnosed when an indi- pressants, including selective serotonin reuptake
vidual is unable to function in his or her society. inhibitors (SSRIs). These campaigns suggest
Controversies regarding definitions of illness are that the cause of mental illness is biological and
exacerbated by the fact that, within a broader cat- therefore caused by factors outside one’s control.
egory of illness, ailments have traditionally been Though many companies have advertised this
divided into two categories: those of the mind and model in campaigns marketing SSRIs, there is no
454 Lay Conception of Illness

direct evidence supporting the hypothesis that Disorders (DSM) included homosexuality as a
depression is solely due to low levels of the neu- sexually deviant behavior as opposed to a nor-
rotransmitter serotonin. A study conducted by mal variation in human sexuality. In conjunction
Jason Schnittker demonstrated that the percent- with changing perspectives, gay rights activism,
age of individuals who believed a chemical imbal- and research findings in psychiatry and psychol-
ance was the likely cause for MDD rose from ogy, the next edition of the DSM removed homo-
73 percent in 1996 to 85 percent in 2006. Thus, sexuality as a disorder. Thus, criteria evolve with
media may be contributing to shifts in public per- changing cultural perspectives. Another example
ceptions of mental illness etiology. is demonstrated in changes in the DSM-5 criteria
While a biological conceptualization of the eti- for depression. Criteria in the previous edition
ology of mental disorders decreases stigma about (the DSM-IV) for diagnosing MDD include an
the development of the disorder and perhaps leads exception for bereavement, which allows symp-
to increases in help-seeking behaviors, it also toms characteristic of depression to persist for
decreases one’s belief in self-efficacy for recovery. two months after the death of a loved one. The
If one believes that MDD is caused by a chemi- DSM-5 has removed the bereavement exception,
cal imbalance, this individual may seek medicinal, which may classify the normal grieving process for
as opposed to psychotherapeutic, forms of treat- some individuals as MDD. The drastic variations
ment. Although experts in the mental health field in expressions of grief cross-culturally have stimu-
endorse a biopsychosocial paradigm of mental lated debate as to whether these cultural devia-
illness while seeking to destigmatize the devel- tions may result in the misdiagnosis of MDD.
opment and treatment of a disorder, the public’s Defining normal behavior is a complex and
conception of mental illness contributes to the continually evolving process. Although concep-
popularity of certain treatments. tions of illness might derive from both dominant
and nondominant cultural perspectives, within
Epidemiology Across Culture and Time the current system, the dominant culture seems to
Expression of mental illness varies on an individ- strongly inform how we characterize illness. Inte-
ual basis, with variation occurring among larger gration of the nondominant perspective may then
cultural groups as well. For example, individuals prevent under- or overdiagnosis of simple varia-
from collectivistic cultures—which emphasize the tions in biological and psychological functioning.
well-being of the whole over the individual—may
experience psychological distress as a lack of Maribel Plasencia
social acceptance or connectedness. Conversely, Lindsay Labrecque
those belonging to individualistic cultures—which Andrew Ninnemann
emphasize the individual over the whole—may Brown University
experience distress as loneliness and guilt. Fur- Gregory L. Stuart
thermore, many studies demonstrate that ethnic University of Tennessee, Knoxville
minorities report more bodily symptoms result-
ing from distress. This may be partially explained See Also: Mass Media; Medicalization, Sociology
by the notion that these groups believe less in the of; Mental Illness Defined: Historical Perspectives;
duality of the mind and the body than major- Mental Illness Defined: Psychiatric Perspectives;
ity groups. Certain pathological manifestations, Mental Illness Defined: Sociological Perspectives;
therefore, are culture bound. For example, ataque Mind–Body Relationship; “Normal”: Definitions and
de nervios (ADN) is a dysphoric state that occurs Controversies; Popular Conceptions; Stigma.
after trauma and is only reported by individuals
from Hispanic cultures. Further Readings
The criteria for a given mental illness may Deacon, Brett J. and James J. Lickel. “On the Brain
change over time to exclude certain behaviors Disease Model of Mental Disorders.” Behavior
once conceptualized as deviant or dysfunctional. Therapist, v.32/6 (2009).
Prior to 1973, the American Psychiatric Associa- Draguns, Juris G. and Junko Tanaka-Matsumi.
tion’s Diagnostic and Statistical Manual of Mental “Assessment of Psychopathology Across and
 Learning Disorders 455

Within Cultures: Issues and Findings.” Behaviour difficulties or impairments, including such things
Research and Therapy, v.41/7 (2003). as reading disabilities (RD), dyslexia, dyscalculia,
Kendell, Robert. E. “The Distinction Between Mental and dysgraphia. The term also includes develop-
and Physical Illness.” British Journal of Psychiatry, mental disabilities (DD) such as autism spectrum
v.178/6 (2001). disorders (ASD), intellectual disabilities (ID),
developmental coordination disorder (DCD), and
attention deficit hyperactivity disorder (ADHD).
All of these disorders are seen as congenital and
genetically influenced to some degree.
Learning Disorders Learning disorders are often misinterpreted
as learning disabilities (LD) when LD is a sub-
Learning disorders consist of neurobiologi- type of learning disorder. The most widely rec-
cal delays or discrepancies and affect individu- ognized and used definition of learning disability
als’ cognition and brain functioning. Within the originates from the Individuals with Disabilities
broad array and variety of learning disorders, Education Act (IDEA). It lays out two main ideas:
these discrepancies can impact the mental health Children with a specific learning disability expe-
functioning of children and adults. Because of rience some sort of deficit or disorder in one or
increased scientific and empirical research and the more of the basic psychological processes under-
growing awareness of labels, the types of learn- standing language (this does not include learning
ing disorders are abundant. However, despite disorders that are the result of cognitive impair-
the issues in diagnosing and measuring learn- ment such as in intellectual disabilities). The sec-
ing disorders, difficulties of this sort are a global ond component operationalizes what this deficit
phenomenon; various cultures report issues with must consist of by examining achievement scores
learning in all populations. Learning disorders and age-appropriate learning experiences. What
are generally diagnosed by assessing not only the is common among all these definitions are central
cognitive abilities of children but also include the nervous system dysfunction, discrepancy in psy-
social environment and psychological functioning chological and biological maturity, difficulty with
of each child. academic and learning tasks, and discrepancy
There are two prevailing theories of why learn- between achievement and the child’s potential.
ing disorders develop, each consisting of three Within this learning disorder type, a variety of
levels of analysis: the distal causes of the disor- learning disability subtypes are postulated: RD,
der, or etiology; brain development, or neuropsy- dyslexia, math disabilities, oral language disabili-
chology; and last, behavior of the child. In one ties, written language difficulties, and nonverbal
theory, learning disorders are thought to develop learning disabilities. Among this vast array of
unidirectionally, that is, some genetic factor (etiol- learning disability subtypes, students also vary
ogy) predisposes to impaired brain development, in the types of symptoms they display. Approxi-
which in turns affects neuropsychological func- mately one in 30 children in the United States has
tioning and manifests in behaviors detectable by been defined as having a learning disability. In
teachers, parents, and peers. The second model of Canada, recent figures from the Participation and
origins hypothesizes a bidirectional system, which Activity Limitation Survey (PALS) have shown
acknowledges that not just faulty neurophysiol- that approximately 3.2 percent of children have
ogy but also aspects of the social environment can a learning disability, and this broad category is
lead to impaired brain development. Others have one of the fastest-growing types of disabilities in
argued that providing the label of “learning disor- Canada that is not related to aging.
der” can open up social opportunities or make the The next type of learning disorder category
child’s situation considerably more difficult. concerns problems in language development.
These include dyslexia, speech sound disorders,
Definition, Types, and Prevalence and language impairments that encompass a
Learning disorders are not learning disabilities large spectrum of subtypes. Common subtypes
but are instead a broad spectrum of learning include apraxia of speech, dysarthria, orofacial
456 Learning Disorders

myofunctional disorders, speech sound disor- Attention deficit hyperactivity disorder

ders, stuttering, voice disorders, language-based (ADHD) can be defined in two distinct but related
LD, selective mutism, and preschool language ways: being forgetful, having difficulty in being
disorders. Children with these types of disorders organized with daily tasks, or even failure to
have difficulty with word recognition, fluency, complete tasks, while others can be interruptive
and accuracy; but definitions (like those of read- of conversations and impulsive. These symptoms,
ing disabilities) encompass two parts: a diagnos- among others, describe the two different subtypes
tic threshold and a list of exclusionary criteria. of individuals with ADHD. In addition to these,
These difficulties must be significantly lower than individuals must also display a significant impair-
the child’s age-appropriate IQ level. Often, these ment in adaptive functioning, have these symp-
disorders are comorbid with other intellectual toms for at least six months, and display inconsis-
disabilities, but they are also more prevalent in tent levels of functioning in comparison to their
males. Prevalence of speech and language disor- normal-developing peers, and cannot be explained
ders is estimated at around 5 to 8 percent of the by another comorbid or underlying unidentified
child population. Again, prevalence rates range, disorder. ADHD is one of the most diagnosed
depending on the population measured. Some disorders of childhood, with a prevalence rate of
have argued that definitions of some forms of approximately 3 to 5 percent of school-aged chil-
dyslexia can be eliminated because of such vari- dren. This prevalence depends on the definition
ability and complexity in diagnosis, but others used. The age of onset, or of diagnosis, can be as
have argued that they have distinctive symptoms early as 3 or 4. ADHD has attracted considerable
and etiology; thus, it remains a valid and recog- controversy, both as a diagnostic entity and over
nized disorder. the drug treatments prescribed for children with
Autism spectrum disorders (ASD) have belat- this disorder.
edly come under much scrutiny. It is likely one Intellectual disability (ID), known in the past
of the most recognized disorders under the learn- as mental retardation, has been the most well-
ing disorder spectrum. The definition of ASD, recognized and established of learning disorders.
according to the American Psychiatric Associa- IDs also lie on a continuum, much like ASD, but
tion’s Diagnostic and Statistical Manual (DSM), in the mild case of ID, diagnosis is dependent on a
falls under the pervasive developmental disor- continuum of intelligence and adaptive function-
ders and exists within a spectrum. Children with ing scales. The DSM defines ID as having three
Asperger’s disorder have impairments in two things: an IQ deficit, an adaptive behavior deficit,
areas: social interaction and activities. However, and an onset before the age of 18. The prevalence
Asperger’s disorder exists on the less severe end of ID depends on the definition and cutoffs used,
of the autism spectrum. The autism disorder con- much like the other categories of learning disor-
tinuum has three areas of difficulty for children: ders, but it is estimated at approximately between
social interaction and behavior, communication, 1 and 3 percent of the population; the majority
and having a range of behaviors and interests. of whom have mild ID. Estimates have come in
Children with ASD have four areas where they showing that approximately 60 to 87 percent of
are delayed and impaired in regard to social inter- the ID population has mild ID.
action: inability to read nonverbal cues, failure to Developmental coordination disorder (DCD) is
develop and maintain peer relationships, inability a newer learning disorder but has been recognized
to take interest in a range of behavior, and activi- in medical circles under different names for the
ties, and lack of social and emotional reciprocity. past 100 years, such as clumsy child syndrome.
Prevalence of ASD ranges, as some studies have DCD is characterized by substantial motor delays
cited approximately five in 10,000 people, while and age-related functional impairment. These
others have cited even higher rates of 6.7 per impairments cannot be from any other medical
1,000. In the debates over the new DSM-5 edi- condition but can be comorbid with other learn-
tion, published in 2013, controversy has swirled ing disorders and disabilities. Children who have
over the validity of these diagnoses as well as the DCD have difficulty with both fine and gross
appropriate boundaries to draw in defining them. motor activities, which can impair their daily
 Learning Disorders 457

functioning and abilities to complete both aca- present themselves again in issues with measure-
demic and social tasks and activities. There is ment and diagnosis. Last, criticism has also come
also evidence that these impairments can last into from the fact that many of these learning disor-
adulthood. The prevalence of DCD is approxi- ders are often comorbid with a number of other
mately 5 to 10 percent of the population, accord- learning disorders. For example, it is not uncom-
ing to several studies. mon to find a child with a learning disability who
Mathematical disorders (MD) are just as com- also has an MD or language-based disorder.
plex as language-based disorders because of the This has led a group of researchers to question
various functions the subject takes on, given that whether there is an underlying problem not yet
math is more than just arithmetic. The definition discovered by science that could explain more
of MD is given by the DSM as an apparent and than one disorder and eliminate spectrum disor-
severe discrepancy between a child’s performance ders such as ASD. Many of these learning disor-
on various math tests and what is expected of ders are genetically based, but this also presents
these children, based on their age, intelligence, some controversy because cultural differences can
and education. This definition, then, relies on dictate not only differences in language and math
both IQ and age-related discrepancies. Using defi- behavior but also in social skills and expectations
nitions based on these criteria has led to research of children and adults.
findings of a 3 to 6.5 percent prevalence rate for
MD. The various subtypes of MD include dyscal- Issues With Measurement and Diagnosis
cula and dysgraphia. In diagnosing learning disorders, there have been
Nonverbal learning disabilities (NVLD) are cases of misdiagnosis, improper communication
the last group. The prevalence of NVLD has been of inabilities and abilities, and even harmful treat-
found at between 1 and 10 percent of clinical ments. As a result, the area of learning disorders
populations. has always been under much scrutiny. Within the
various subtypes of learning disabilities, much
Cultural Difference scrutiny has been laid against the variability in
One of the emerging issues with learning disor- definitions. While many draw from the IDEA
ders concerns the growing cultural diversity of definition, there are others used in measuring and
school populations and how this can affect diag- diagnosing learning disorders. Once a definition
nostic screening of children who may or may not has been selected for assessment, the controversy
have a learning disorder. Because diagnostic cri- does not end there; many contend that the sub-
teria have been dominated by a medical model types of learning disorders are highly contentious
approach, accounts and consideration of cultural and inaccurately measured. This has had many
and linguistic differences were relatively unheard questioning, such as in the case of the DSM cre-
of until recently. More recently, the dominat- ation, whether there really are such disorders or if
ing medical model has come under scrutiny, and the true disorder has not been found yet. This has
as many studies have pointed out, not only are resulted in a flood of research conducted in brain
diagnoses more frequently given to various social development and functioning.
strata, but clinicians can also inaccurately mea- More recently, scrutiny has been given to the
sure cultural differences. For example, Robert cutoff values associated with measuring IQ and
Reid and his colleagues assessed how well the disorders in general, which has led to a flood of
ADHD-IV rating scale captured the cultural dif- research conducted on the internal and external
ferences among one school population of 5 to 18 validity of measures and on the overall reliability
year olds. They found that this scale did not work of such measures. A group of social researchers
well across all types of cultural groups and that has argued that these cutoffs are nothing but a
there is other behavior that is also considered in social construct and, as a result, many children
informally diagnosing these students. can be unnecessarily labeled. More importantly,
They also suggest that student ethnicity may some groups within society advocate these labels
affect the likelihood that teachers will endorse as a means of pursuing accommodations and
an ADHD diagnosis. These cultural differences opportunities, which has led to further scrutiny
458 Legislation

about the validity of learning disorder labels. Legislation

Colin Ong-Dean points out that privileged par-
ents have access to the means of acquiring these In the United States, mental health services have
diagnoses to help their children advance in been regulated through national legislation
education. enacted by Congress as well as state legislation.
Other researchers argue that many of the In addition, U.S. Supreme Court rulings have
symptoms presented in one disorder greatly interpreted the constitutionality of existing legis-
overlap with other disorders and that no con- lation and influenced subsequent legislation. Con-
crete diagnosis can be made without it appear- gress played a leading role in legislating mental
ing to be a very subjective process. Deciphering health services beginning in the mid-20th century.
the symptoms of each disorder is the business From the mid-1950s until 1980, a series of federal
of individuals in nosology, and determining laws supported efforts to fund community-based
the nosology of any disorder requires extensive treatment. As civil rights became prominent in
external and internal validity testing, as well as the 1970s, legislation was enacted to protect civil
reliability. Two learning disorders that have pre- rights and patient confidentiality for individu-
sented themselves in research as less validated als with psychiatric disabilities. Notable pieces
are central auditory processing disorder and sen- of legislation have supported the rights of those
sory modulation disorder. Both are absent from with mental illness to access community-based
the DSM-IV-TR and, as Bruce Pennington points care and codified how confidentiality should be
out, these two disorders have lacked sufficient addressed. Since the turn of the century, legisla-
empirical evidence of validity. Because of these tion also has regulated equal access to mental
fierce debates, some scientific advances, and the health services. Although national legislation has
continual work of clinicians and social and psy- been influential in implementing important policy
chological researchers, the diagnosis of learning changes and providing funding streams, state leg-
disorders has become much more sophisticated islation also has played a significant role since the
and quite complicated. 1980s, especially in several key areas such as civil
commitment.
Christina DeRoche
McMaster University Community-Based Treatment
At the height of institutionalism, in the mid-
See Also: Attention Deficit Hyperactivity Disorder 1950s, over 550,000 individuals were confined
(ADHD); Autism; Children; Intelligence; Labeling. to state psychiatric hospitals. As public investiga-
tions into state psychiatric hospitals uncovered
Further Readings cases of egregious abuse and psychotropic medi-
Davis, John. Nonverbal Learning Disabilities in cations became available, President Dwight Eisen-
Children: Bridging the Gap Between Science and hower’s 1955 Mental Health Study Act mandated
Practice. New York: Springer, 2011. a national study of psychiatric hospitals. The final
Maston, Johnny L. Autism and Child report, “Action for Mental Health,” was issued in
Psychopathology: International Handbook of 1961 by the Joint Commission on Mental Health
Autism and Pervasive Developmental Disorders. and Illness and documented the harsh and often
New York: Springer, 2011. inhumane conditions found. The report recom-
Millichap, Gordon J. Attention Deficit Hyperactivity mended that (1) timely and voluntary care for the
Disorder Handbook: A Physician’s Guide to mentally ill be provided in community settings,
ADHD. New York: Springer, 2010. (2) fully staffed mental health clinics be univer-
Ong-Dean, Colin. Distinguishing Disability: Parents, sally available, and (3) community-based mental
Privilege, and Special Education. Chicago: health services be expanded.
University of Chicago Press, 2009. After President John F. Kennedy submitted the
Pennington, Bruce F. Diagnosing Learning Disorders, first presidential message to Congress on mental
2nd Edition. A Neuropsychological Framework. health issues in 1963, Congress passed the Com-
New York: Guilford Press, 2009. munity Mental Health Act (CMHA) of 1963,
 Legislation 459

which marked a new turn in federal policy on Least Restrictive Setting and
psychiatric disabilities. The CMHA established the Olmstead Standard
and funded a network of community mental The principle of “least restrictive” setting has
health centers across the country. Over a decade increasingly guided both state and national legis-
later, the Community Mental Health Centers lation. In 1966, the U.S. Court of Appeals for the
Extension Act of 1978 reinvigorated the waning District of Columbia Circuit Court found, in Lake
program with additional funding. A few years v. Cameron, that patients in psychiatric hospitals
later, in 1980, following the recommendations of have the right to receive treatment in a setting
President Jimmy Carter’s Commission on Mental that is least restrictive, meaning that individuals
Health, the Mental Health Systems Act (MHSA) who could be treated in the community should
reauthorized the community health center pro- be treated in that setting. It would be almost 30
gram with improved services to those who were years, however, before that standard became a
among the most difficult to serve in community- national mandate.
based settings: individuals with persistent and In 1995, the Atlanta Legal Aid Society brought
severe mental illnesses. a case on behalf of Lois Curtis and Elaine Wil-
By 1980, however, the ideal of community son that eventually made its way to the Supreme
mental health remained largely unrealized, due in Court as Olmstead v. L.C. In what is known as the
part to inadequate resources and uncoordinated Olmstead decision (1999), the court case argued
or insufficient services. Beginning in the 1980s, that the women had been segregated in a psychi-
the federal government took an increased role in atric hospital because, although staff supported
research and, with the exception of Medicaid, a their release, no supportive community treatment
more limited administrative role in funding state- placements existed. The Supreme Court ultimately
level service capacity, while states and local health decided on behalf of the women. First, their place-
providers increased their role in providing mental ment in psychiatric institutions was found to be
health services. Under President Ronald Reagan, discriminatory because it was based on “unwar-
the Omnibus Budget Reconciliation Act (OBRA) ranted assumptions” about the capabilities of
of 1981 overturned many of the community-based those with psychiatric disabilities to live in com-
initiatives, including the MHSA, and eliminated munity settings. Second, commitment to psychiat-
all regional offices of the National Institute of ric institutions was deemed to be restrictive in that
Mental Health. Through establishing what would it severely limited the individual’s opportunity to
become the Mental Health Block Grant (MHBG), engage in everyday activities and relationships.
OBRA returned authority to the states to fund and The Olmstead decision now is the guiding prin-
implement mental health services while requiring ciple for selecting the setting in which psychiatric
them to develop comprehensive services plans for treatment should be offered: the setting should
persons with serious mental illnesses. offer the least restriction on individual freedom
Because MHBG funds are based on an annual and the greatest opportunity for integration and
formula (revised to now include the three factors participation in the community. For many, this
of size of the population in need, cost of provid- means community-based treatment. However, for
ing services, and each state’s fiscal capacity), allo- others who require institutional treatment, the
cations vary considerably, ranging between 1 and effect of Olmstead has been that voluntary admis-
33 percent of each state’s mental health expendi- sion and voluntary treatment is now emphasized.
tures, including Medicaid. States’ use of MHBG Change has come slowly. Although national
dollars is limited to funding community services, rates of institutionalization for psychiatric disor-
often combining MHBG funds with other state ders continue to decline, the rate of decline since
and federal dollars to pilot innovative programs Olmstead has slowed. Litigation often has required
and make systemic changes in the state system. reference to the gold standard of Olmstead.
Over time, however, state funding has not kept One barrier to fuller implementation of the
pace with population needs; from 1981 to 2005, Olmstead principle has been inadequate funding
adjusting for population growth and inflation, of community-based services, despite the call to
state spending on mental health services decreased. expand community-based services in the 2002
460 Legislation

“Report of the President’s New Freedom Com- to prohibit discrimination against those with dis-
mission.” The Centers for Medicaid and Medi- abilities was the Rehabilitation Act of 1973. This
care Services (CMS) has encouraged states to shift law applied only to federal programs (including
Medicaid funds (the primary funder of publicly federal agencies and contractors/programs receiv-
funded mental health programs) from institutional ing federal funding) and encompassed all disabili-
care to community-based services that maximize ties. Additional federal legislation was enacted in
self-determination of service users. The Indepen- the 1980s that had a broader purview (beyond
dence Plus Initiative is one 1115 waiver program rights protections within federal programs) and
operated by CMS that provides cash to people explicitly protected the rights of those with psy-
with disabilities to purchase their own services. chiatric disabilities, including those living in the
These waivers to traditional Medicaid, however, community.
require that states file legislation to implement the Modeled after the Developmental Disabili-
alternative program. ties Act, the 1985 Protection and Advocacy for
the Mentally Ill Act (PAIMI) protects the rights
Protection of Civil Rights of psychiatric patients receiving publicly funded
Several federal laws were passed in the 1970s and treatment. Initially, the PAIMI Act mandated that
1980s that protected the civil rights of those with states establish a protection and advocacy (P&A)
psychiatric disabilities in housing, education, and agency to provide advocacy services for those
employment. The first federal rights legislation with serious mental disturbances who receive

President John F. Kennedy greets members of the President’s Panel on Mental Retardation in the White House Rose Garden on
October 18, 1961. Congress passed the Community Mental Health Act in 1963, marking a new turn in federal policy on psychiatric
disabilities. The quest for mental health legislation was a personal one for Kennedy; his own sister Rosemary was born with mild
mental retardation, possibly from brain damage at birth, and underwent a lobotomy in 1941 when she was 23.
 Legislation 461

psychiatric services in publicly funded residen- comprehensive federal civil rights legislation.
tial institutions. P&A agencies are either located It prohibits discrimination against people with
within state agencies (state-operated) or are part mental as well as physical disabilities in a vari-
of private, nonprofit organizations. ety of settings, including employment, education,
Amended in 2000, although prioritizing resi- public accommodations, transportation, telecom-
dential patients, the act now also covers individu- munications, and state and local government ser-
als who receive publicly funded care in the com- vices. Qualified individuals who have a disability
munity. PAIMI programs are implemented at the must be granted reasonable accommodations. All
state level and investigate individual complaints employers with 15 or more employees (includ-
as well as systematic instances of abuse, neglect, ing nonprofit and for-profit businesses, religious
and denial of constitutional and statutory rights. organizations, and state and local governments)
Each P& A agency must have an advisory council must abide by ADA regulations. Furthermore, the
with at least 60 percent of its membership consist- ADA protects not only those who currently have
ing of direct recipients of mental health services a disability but also those who have had a his-
or their family members. tory of a disability. This is a significant feature
The Fair Housing Act (FHA) was first passed of the law for people with psychiatric disabilities
in 1968. The legislation covers the rental and sale who may experience intermittent cycles of recov-
of most housing, excluding (1) buildings with ery and illness. In 1997, the Equal Employment
four or fewer units if one of the units is owner- Opportunity Commission (EEOC), the agency
occupied and (2) private, individual owners who responsible for ADA enforcement in employ-
do not own more than three single-family homes, ment, drafted a policy offering guidance about
do not use real estate agents, and do not discrimi- how the ADA applied to people with psychiatric
nate in advertisements. The Fair Housing Amend- disabilities.
ments Act of 1988 extended protections to indi- Finally, the protection of civil rights for those
viduals who have, have had, or are regarded as who are in psychiatric treatment facilities is cov-
having psychiatric disabilities that substantially ered not only by PAIMI but also by the Civil
limit one or more major life activities. For exam- Rights of Institutionalized Persons Act (CRIPA)
ple, landlords cannot refuse modifications made of 1980, which authorizes the U.S. attorney gen-
at the tenant’s expense that are necessary to make eral to investigate conditions of confinement at
the housing habitable for the individual nor can state and local institutions, including institutions
they refuse to modify the rules, policies, practices, for people with psychiatric disabilities. While
or services for the individual to be able to use the CRIPA authorizes the attorney general to file law-
housing (such as psychiatric service animals in suits on behalf of psychiatric patients in cases of
housing units that have no-pet policies.) “egregious harm,” it does not create new rights.
The FHA has been used to contest municipal Rather, the attorney general acts on behalf of insti-
laws that impose special restrictions on hous- tutionalized individuals who may not be in a posi-
ing for those with mental illness (such as safety tion to act on their own. After receiving a CRIPA
or zoning requirements not generally applicable filing, the Civil Rights Division of the Department
to similar dwellings). However, some states and of Justice determines whether an investigation is
municipalities have laws that predate the FHA, warranted; if it is, a 49-day waiting period fol-
including “dispersal legislation” that requires lows the release of the findings letter before a suit
community-based psychiatric housing units to be is filed. During this time, most CRIPA cases are
located a minimum distance from any other simi- resolved outside the legal system through negotia-
lar unit. States have reached various decisions tion with the facility.
about these laws. Nonetheless, the FHA remains
a tool that can be used to challenge restrictions Patient-Centered Care: Self-Determination
on housing for individuals with psychiatric and Confidentiality
disorders. The 21st century has seen new assertions of the
The Americans with Disabilities Act (ADA), principle of patient-centered care in legislation and
passed in 1990, is often cited as the most policy covering psychiatric care. For example, the
462 Legislation

Federal Patient Self Determination Act of 1990 providing equal benefits), however, was limited
outlined the use of advance directives. Psychiatric to lifetime and annual dollar limits. The Men-
advance directives (PADs) are legal documents tal Health Parity and Addiction Act of 2008
that define patient choices for future hospitaliza- (MHPAA) addressed several loopholes in the orig-
tions should the individual become incapacitated. inal legislation, including adding parity to deduct-
PADs may address which treatments (including ibles, copayments, coinsurance, and out-of-pocket
medications) patients wish to receive as well as expenses, and to all treatment limitations, includ-
those they refuse; define which financial strate- ing frequency of treatment, number of visits, days
gies should be used for their care; and identify of coverage, and other similar limits. Coverage
who can visit them. Although by law all states of in-network and out-of network mental health
receiving Medicaid or Medicare funds must insti- services must be equal. The MHPAA, however,
tute procedures for filing such directives, state does not cover significant groups, including small
laws govern filing procedures and forms to be business (with less than 50 employees), indi-
used. In addition, some state laws grant provid- vidual health insurance policies, and Medicare.
ers the right to refuse PADs, most often due to While there was some concern that the 2008 act
a “conscientious objection,” such that adequate would cause employers to exclude mental health
care could not be given in good conscience if the coverage, a poll by the Kaiser Family Foundation
directive were followed. State laws must specify documented that only 2 percent did.
the process for making such decisions, includ- Similarly, the Patient Protection and Affordable
ing identifying the state legal authority that may Care Act (ACA) of 2010 offers increased cover-
grant a conscientious objection. age for many individuals with psychiatric condi-
The Health Insurance Portability and Account- tions. The ACA extends parity by requiring all
ability Act (HIPAA) of 1996 protects patient con- insurers who sell policies on public exchanges to
fidentiality as the first comprehensive protection include similar levels of mental health as physical
of health and mental health information. The law health coverage in their benefit packages. In addi-
is designed to protect patient privacy without tion, the ACA forbids denial of coverage based
interfering with access to care. The “privacy rule” on pre-existing conditions, including psychiatric
covers all legally defined “protected health infor- conditions. Although the ACA initially expanded
mation” (PHI, including individually identifiable Medicaid coverage, a Supreme Court ruling gave
information) and limits the instances in which the states the right to opt out of the expansion, thus
PHI may be disclosed to insurers and other enti- limiting access to mental health treatment by
ties. Entities/providers are required to follow the those close to poverty.
“minimum necessary rule” and disclose only the
minimum information required for the transac- State Legislation
tion. HIPAA also limits the information that may The uneven implementation of federal legislation
be disclosed when an individual is incapacitated. as well as the passage of different state laws on
If states have more stringent privacy laws, then key issues not governed under federal law has
those laws remain in effect after HIPAA. produced a patchwork of mental health services
across the country.
Access to Psychiatric Care First, although Medicaid is a federal program
More recently, national legislation has addressed used to finance public mental health services, the
the need to ensure equitable access to mental program is administered by states, which have
health services. The federal Mental Health Par- discretion in many areas. Key among them is the
ity Act (MHP) was passed in 1996. Based on the decision to use a traditional Medicaid program or
premise that some mental health conditions have to institute pilot programs through waivers.
a biological component, the MHP required insur- Second, many key laws (such as civil commit-
ance companies offering mental health benefits ment and the “insanity defense”) are not gov-
to provide policies that covered those biologi- erned directly by federal legislation. For example,
cally based mental health disorders to the same although the Supreme Court has ruled on specific
extent as other biological conditions. Parity (or cases that shape subsequent laws, every state
 Life Course 463

maintains its own commitment laws that outline Further Readings

standards and procedures for involuntary psy- Cauchi, Richard, Steven Landess, and Andrew
chiatric care. For example, the Supreme Court Thangasamy. State Laws Mandating or Regulating
ruled in 1975 in O’Connor v. Donaldson that the Mental Health Benefits. National Conference of
15-year commitment of Kenneth Donaldson was State Legislatures, December 2011. http://www
unconstitutional. .ncsl.org/issues-research/health/mental-health-ben
As a result, some states limit involuntary com- efits-state-laws-mandating-or-re.aspx (Accessed
mitment to those posing imminent danger to December 2012).
themselves or others and impose a 72-hour eval- Frank, Richard G. and Sherry A. Glied. Better but
uation period. Nonetheless, there is variation Not Well: Mental Health Policy in the United
among states, and others invoke the standard States Since 1950. Baltimore, MD: Johns Hopkins
that the individual merely be in “need of treat- University Press, 2006.
ment.” In addition, 44 states and the District of “Rosemary Kennedy, JFK’s Sister, Dies at 86.”
Columbia have various laws governing civil out- MSNBC (January 18, 2005). http://www.nbcnews
patient treatment, including laws used to insti- .com/id/6801152/ns/us_news/t/rosemary-kennedy
tutionalize sex offenders who are at high risk of -jfks-sister-dies/#.UdXbIT7C5Cd (Accessed June
reoffending, are diagnosed with a mental disor- 2013).
der, and have completed their prison sentence. Testa, Megan and Sara G. West. “Civil Commitment
Although federal legislation has advanced in the United States.” Psychiatry, v.7/10 (2006).
policies that favor community-based treatment,
protection of civil rights, patient-centered care,
and access to care, state-level programs vary con-
siderably. Some states (such as California) have
long-standing histories of legislating on behalf of Life Course
community-based patient rights (even preceding
the 1963 CMHA), while other states have less The life course perspective describes an intraso-
vigorous track records. The National Alliance cial institutional population or group that coheres
on Mental Illness, an advocacy organization, has based on age-specific mental, social, physical,
produced two “report cards” on the state of pub- cultural, structural, and contextual attributes. It
lic mental health services. In 2006 and again in focuses on individual-level influences on develop-
2009, the majority of states were graded “C” or ment; life stage, which is a time series of age pro-
“D” (with six “Fs”). gression from infancy until the end of life; and life-
Federal and state legislation has been instru- cycle, which views the patterned stages of behavior
mental in changing service delivery systems and over time. Mental illness can be age, stage of life,
modifying public policy to address the needs of and developmentally governed, based on cultur-
individuals with psychiatric disabilities and will ally mediated expectations for maturation, devel-
likely continue to do so in coming years. opment, and health trajectory in the course of life.
Knowledge of the life course is an essential ele-
Deborah A. Potter ment in the social and culturally bound definitions
University of Louisville of normality and pathology, which includes men-
tal illness. Many Western ideas about mental ill-
See Also: Commitment Laws; Community ness were historically conceptualized as universal,
Mental Health Centers; Compulsory Treatment; inflexible, and driven by definitions of normality
Deinstitutionalization; Human Rights; Informed for the majority. However, this approach is flawed
Consent; Insanity Defense; Law and Mental Illness; and tempered by individual differences.
Medicare and Medicaid; National Alliance on Mental Mental illness can afflict an individual in an
Illness; Patient Rights; Policy: Federal Government; early stage of life. The number of children (ages 1
Policy: State Government; Right to Refuse Treatment; to 11) and adolescents (ages 12 to 17) who exist
Right to Treatment; State Budgets; United States; with a diagnosable form of mental illness world-
Voluntary Commitment; Welfare. wide is about 20 percent, or one in five. In the
464 Life Course

United States, about 5 million children and ado- diagnosis of mental illness has been linked to
lescents suffer with mental illness, causing signifi- social norms and fulfilling the expectations to
cant functional impairment at home and in school achieve those norms that are unique for women.
environments. Anxiety (separation and general), Postpartum depression, anxiety, and eating disor-
attention deficit hyperactivity disorder (ADHD), ders are all common challenging illnesses that are
disruptive, pervasive, and eating disorders are all most often exhibited in women. The high preva-
common among children and adolescents with lence of violence among women, both sexual and
mental illness. Major depressive disorder is most through military service, renders women the larg-
often diagnosed at the onset of adolescence. The est single group of people affected by post-trau-
prevalence of depression is an international issue matic stress disorder (PTSD).
and is associated with psychosocial impairment Mitigating the effects of these illnesses are the
and risk of suicide. Suicide is the third leading accepted norms of society. Social anxiety disorders
cause of death among adolescents. frequently co-occur with these illnesses, adding to
Children and adolescents with a mental ill- internalized feelings of acceptance and rejection.
ness may be misdiagnosed and perceived as going Striving to meet expectations, portrayed by social
through the natural cycle of development, in influences, affects what women will do to achieve
part because children and adolescents progress acceptance. As they age, women are more likely
behaviorally at varying rates. In addition to lack to be diagnosed with depression, organic brain
of diagnosis, treatment for children is not as well syndromes, and dementias.
understood in the medical community. Treatment
options include medication, psychotherapy, and Men and Mental Illness
creative therapy; however, it is uncertain which Mental illness among men is considered a silent
treatments are most effective. Children and ado- crisis. It has been an issue among men for decades,
lescents who are properly diagnosed and receive but gender-specific health awareness and research
treatment often learn how to cope with their ill- has focused predominantly on women. However,
ness though adulthood. illness among men has most recently been high-
Statistics demonstrate that one in 17 American lighted by the increasing number of military per-
adults live with a serious mental illness. Adults sonnel diagnosed with PTSD. Increased awareness
ages 18 to 25 have the highest prevalence of men- has also led to the knowledge that men experience
tal disorders, at 29.9 percent, while adults 50 years higher rates of autism, early onset schizophrenia,
and older have the lowest incidence of any mental are three times more likely to be diagnosed with
illness (14.3 percent). Statistics also indicate that antisocial personality disorder, and have twice the
less than one-third of adults with a diagnosable rate of alcohol dependence.
mental disorder receive mental health services in Mental illness is often underreported among
a given year. Whites and Native Americans are men of all ages, in large part because of social
more likely to seek help than blacks, Latinos, and stigma. Certain types of mental illnesses are fre-
Asians. Women have higher rates than men; how- quently misdiagnosed (depression versus personal-
ever, this may be because women are more likely ity or substance abuse disorder) or are missed alto-
to seek help for a mental illness. Women seeking gether in men. Admitting to mental issues is viewed
professional help are more likely to be prescribed as unmanly and a sign of weakness. Changes in
psychotropic drugs from a primary care physician. societal dynamics at a job, in one’s family, and in
Men are likely to seek specialist mental health personal life all directly affect perceptions around
care through the use of psychotherapy because male masculinity. Antisocial personality disorders
most men hesitate to talk to mental health pro- often lead to externalizing emotions, demonstrated
fessionals. There is increasing evidence that when by aggressive, noncompliant, or impulsive behav-
blacks who live in Western societies present for ior. Mental issues are masked, often go undiag-
care, they present in a manner different from their nosed, and lead to dire consequences. For example,
Caucasian counterparts. it is estimated that at least 6 million American men
There are distinct psychological factors that suffer from depression each year and are almost
contribute to mental illness by gender. The four times more likely to commit suicide.
 Life Expectancy Trends 465

Factors that protect against the development of at death of all individuals in a specific popula-
depression include: access to material resources tion and then dividing that figure by the num-
that assist in making decisions; having autonomy ber of people in that population. In most coun-
to exercise some control in response to severe tries, life expectancy is higher for females than
events; and psychological support from family, for males. This depends partially on the level of
friends, or health providers. Once a person has development in the country. In developed coun-
been diagnosed, steps to keep symptoms under tries such as the United States, England, France,
control include knowing warning signs, seeking Sweden, and Japan, women generally live six to
help and routine medical care, and maintaining a eight years longer than men. In contrast, in some
healthy schedule. developing countries such as India, Egypt, and
South Africa, women live only three to five years
Candace S. Brown longer than men.
Virginia Commonwealth University
Keith E. Whitfield Historical Trends
Christopher L. Edwards Women have not always lived longer than men
Duke University across various historical eras. In most countries,
as recently as the beginning of the 20th century,
See Also: Age; Dementia; Gender; Life Expectancy the advantage of women over men in life expec-
Trends; Mortality; Nursing Homes; Women. tancy was small because more women died giv-
ing birth. For example, in 1900, the overall U.S.
Further Readings life expectancy at birth was 47.3 years, with 46.3
Cooper, C., P. Bebbington, S. McManus, H. Meltzer, years for men and 48.3 years for women. By
R. Stewart, M. Farrell, M. King, R. Jenkins, and G. the 1940s, death rates from childbirth began to
Livingston. “The Treatment of Common Mental decline substantially in most developed countries,
Disorders Across Age Groups: Results From the leading to a widening life expectancy differen-
2007 Adult Psychiatric Morbidity Survey.” Journal tial. In 1950, overall U.S. life expectancy at birth
of Affective Disorders, v.127/1–3 (2010). was 68.2 years, with 65.6 years for men and 71.1
Eaton, N., R. Kruger, K. Keyes, D. Hasin, S. Balsis, A. years for women. In the United States, women
Skodol, K. Markon, and B. Grant. “An Invariant added years at a faster rate than men until the
Dimensional Liability Model of Gender Differences 1980s. In 1980, the gap in life expectancy at birth
in Mental Disorder Prevalence: Evidence From between men and women in the United States was
a National Sample.” Journal of Abnormal seven years. At that point in time, some advances
Psychology, v.121/1 (2011). and progress against deaths from heart disease
Parens, E. and J. Johnston. “Mental Health in in men led to improvements in male life expec-
Children and Adolescents.” In From Birth tancy and some closing of the gender gap in the
to Death and Bench to Clinic: The Hastings United States. By 2000, life expectancy at birth
Center Bioethics Briefing Book for Journalists, was 76.8 years, 74.1 years for men and 79.3 years
Policymakers and Campaigns, M. Crowley, ed. for women.
Garrison, NY: Hastings Center, 2008.
Current Trends
In the United States, using the most recent fig-
ures (2009), the overall life expectancy at birth is
78.5 years: 76 years for men and 80.9 years for
Life Expectancy Trends women. In addition to differences for men and
women, there are differences by race and ethnic-
Life expectancy is the average number of years ity. Overall life expectancy at birth is 78.8 years
people in a given population can expect to live. for whites and 74.5 years for African Americans.
Another way to think about the concept is that Comparing rates for men and women, the high-
it relates to the mean age at death. Life expec- est life expectancy is for white women (81.2
tancy is calculated by taking the sum of the ages years), followed by African American women
466 Life Expectancy Trends

(77.6 years), white men (76.4 years), and African survival from age 80 to 90 years was on aver-
American men (71.1 years). Separating Hispan- age 15 to 16 percent for women and 12 percent
ics from both the white and African American for men. These numbers have been improving: in
population, Hispanic females have the highest 2002, these values were 37 percent for women
life expectancy at birth, followed by white non- and 25 percent for men. Because death rates of
Hispanic women, Hispanic men, African Ameri- children and young adults are already quite low
can non-Hispanic women, white non-Hispanic in most developed countries, additional increases
men, and African American non-Hispanic men. in life expectancy must be achieved through fur-
In addition to life expectancy at birth, figures ther improvements in the oldest age groups. Not
are also available in the United States for life only are people living longer, but those added
expectancy after older ages, such as 65 and 75. years of life are spent with less disability and
Men who reach 65 years of age can expect to live fewer limitations on daily life than in the past.
another 17.6 years, while women who reach 65 In addition, preliminary evidence suggests short-
years of age can expect to live another 20.3 years. ened working weeks over extended working lives
At 75 years of age, men can expect to live an addi- (which has been the trend in these 30 developed
tional 11 years and women an additional 12.9 countries, although that trend is less true for the
years. The gender gap is less at these older ages United States) might further extend increases in
because many men have already died from a vari- life expectancy and health.
ety of illnesses; thus, the men left as a group have
already lost some of their least healthy members. Mental Illness, Disabilities, and
Some changes in life expectancy at older ages are Active Life Expectancy
found by race and ethnicity, although the pattern For individuals with mental illness, there are
is not different for the groups at 65 than it is for some different trends in terms of life expectancy.
life expectancy at birth. However, for those who Recent research shows that serious and persistent
reach 75 years of age, the longest life expectancy mental illness can result in patients losing up to
is for Hispanic women, followed by white non- four years of life compared to individuals with-
Hispanic women, African American non-Hispanic out mental illness. Earlier research has mentioned
women, Hispanic men, white non-Hispanic men, greater differences in life span partially because of
and African American non-Hispanic men. Thus, higher suicide rates for people with mental illness
by 75 years of age, all groups of women have (more than 90 percent of suicides are linked to
more expected years of life remaining compared mental illness, and persons with bipolar disorders
to men, whatever their racial or ethnic group. have a 10 to 20 percent lifetime risk of suicide).
If current life expectancy trends continue, more To accurately assess the true impact of serious
than half of babies born in wealthier nations and persistent mental illness on years of potential
today may live to 100 years. The 20th century life lost, Elizabeth Piatt and colleagues retrospec-
witnessed enormous increases in life expectancy tively matched 647 case-management files from
of more than 30 years in most developed coun- patients who had been treated at a community
tries. Death rates in nations with the longest life health center prior to their deaths to 15,517 state
expectancy, such as Japan, Sweden, and Spain, death records from a general population. The
may indicate that even if health conditions do not mean age of death for psychiatric patients was
improve, three-quarters of babies will live to see 73.4 years compared to 79.6 years for the general
their 75th birthdays. population. Heart disease was the leading cause
Consequently, disease and disability rates in of death for each group. After statistical adjust-
old age will have an increasing effect on the sus- ments were made for gender, race, education, and
tainability of modern society. The increases in life marital status, the greatest differences in cause of
expectancy in wealthier countries, apparent since death between the two groups were in suicide,
1840, show no signs of slowing. In wealthier cancer, accidents, liver disease, and septicemia.
nations, mortality in people older than 80 years Today, in addition to general life expectancy,
is still on the decline. Using data from over 30 scholars discuss the concept of active life expec-
developed countries, in 1950, the probability of tancy. This is the number of years a person can
 Life Skills 467

Further Readings
Centers for Disease Control and Prevention.
“Faststats” (2012). http://www.cdc.gov/nchs
/fastats/lifexpec.htm (Accessed November 2012).
Christensen, Kaare, Gabriele Doblhammer, Roland
Rau, and James W. Vaupel. “Aging Populations:
The Challenges Ahead.” The Lancet, v.374
(October 3, 2009).
Liang, Jersey, Joan Bennett, Benjamin Shaw, Ana
Quiones, Wen Ye, Xiao Xu, and Mary Beth
Ofstedal. “Gender Differences in Functional
Status in Middle and Old Age: Are There Any
Age Variations?” Journal of Gerontology, v.63B/5
(2008).
Manton, Kenneth, XiLiang Gu, and Gene Lowrimore.
“Cohort Changes in Active Life Expectancy in
the U.S. Elderly Population: Experience From the
1984–2004 National Long-Term Care Survey.”
Journal of Gerontology, v.63B/5 (2008).
Hani women gather at Laomeng Market, near Yuanyang, National Center for Health Statistics (NCHS).
Yunnan province, China, December 2007. China’s average “Health, United States, 2011: With Special Feature
life expectancy rose to 74.83 years as of the end of 2010; for on Socioeconomic Status and Health.” Hyattsville,
women, it rose 4.04 years to 77.37 years. MD: NCHS, 2012.
Piatt, Elizabeth E., Mark R. Munetz, and Ritter
Christian. “An Examination of Premature
Mortality Among Decedents With Serious Mental
expect to live without a disability. In the United Illness and Those in the General Population.”
States, men have an active life expectancy of 60 Psychiatric Services, v.61/7 (2010).
years, or 84 percent of their whole life expec- Xinhua. “Life Expectancy Rises in China” (August
tancy. Women have an active life expectancy of 9, 2012). http://news.xinhuanet.com/english/
58 years, or 82 percent of their lifetime. This dif- china/2012-07/11/c_131709242.htm (Accessed
ferential is linked to the fact that women live lon- June 2013).
ger but with some disabilities. One reason women
have fewer years of active life expectancy is they
are more likely to live past 85, a point at which
the risk of becoming disabled from chronic con-
ditions increases. In addition, women are more Life Skills
likely to have certain disabling conditions such
as arthritis and osteoporosis. The gender gap has Certain skills improve psychological well-being
been declining among younger cohorts of women. in those without mental illness and improvement
Overall, active life expectancy has been improv- in symptoms for those with mental illness. These
ing for both men and women, and thus people are skills are often taught preventively in school or
living longer in better health. community settings and are often used as a sup-
plement to psychological treatment as a means of
Jennie Jacobs Kronenfeld providing an individual with more resources to
Arizona State University cope with life stressors. By providing training or
guidance in these skill areas, clinicians hope that
See Also: Age; Disability; Gender; Life Course; the client will be less likely to experience relapse
Race; Race and Ethnic Groups, American; Racial of psychological distress. These skills are benefi-
Categorization; Suicide; Women. cial to all individuals, even those not experiencing
468 Life Skills

psychological distress or difficulties. These skills immediately or the emotional reaction is particu-
include emotion regulation, distress tolerance, larly acute.
stress management, relaxation, healthy eating,
and exercising. Distress Tolerance
Marsha Linehan devised a skill set for situations
Emotion Regulation when emotion regulation fails and an individual
Emotion regulation is defined as the ability to is left in an extreme negative emotional state that
be aware of, identify, and regulate one’s emo- can be painful. This particular skill is called dis-
tions. Regulation refers to being able to return to tress tolerance. Distress tolerance involves being
“baseline” after experiencing an emotion. Emo- able to survive emotional and psychological suf-
tion regulation training typically involves learn- fering. It encourages getting through the moment
ing about emotions and being able to notice and and recognizing that the suffering will not be per-
label the emotion experienced. It also involves manent. The specific techniques for distress toler-
being taught about different emotion regulation ance include distraction, self-soothing, improving
strategies and learning which are the most effec- the moment, and accepting reality.
tive for that individual. The first skill of distress tolerance is distrac-
For instance, one may be encouraged to notice tion. Distraction can be achieved through activi-
body sensations that are associated with a par- ties (e.g., going for a walk, engaging in hobbies, or
ticular emotional state (such as a tensing of the shopping), contributing by volunteering or helping
muscles with anxiety) and to try to identify an someone, comparing one’s situation to that of oth-
emotion based on that. Strategies to regulate neg- ers who are less fortunate, distracting with oppo-
ative emotions include acceptance, reappraisal, site emotions such as reading an emotional book or
distraction, and suppression. watching an emotional movie, and pushing away a
Acceptance refers to the ability to experience distressing situation by taking a mental break from
one’s emotions without trying to distract oneself it. The second skill is self-soothing. This technique
or change the emotion. For instance, if someone involves using different types of sensory stimula-
is feeling anxious, an acceptance strategy would tion to make oneself more comfortable. It offers
involve sitting with the anxiety and observing suggestions for all of the five senses: vision, hear-
it until it decreases. Research indicates that this ing, smell, taste, and touch. For instance, a touch
strategy is highly effective because most emotions technique may include putting on a silky shirt, tak-
are fleeting and will naturally decrease over time. ing a bubble bath, or petting an animal.
With the acceptance strategy, the person does Distress tolerance encourages improving the
not try to distract him, or herself or control the moment through mental imagery, prayer, relax-
emotion. Another effective strategy, reappraisal, ation, and focusing on the moment. It also
involves viewing the distressing situation from a encourages finding or creating meaning in one’s
different perspective. For instance, someone who current suffering. The final skill of distress tol-
has lost their job could try to view the situation erance is acceptance. The individual is encour-
as an opportunity to try a new and more fulfill- aged to think about the pros and cons of accept-
ing career. ing versus not accepting the moment. Principles
Distraction involves focusing on another for accepting reality include radical acceptance,
thought or emotion, or trying to introduce a new turning the mind, and willingness over willful-
emotion (such as watching a comedy on television ness. Radical acceptance is deciding to tolerate
when one is feeling sad). Distraction should not the moment and acknowledging what it is. Turn-
be confused with suppression, which is when an ing the mind is making an inner commitment to
individual actively tries to control the emotion or accept the moment. Willingness over willfulness
tries not to feel the emotion. Research indicates is doing what is needed as opposed to giving up.
that these strategies may actually cause the emo- Distress tolerance can reduce emotional distress
tional reaction to intensify or last longer. There- or behaviors that would actually make an indi-
fore, suppression and distraction are thought to vidual’s situation worse in the long run (e.g., self-
work best when emotions need to be reduced injury or substance abuse).
 Life Skills 469

Stress Management and Relaxation are improved when exercise is added to therapy.
Stress management refers to techniques used Research indicates that exercise stimulates the
to cope with or reduce stress. It encompasses a genesis of neurons in a region of the brain that
wide area and can take place inside or outside a has been found to be stunted in depressed indi-
therapeutic setting. Typically, stress management viduals. Exercise also increases endorphins that
requires that one identify the areas that are caus- make people feel happier. The Centers for Disease
ing stress. Often, individuals seeking help for stress Control and Prevention reports that only 46.9
are given a questionnaire in which they are asked percent of adults over age 18 in the United States
to identify the areas that are the most stressful for meet the exercise requirements for aerobic activ-
them. Once the stressor is identified, a number of ity, 24 percent meet the requirements for strength
techniques can be employed to manage it. activity, and 20.4 percent meet the requirements
Stress management can focus on the actual for both, indicating that exercise habits related to
stressor or on the experience of stress. Manag- improved physical and mental health are lacking
ing the stressor would involve organizational or in the majority of U.S. citizens.
planning techniques such as dividing a task into Maintaining healthy eating habits is also impor-
smaller steps, keeping an organizer, and learn- tant because nutrients are important for maintain-
ing more effective time management skills. Man- ing energy and effective functioning of the body.
aging the feelings and responses of stress would Nutritional deficits can also impact brain chemis-
include techniques such as meditation, prayer, try, leading to issues such as depression and anxi-
deep breathing, and exercise. These techniques ety. Multiple research studies indicate that main-
are thought to decrease the physiological arousal taining a regular and healthy eating schedule is
associated with stress, making an individual feel linked to improved psychological health.
calmer. Specific therapy techniques can also focus
on stress, such as mindfulness-based stress reduc- April Bradley
tion, biofeedback, cognitive-behavior therapy, Katie Miller
and relaxation training. University of North Dakota
Relaxation is another type of stress manage-
ment technique, but it can also have other uses. See Also: Prevention; Psychosocial Adaptation;
Relaxation is defined as the absence of arousal Self-Help; Stress.
and a state of low tension. Typically, relaxation
is achieved through physiological techniques such Further Readings
as deep breathing. One type of relaxation is pro- Centers for Disease Control and Prevention. Health,
gressive muscle relaxation, in which an individual United States, 2011: With Special Feature on
is encouraged to flex a muscle for several sec- Socioeconomic Status and Health. Hyattsville,
onds and then release it, focusing on the feeling MD: National Center for Health Statistics, 2012.
as the tension is released and the muscle relaxes. Davis, M., E. Robbins Eshelman, and M. McKay.
Another method is guided imagery, in which a The Relaxation and Stress Reduction Workbook.
person is guided through a mental journey that Oakland, CA: New Harbinger, 2008.
is calming and peaceful. Relaxation can also be Frydenberg, E., J. Deans, and K. O’Brien. Developing
experienced through massage, in which the mus- Everyday Coping Skills in the Early Years:
cles are manipulated to release tension and pro- Proactive Strategies for Supporting Social and
mote healing. Emotional Development. New York: Continuum,
2012.
Healthy Eating and Exercise Greenberg, J. Comprehensive Stress Management.
Maintaining physical health is an important life New York: McGraw-Hill, 2010.
skill; individuals are less prone to emotional or McKay, M., J. C. Wood, and J. Brantley. Dialectical
behavioral dysfunction if they are physically Behavior Therapy Workbook: Practical DBT
healthy. Exercise especially has been implicated Exercises for Learning Mindfulness, Interpersonal
as important to mental health. Some studies indi- Effectiveness, Emotion Regulation, and Distress
cate that depression recovery and relapse rates Tolerance. Oakland, CA: New Harbinger, 2007.
470 Lithium

Lithium remarkable improvement. Mogens Schou, in

Denmark in 1952, learned of Cade’s work and
Lithium compounds have been used in medicine began an early double blind trial in which patients
for a range of physical and psychological condi- were switched between lithium and a placebo.
tions beginning in the mid-19th century. They Schou’s study found lithium effective, and he rec-
fell out of favor by the early 20th century, and ommended using it with a maintenance dose; in
by midcentury, they were rediscovered and began later work with Paul Baastrup in the 1960s, he
a contested rise to prominence as a psychiatric advocated for prophylactic use and defended the
medication. Today, lithium is known as a mood methods of his earlier studies (Cade, too, faced
stabilizer and is mainly used in the treatment of criticism for his methods). Lithium was accepted
bipolar disorder (formerly manic-depressive ill- sooner in western Europe, with governments
ness). Its effectiveness in treating bipolar disor- granting approval for its use in 1961 in France,
der, despite its mechanism of action remaining 1966 in the United Kingdom, 1967 in Germany,
unknown, makes it one of modern psychiatry’s and 1970 in Italy.
success stories. The history and continuing use In the United States, the acceptance of lith-
of lithium is important to our understanding of ium was significantly hindered by the Food and
bipolar disorder, the concept of the mood sta- Drug Administration’s (FDA’s) decision to ban it
bilizer, and personal implications of psychiatric in 1949 after a few cardiac patients died when
medication use, as well as the political economy they used it as a salt substitute. The dominance of
of psychopharmaceuticals. psychodynamic approaches to psychiatric illness
In the 19th century, physicians used lithium also slowed the acceptance of lithium by Ameri-
for a variety of disorders based upon the theory can psychiatrists. However, by the early 1970s,
of uric acid diathesis, a belief that uric acid, a lithium was developing a reputation as a prophy-
breakdown product of urea, led not only to lactic treatment for bipolar disorder, and in the
gout but also to a number of other ills ranging United States, where work by Samuel Gershona
from cardiac disease to mania. The finding that and Baron Shopsin helped bring it to the fore,
lithium dissolves urate stones led to the logical its use was already gaining momentum without
notion that lithium might effectively treat those government approval. The United States was the
illnesses believed to be due to precipitates of uric 50th country to formally approve its use, in 1970,
acid. Between 1859 and 1876, the English phy- for treatment of acute mania and, in 1975, for
sician Alfred Baring Garrod described the use mania prophylaxis (although never for depres-
of lithium for gouty conditions that included sion prophylaxis). The United States was also
mania and other forms of psychological distress. a country in which alternate, but not necessar-
In 1870 in the United States, Silas Weir Mitch- ily more effective, therapies were put forward by
ell advocated its use as a hypnotic and, in 1877, pharmaceutical firms to challenge lithium’s pre-
for general nervousness. In 1871, William Ham- ferred status in the treatment of bipolar disorder.
mond prescribed it for acute mania. In Den-
mark in 1886, Federik Lange identified periodic Unique Bipolar Treatment
depression, a melancholia without psychotic fea- Lithium is unique among medications used for
tures, and suggested lithium carbonate to prevent bipolar disorder, in that popular preparations
symptoms from recurring over time. Although such as lithium carbonate cannot be patented,
lithium was still available in patent medicine in and as a result, lithium was never aggressively
the United States into the early 20th century, it promoted by pharmaceutical firms. Furthermore,
fell out of favor in medical practice as the theory when more profitable, patented medications
that underpinned its use became discredited. appeared, they were immediately marketed as
Lithium as a psychotropic drug reappeared in superior alternatives to lithium, regardless of clin-
1949 in Australia with John Cade, who was aware ical evidence for these claims. This occurred first
of Garrod’s work and curious if uric acid could with anticonvulsant medications (carbamazepine,
lie behind mania. Of Cade’s 10 patients, those valproate, and lamotrigine) described as mood
with mania who remained on lithium showed stabilizers and, since the late 1990s and 2000s,
 Lobotomy 471

with the new generation of atypical antipsychot- creativity and decidedly less creative periods of
ics. Abbot’s anticonvulsant medication Depakote hopelessness and depression is accompanied by
(valproate) gained traction as an off-label alter- the question of the potential side effects from
native to lithium for mania in the late 1980s, as drugs such as lithium. Lithium illustrates con-
did Novartis’s Tegretol (carbamazepine). (A simi- tradictions within the pharmaceutical industry,
lar link between anticonvulsant properties and as its effectiveness has not been matched with
positive psychological outcomes was observed equal amounts of medical interest or commercial
for lithium in the 19th century.) In 1985, Abbott promotion, especially in the United States. There
received FDA approval for the treatment of bipo- is concern, for example, that many psychiatrists
lar disorder (manic episodes) with valproate, are comparatively undertrained in the adminis-
which was followed by GlaxoSmithKline’s 2003 tration of lithium, thereby reducing the drug’s
FDA approval for Lamictal (lamotrigine) for effectiveness. Nonetheless, it remains a front-line
bipolar disorder (type I) in 2003. treatment for bipolar disorder.
Clinical demonstrations of lithium’s ability to
treat bipolar mania and depression, combined Bradley Fidler
with its comparative ineffectiveness with both University of California, Los Angeles
schizophrenia and unipolar depression, contrib-
uted to the perception that bipolar disorder was See Also: Bipolar Disorder; Mania; Mood Disorders;
unique from both conditions. By the 1970s in the Pharmaceutical Industry; Suicide.
United States, lithium’s effectiveness was begin-
ning to influence diagnostic practices for bipolar Further Readings
disorder (types I and II), with favorable response Baastrup, Poul Christian and Mogens Schou.
to the drug counting toward a diagnosis for the “Lithium as a Prophylactic Agent: Its Effect
condition. Against Recurrent Depressions and Manic-
From the mid-1990s until the turn of the cen- Depressive Psychosis.” Archives of General
tury, there began a decline, led by the United Psychiatry, v.16/2 (1967).
States, in the prescription rates of lithium for Cade, John Frederick Joseph. “Lithium Salts in the
bipolar disorder, just as Depakote (and then Treatment of Psychotic Excitement.” Medical
Lamictal) prescriptions increased. This decline Journal of Australia, v.2 (1949).
was linked to intense marketing for these alterna- Harris, Margaret, Summit Chandran, Nabonita
tives to lithium; a study in the American Journal Chakraborty, and David Healy. “Mood-Stabilizers:
of Psychiatry noted that, while lithium was the The Archeology of the Concept.” Bipolar
most common mood stabilizer in 1995, prescrip- Disorders, v.5/6 (2003).
tions dropped 40 percent by 1999, a change that Healy, David. Mania: A Short History of Bipolar
cannot be said to result from the clinical char- Disorder. 1st ed. Baltimore, MD: Johns Hopkins
acteristics of patients. At this time, research on University Press, 2011.
lithium moved toward studies comparing it to Jamison, Kay Redfield. An Unquiet Mind: A Memoir
these and other (atypical antipsychotic) poten- of Moods and Madness. New York: Vintage Press,
tially mood-stabilizing compounds. Questions 1996.
remain about the extent of its effectiveness, owing Shorter, Edward. “The History of Lithium Therapy.”
at least in part to the ethics of entering severely ill Bipolar Disorders, v.11 (2009).
patients in placebo groups in the long-term trials
that could help establish this effectiveness and the
consequent lack of clinical guidelines.
Lithium is held up both as a major success
of psychiatry for its ability to relieve suffering Lobotomy
and prolong life and as a symbol of the poten-
tial trade-offs associated with the use of psy- As early as 1888, Swiss psychiatrist Gottlieb
chiatric drugs. The long-standing association of Burckhardt initiated the first psychosurgery,
bipolar disorder with both elevated periods of excising portions of the cerebral cortex in six
472 Lobotomy

psychotic patients. His disappointing results were into the prefrontal lobe of previously irritable
met with hostility and ridicule when he presented and unpredictable chimpanzees produced much
his research to colleagues, and both Burckhardt gentler, tame animals. Moniz was in the audi-
and his work faded into obscurity. With the ence. Moniz’s acknowledgment of Richard
somatic counteroffensive to psychoanalysis under Brickner’s 1932 paper on how ablated prefron-
way, physical treatments of mental illness gained tal lobes in humans produced a flattened affect
renewed vigor in the period between 1910 and without reduced intellect in neurosurgical cases
1940. is another possible source of inspiration for his
Efforts to isolate the biological mechanisms procedure.
that produced mental illness increased as psy-
chiatrists sought to keep up with the success Development of the Procedure
of other medical disciplines in identifying the Moniz pioneered the first human prefron-
causal factors of physical illnesses. These medi- tal lobotomy in 1935 by having his colleague,
cal advances (signaled by the bacterial revolu- Pedro Almeida Lima, drill holes into the skull
tion) and the overwhelming consensus on the and inject the prefrontal lobes with alcohol. This
inadequacy of existing treatments for mental procedure was almost immediately refined to
illness, inspired psychiatrists and neurologists make use of the leucotome, a surgical instrument
alike to aggressively pursue physical solutions to with a wire loop that could be inserted into and
mental problems. Portuguese neurologist Egaz then retracted from the brain, removing cores of
Moniz contributed to this emerging tradition tissue. Lima operated on 20 patients at Moniz’s
and received acclaim for his psychosurgical pro- direction, and, as opposed to Burckhardt, there
cedure, the lobotomy, or leucotomy. First under- were no deaths. Moniz claimed that approxi-
taken in 1935, it won Moniz the Nobel Prize for mately 70 percent of the patients displayed
Medicine in 1949. favorable results. The criteria for this assessment
There is controversy about the origins of were unspecified. These patients were rendered
Moniz’s procedure. A paper presented by Ameri- incapable of initiative and lost inhibitions but,
can physicians John Fulton and Carlyle Jacob- in most cases, became more docile, manageable,
sen at the Second Conference of Neurology in and less obsessed with their mental troubles.
London in 1935 demonstrated that an incision The acceptance and subsequent rejection of the

Surgical instruments used in performing lobotomies (left) were inserted into the eye socket; the brain’s frontal lobe nerves were then
severed. While lobotomy was being promoted in the popular press in the 1930s and 1940s, the procedure was being severely criticized
in some medical circles. In a May 24, 1941, Saturday Evening Post story titled “Turning the Mind Inside Out” (right), Dr. Walter Freeman
points to an X-ray prior to a psychosurgical operation while Dr. James W. Watts looks on. Watts later made a break from Freeman.
 Lobotomy 473

lobotomy serve as an excellent gauge for what these procedures voluntarily, and in fact sought
both the medical establishment and society value Freeman out, others underwent the operation
in humanity. without their consent. In an era with no notion of
Moniz’s monograph on his operations, pub- informed consent, desperate families often sought
lished in Paris in 1936, helped disseminate his out the procedure.
innovation beyond Portugal. Acceptance of the
lobotomy was aided by the adoption of the oper- The Rejection of the Lobotomy
ation by American neurologist Walter Freeman Not all patients who were lobotomized ended
and his colleague, neurosurgeon James Watts. up like human vegetables, because the brain is a
Watts had trained at Yale under John Fulton, remarkably resilient organ; but irreversible brain
who also helped the operation to spread by cir- damage meant that even the better outcomes led
culating Moniz’s monograph to other neurosur- to a loss of initiative and inhibitions and a flat-
geons. Though the operation initially drew criti- tened effect. Toward the end of his career, Free-
cism from American psychiatrists, with crucial man lobotomized unruly children and unhappy
support form Adolf Meyer of Johns Hopkins and mothers, until his final patient died on the oper-
unabashed salesmanship from Freeman, it gradu- ating table. Despite the thousands of cases that
ally took hold. displayed physically and mentally devastating
Initially, lobotomies required extensive prepa- effects after the psychosurgery, Freeman was not
ration and the services of a scarce neurosurgeon. held legally accountable for his crippling work,
After World War II, Freeman, who wanted to which speaks to the lack of patients’ rights and
bring its “benefits” to the mass of institutional- the power held by the medical establishment at
ized patients, adopted a technique suggested by this time. The transorbital lobotomy procedure
an Italian psychiatrist, Amarro Fiamberti: the eventually lost popularity following the intro-
transorbital lobotomy. Using an ice pick, he broke duction of a psychotropic medication in 1955,
through the roof of the orbit and severed portions known as Thorazine. The French pharmacologist
of the frontal lobes. Transorbital lobotomy was who first demonstrated the therapeutic effects of
simple and quick, and Freeman boasted that he Thorazine for psychiatric patients described the
could train anyone, including a psychiatrist, to drug as a “chemical lobotomy.”
perform it. His use of the operation caused a While writers have been inspired by mental ill-
break with Watts and fierce criticism from Fulton, ness for centuries, in the latter half of the 20th
neither of which deterred him. century writers were particularly fascinated with
Freeman had a knack for self-promotion, and the detrimental effects of lobotomy. American
the media began describing his work as the lat- playwright Tennessee Williams, whose sister
est and greatest cure for mental illness. Amid Rose had been lobotomized and rendered inca-
photojournalistic and social scientific exposés of pacitated, depicted a character in his play Sud-
the horrifying and depressing conditions of the denly, Last Summer who was threatened with
state mental hospitals, Freeman set out to dem- a lobotomy to prevent her from releasing infor-
onstrate that there was hope for those suffering mation that would incriminate her cousin. The
from acute and chronic mental illnesses. Freeman line given by the woman’s aunt Violet, “But after
toured the country, both performing lobotomies the operation, who would believe her, Doctor?”
and instructing others in his technique. He main- shows Williams’s cultural commentary on the
tained that it would reduce the numbers in the procedure. Similarly, in Ken Kesey’s best-selling
crowded state mental hospitals, in addition to novel One Flew Over the Cuckoo’s Nest, the
cutting costs because his reformed procedure was evils of the lobotomy are a central theme, and
simple and inexpensive. Marketing his transor- are even more so in the film version starring Jack
bital lobotomy procedure directly to the public, Nicholson.
a measure typically frowned upon by the medi- In addition to its literary afterlife, the cata-
cal profession, Freeman and those following his strophic outcomes of some lobotomies also
lead performed over 40,000 procedures on men- encouraged philanthropy. As an adolescent, Rose-
tal patients. While many of the patients received mary Kennedy, the younger sister of the future
474 Lobotomy

President John F. Kennedy, was lobotomized by Further Readings

Freeman, becoming incontinent and mentally dis- Abrams, Richard. Electroconvulsive Therapy.
abled. Her sister Eunice Kennedy (Shriver) was Oxford: Oxford University Press, 2002.
inspired by her fate to start the Special Olympics. Diefenbach, Gretchen J., Donald Diefenbach,
Mental health reform was important to President Alan Baumeister, and Mark West. “Portrayal of
Kennedy, who helped prompt the legislation that Lobotomy in the Popular Press: 1935–1960.”
established community health centers. Journal of the History of the Neurosciences, v.8/1
(April 1999).
Lauren D. Olsen Pressman, Jack D. Last Resort: Psychosurgery and
University of California, San Diego the Limits of Medicine. New York: Cambridge
University Press, 1998.
See Also: Asylums; Deinstitutionalization; Valenstein, Elliot. Great and Desperate Cures: The
Electroconvulsive Therapy; Ethical Issues; Mental Rise and Decline of Psychosurgery and Other
Illness Defined: Historical Perspectives; Mental Radical Treatments for Mental Illness. New York:
Institutions, History of; Movies and Madness. Basic Books, 1986.
 M
Malaria Therapy psychiatric condition with equally profound neu-
rological symptoms, hence its initial designation
Sparking a wave of eclectic somatic treatments for as GPI. Approximately 20 percent of admissions
mental illness that swept over Western psychiatry to New York mental hospitals had GPI in the first
in the early 20th century, the Austrian psychiatrist quarter of the 20th century, with similar numbers
Julius Wagner-Jauregg introduced malaria therapy in western Europe; 88 percent of these patients
in 1917, receiving the Nobel Prize for his efforts a died of the disease. In approaching this interna-
decade later. While Wagner-Jauregg asserted that tional health crisis, Wagner-Jauregg believed in a
pyrotherapy, or fever-induced physical treatments, biological antagonism between fever and psycho-
would yield the ultimate cure for all psychoses, the sis, contending that the malaria parasite would
primary function of malaria therapy was for the induce a high and prolonged fever that would raise
treatment of general paresis of the insane (GPI), the body temperature enough to kill the mental ill-
identified definitively as tertiary- or neurosyphi- ness—which in this case was the syphilitic spiro-
lis in 1913 by Hideyo Noguchi and J. W. Moore. chete, known to be vulnerable to temperatures of
The treatment enjoyed a short-lived tenure, and its around 105 degrees Fahrenheit in vitro.
actual efficacy still remains debated by scholars, While syphilis had been well documented as a
as it was replaced by antibiotic therapy (penicil- horrifying disease in literary and medical works
lin) in 1945 before it could be properly evaluated alike, its cause and treatment remained elusive
through controlled clinical trials. until the 20th century. In 1905, Fritz Schaudinn
and Erich Hoffmann isolated the causative organ-
The Horror of Syphilis ism of syphilis, known as Treponema palladium,
At the end of the 19th century, GPI was an immedi- in the tissue of syphilitic patients. The following
ate and pervasive public health threat in the West, year, August Paul von Wassermann developed a
as the residual hypocrisy of Victorian sexual prud- revolutionary blood test for the early identifica-
ery turned a blind eye to men’s visits to brothels, tion of syphilis. This test’s cultural legacy outlived
where syphilis ran rampant. Syphilis did not dis- its medical usage, as it was deployed as a part of
criminate; both upper and lower classes contracted the eugenics movement in an attempt to restrict
the disease. While the visible marks of primary who could marry whom. By 1910, Paul Ehrlich
syphilis made it easily identifiable, the symptoms had formulated a potent mix of arsenic chemicals,
of neurosyphilis manifested as a deteriorating known as Compound 606 or Salvarsan, marketed

475
476 Malaria Therapy

to treat primary and secondary syphilis. Scholars and Wagner-Jauregg concluded that the artificial
argue about the actual efficacy of this drug, as the fevers did not reach the necessary temperature.
nature of drug trials was not nearly as standard- Then an Italian prisoner of war came under his
ized as it became in 1948 with the introduction of care, suffering from malaria but faring remark-
streptomyecin as a cure for tuberculosis. ably well with his syphilis. Wagner-Jauregg, acting
As the connection between GPI and syphilis with little regard for patient safety, sampled his
was being empirically verified, Wagner-Jauregg blood and injected the Plasmodium vivax parasite
was operating as a military physician in the Aus- into nine syphilitic soldiers. Six patients recovered
tro-Hungarian army during World War I and enough to return to their posts, even though four
had many syphilitic soldiers—in all stages of eventually relapsed in following years. Amid a
the disease—in need of treatment. Eager to find climate of widespread desperation for syphilitic
a fever cure, Wagner-Jauregg had attempted to cures, Wagner-Jauregg’s malaria therapy was
induce fevers with erysipelas, tuberculosis, and rapidly embraced as the best possible treatment
typhoid fever, as he had previously observed that for progressive neurosyphilis by many Western
some paretics fared better in febrile states. These medical practitioners. This inspired a generation
forms of pyrotherapy were clinically ineffective of other physical treatments aimed at physically

Dr. Walter Edmondson (right) with the Tuskegee Syphilis Study injects a patient with a placebo, circa 1932. Under the guise of free health
care, this clinical study conducted by the U.S. Public Health Service from 1932 to 1972 examined the natural progression of untreated
syphilis in rural African American men, for whom treatment was not provided. Similar to the exploits of Wagner-Jauregg’s malaria therapy,
this unethical breach of ethical considerations demonstrates that standards of patients’ rights and protection are a newer phenomenon.
 Malpractice 477

eradicating mental illness, such as surgical bac- See Also: Ethical Issues; Eugenics; Human Rights;
teriology, electroshock and insulin coma therapy, Iatrogenic Illness; Insulin Coma Therapy; Nazi
lobotomy, and diathermy machines. Extermination Policies; Neurosyphilis; Patient Rights;
Sex; Stigma; Therapeutics, History of; War.
Questionable Triumph
Typical of the era, this medical triumph of malaria Further Readings
therapy was rife with questionable ethics. This Braslow, Joel. Mental Ills and Bodily Cures:
vast and dangerous experimentation, in addition Psychiatric Treatment in the First Half of the
to the less-than-adequate safety precautions taken Twentieth Century. Berkeley: University of
by physicians implementing the therapy, led to California Press, 1997.
many deaths and iatrogenic maladies. For exam- “Pyrotherapy of G.P.I.” The Lancet, v.237/6133
ple, as highlighted by William Alanson White, (1941).
the superintendent of St. Elizabeth’s Hospital in Scull, Andrew. Madhouse: A Tragic Tale of
Washington, D.C., the symptoms of neurosyphi- Megalomania and Modern Medicine. New Haven,
lis closely resembled other mental illnesses so that CT: Yale University Press, 2005.
many nonsyphilitic patients were given not only
malaria but also syphilis in the attempt to “cure”
them. Such carelessness and disregard for the
value of the lives of vulnerable patients was char-
acteristic of the medical establishment at the time. Malpractice
The American psychiatrist Henry Cotton per-
haps best exemplifies this outrageous breach of Malpractice is a legal concept used to indicate
ethical considerations. In his surgical bacterio- that someone in the practice of their professional
logical exploits—serious injuries and deformities role engaged, either by omission or commission,
aside—he achieved a 44 percent mortality rate. in conduct that is unacceptable by professional
Modern standards of patients’ rights and protec- standards; it is legally regarded as an appropriate
tion are a new phenomenon, as Wagner-Jauregg, basis for awarding damages to another who was
Cotton, and the researchers involved in the Tuske- harmed by that behavior. The term malpractice
gee experiment clearly demonstrate. Essentially, comes from a combination of a Latin word and
any scientist or physician could conceive of a a Greek word; “mal” is from the Latin malum,
hypothesis and conduct experiments on the popu- meaning an evil, and “practice” is from the Greek
lation at their own discretion. This ended when praxis, an action; thus, malpractice means an evil
the medical atrocities in Germany and Japan dur- action. Malpractice is somewhat common with
ing World War II, exposed by photojournalists, respect to areas of mental health.
came to light. There are two standards that are typically
In addition to the glaring violation of mental applied to determine whether general liability for
patients’ rights, another crucial implication of the malpractice exists. These are the average practi-
introduction and acceptance of malaria therapy tioner standard and the reasonably prudent prac-
was the cultural meaning embedded in an effica- titioner standard.
cious treatment. Many middle- and upper-class The average practitioner standard still holds
individuals in the West contracted and suffered for less than half the states in the United States,
from syphilis, and therefore the introduction and the rest now hold to the reasonably prudent
of what appeared to be an effective treatment practitioner standard. Under the latter, one can
altered the course of not only the patient’s accep- be found liable if one failed to provide reason-
tance of medical care but also the way in which able and prudent care, considering all circum-
they were perceived by their physicians and the stances, whereas under the former, one could not
public at large. be found liable if one adhered to the customary
practice of the average professional in the field.
Lauren D. Olsen The determinants of the standard of care have
University of California, San Diego included federal and state guidelines for mental
478 Malpractice

health practitioners, other court cases, the profes- For example, if a mental health professional
sional literature (including journal articles, text- takes advantage of his or her position of power
books, and Web sites), and institutional policies or trust and crosses expected boundaries, then
and procedures. These standards also hold for there may be adequate grounds for a malpractice
mental health practice. case. A mental health professional having sexual
Another condition that must be met to substan- relations with a patient is one of the more com-
tiate a mental health malpractice case is that of mon examples of violating the trust relationship.
foreseeable harm caused by the negligence of the If nothing else, emotional harm to the patient
mental health professional or agency involved. would generally result from such a breach of the
This harm can take on many different forms; expected trust relationship. Another common
the types of harm used to prove a case of mal- type of malpractice is when a physician prescribes
practice include pain and suffering on the part of the wrong medication, or even the wrong dos-
the victim or his or her family, the cost of future age if an appropriate medication for the patient’s
treatments to remediate whatever other harms mental health condition was prescribed.
were caused by the negligence, the loss of earning A less common type of mental health malpractice
capacity, and the loss of the ability to enjoy life. is that of third-party liability. This would involve
The issue that must be demonstrated is that the the patient threatening to harm another individ-
purported negligence on the part of the mental ual. If the mental health professional was aware
health professional or agency actually caused the of the threat and believed this threat to be cred-
harm. Establishing this causal link can sometimes ible but failed to warn the intended victim, then
be very difficult. the patient or his or her surviving family could sue
the professional for malpractice. This became the
Types of Legal Cases in Mental Health Care standard of mental health care in 1976, with the
The risk of liability for malpractice is signifi- Tarasoff v. Regents of the University of California
cantly enhanced if it can be demonstrated that case, which held that a mental health professional
the professional or agency failed to follow its had a duty to protect others from potential serious
typical practices and procedures for treating a danger of violence from one of their patients. In
mental health patient. Expert testimony is usu- other words, the mental health professional incurs
ally necessary to support the contention of dam- an obligation to use reasonable care to protect the
age, as well as to support the claim of direct cau- intended victim from such possible harm by one of
sation. For example, if a patient caused a motor their patients.
vehicle accident, and if it can be demonstrated Although a mental health professional may
that the treatment, such as a sedative prescrip- contract to render services, a malpractice suit is
tion, was somehow responsible for an error in based on the law of torts, not on that of con-
judgment on the part of the driver, then a mal- tract law. Tort law imposes the duty of a pro-
practice case may ensue. Consequently, the harm fessional to exercise the normal skill and judg-
that occurs must be shown to be the direct result ment of the respective scope of practice; if this
of the specific treatment chosen and implemented is not done, then he or she can be held liable
by the mental health professional or agency. A for negligence. The fact that the mental health
related issue sometimes raised by the defense in professional performed “as well as they could,”
malpractice suits is that of contributory negli- which failed because of a lack of proper train-
gence on the part of the patient, but most courts ing or additional expertise or experience, may
have held this position to be somewhat anoma- not be sufficient to protect against a tort claim.
lous because it is the patient’s high-risk behaviors Further, if the mental health professional guar-
that generally brought them to the attention of anteed the results of their work, the law could
the mental health professional for treatment in endeavor to enforce that guarantee. However, if
the first place. no guarantee was made, the professional will be
The most common type of mental health mal- judged by the standard of a reasonably prudent
practice case involves exploitation of the trust rela- mental health professional in the same or simi-
tionship between the patient and the professional. lar circumstances. In addition, the mental health
 Malpractice 479

professional with superior knowledge, skills, As soon as the allegation of malpractice is made,
and training can be judged by a higher standard the mental health professional is on the defen-
than that of the average professional in a similar sive as his or her reputation is instantly on the
circumstance. This is sometimes referred to as line, regardless of the purported assumption of
the “standard of excellence.” innocence. The charge of malpractice, even if
Temporality is an issue related to when the unfounded, can carry a heavy burden of stigma
actual claim of malpractice arises. Previously, it for the mental health professional.
was widely held that the malpractice claim arose
when the defendant professional in some way Mitigation of Malpractice Suits
damaged the patient or plaintiff. This tenet fre- Informed consent is a relatively important doc-
quently protected mental health professionals trine that requires mental health professionals
from their negligent actions. However, it is now to adequately inform patients about any signifi-
more commonly held that a claim of malpractice cant risks that may be connected with the specific
arises with respect to mental health, not at the treatment approach considered. If the provider,
time of the actual damage, but rather when the whether a psychiatrist or other mental health
plaintiff discovered, or reasonably could have dis- professional, fails to fully inform the patient and
covered, the harm and its likely cause. Further, harm subsequently occurs, then the patient may
most malpractice cases are settled for a fee before have a valid claim of malpractice, even if the
going to trial. professional had exercised reasonable care in the
In most cases, the judge and jury are in no posi- delivery of services.
tion to assess the specifics of what would consti- Victims of mental health malpractice have
tute the normal standard of care for most mental recourse to several options. They can consult with
health professionals in the same or similar cir- a lawyer and/or a mental health advocate to con-
cumstances. Accordingly, the plaintiff, the person sider whether to bring forth a malpractice law-
charging an act of malpractice on the part of a suit. They can also file a human rights complaint
mental health professional or agency, must gen- with the appropriate local human rights officer. A
erally provide expert testimony to help explain complaint can also be filed with the alleged per-
what the accepted standard of care is and to petrator’s employer, whether an agency, hospital,
educate the jury on this conduct so that they can state, or other public or private entity. In addi-
determine whether malpractice has actually been tion, an ethics charge can be filed against the pro-
committed or not. fessional involved if there was a deviation from
In the past two decades, there have been several the accepted standard of care.
high-profile psychiatric malpractice suits. These There are codes of professional ethics that
generally have involved circumstances such as a mental health professionals must abide, and the
patient’s suicide, a mental health professional’s respective organizations that certify or license
sexual misconduct against a patient, a patient’s respective professionals generally review such
violent acts against others, the propriety of invol- charges, which could ultimately impact the keep-
untary treatment, or the use of unconventional ing of the respective professional credential that
treatments. Betrayal and violence are recurring allows them to practice their trade. The aggrieved
themes in these types of mental health malprac- party could also speak directly to the professional,
tice cases. seeking an apology, admission of guilt, or even
Many mental health malpractice cases have no redress. Alternatively, one could collaborate with
substantial merit, yet they can be extremely diffi- other victims of the same mental health profes-
cult for the mental health professional to endure, sional or agency and consider deciding upon an
even if they are ultimately exonerated. Expert action as a group. Mental health support groups
testimony is likely to be given by the prosecution can be helpful in this process, particularly when
that will attempt to portray conscientious and trying to identify other alleged wronged individu-
compassionate mental health care on the part of als. Some settlements in psychiatric malpractice
the defendant as below the standard of accepted cases have been in the range of hundreds of thou-
care, which is very difficult to define objectively. sands of dollars.
480 Mania

There was a general medical malpractice insur- Mania

ance crisis in the United States in the 1990s and
early 2000s, similar to another crisis that had Mania is a partial symptom of bipolar disorders,
appeared in the early 1970s. These crises, which a type of mood disorder that has been observed in
significantly impact mental health practitioners, most cultures. Mania is characterized by unusu-
were caused by changes in the laws that were ally elevated mood, increased energy, excitabil-
more favorable to a finding for plaintiffs. As a ity, and is often accompanied by unrestrained
direct consequence of such legal changes, the irritability, restlessness, and hostility. Over time,
costs of obtaining malpractice insurance rose people exhibiting or viewing manic behavior
prohibitively. This made it extremely difficult have expressed conflicting views of the need for
for many mental health professionals to obtain treatment. Because mania has occasionally been
or afford reasonable coverage. However, there is associated with recreational drug intoxication,
some evidence that the insurance industry over- or even creativity and artistic talent, the manic
reacted to the legal changes, and the accumulat- traits do not always necessitate serious con-
ing evidence did not support a substantial rise cern. Diagnostic criteria for mania have changed
in either the number or the size of malpractice over time and across cultures. Researchers
claims. Some critics noted that there appeared to have defined mania as part of a mood disorder.
be an increase in the number of frivolous lawsuits Mania’s etiology remains unclear, though it has
brought about by attorneys seeking high com- been speculated that its symptomology develops
missions. On the other hand, many cases of men- through an interaction of demographic, genetic,
tal health malpractice are never reported because and social factors.
the victims may be emotionally unstable or even Decades ago, clear diagnostic criteria for mania
somewhat uncertain as to the specific nature of were not available, leading to varied definitions of
their mental illness. manic traits. Today, however, the efforts to maxi-
mize the reliability of psychiatric diagnoses means
Victor B. Stolberg that there are clear definitions and diagnostic cri-
Essex County College teria for mania in the Diagnostic and Statistical
Manual of Mental Disorders (DSM). Diagnoses
See Also: Competency and Credibility; Courts; with mania are more prevalent in recent times,
Ethical Issues; Informed Consent; Psychiatric so this clarification and perhaps broadening of
Training; Right to Refuse Treatment; Suicide: Patient’s diagnostic criteria has led to the higher reported
View. prevalence. Several standardized diagnostic
instruments have been developed to reduce vari-
Further Readings ability in mania-related assessment. Some cultural
Kelley, James L. Psychiatric Malpractice: Stories factors may put individuals at risk for developing
of Patients, Psychiatrists, and the Law. New manic symptoms.
Brunswick, NJ: Rutgers University Press, 1996.
Knoll, James and Joan Gerbasi. “Psychiatric Definitions and Characteristics
Malpractice Case Analysis: Striving for The DSM states that disturbances in mood are
Objectivity.” Journal of the American Academy of the primary traits of mood disorders, including
Psychiatry, v. 34/2 (2006). the symptom of mania. Manic episodes are char-
Robertson, Jeffrey D. Psychiatric Malpractice: acterized by a reduced need for sleep, disturbed
Liability of Mental Health Professionals. New and scattered thought processes, forceful speech
York: Wiley Law Publications, 1988. patterns, increased impulsivity (e.g., hypersexu-
Simon, Robert I. Psychiatric Malpractice: Cases and ality, social and occupational impairment) and
Comments for Clinicians. Arlington, VA: American increased risk-taking behavior. Manic distur-
Psychiatric Publishing, 1992. bances can be severe enough that an individual
Smith, Joseph T. Medical Malpractice: Psychiatric may require hospitalization or institutionaliza-
Care. Colorado Springs, CO: Shepard’s/McGraw- tion so that he or she does not harm him- or
Hill, 1986. herself. There are gender differences in manic
 Mania 481

symptomology. Males present more often with

hyperactivity, risk-taking behavior, unusually
high self-confidence, and distractibility. Females,
on the other hand, often present with primary
symptoms of distractibility and racing thoughts.
Individuals who suffer from mania often experi-
ence delusions, which is why mania can be con-
fused with schizoaffective disorders.
Multiple manic episodes must be present for
a mood disorder diagnosis to be considered. At
least one manic episode expressing persistently
elevated mood and irritability and lasting at least
one week must be present to meet the criteria for a
bipolar I disorder. Less severe manic states such as
hypomania often do not impair functioning to the
same degree as a full manic episode. During cyclo-
thymia (a noticeable fluctuation in high and low
moods, often accompanied by a stable baseline
mood that is not as intense as the mood variation
in bipolar I disorder), hypomanic (below manic) Thomas Rowlandson’s The Maniac, or Visiting Papa in Bedlam
episodes oscillate between depressive symptoms (1787). In the 1700s, treatment for “mania” at Bethlem
and may include psychotic features such as gran- (Bedlam) Royal Hospital in London was brutal and humiliating.
diosity, hallucinations, and delusions and gener- Today, there are clear definitions and diagnostic criteria.
ally have a duration of at least four days. It is pos-
sible for mania sufferers to exhibit mixed states,
where individuals are experiencing both depres-
sive and manic symptoms concurrently. white males tend to have more manic episodes
than Hispanic males. One epidemiologic study
Cultural Variations of mood disorders among the Amish showed an
Researchers have noted that certain cultures seem extremely low prevalence of mania and depressive
to be associated with higher rates of bipolar-related symptoms, suggesting that strict religious back-
illness. It is unknown whether this difference is grounds and reduced exposure to drugs/alcohol
because of genetic or specific cultural factors. may reduce the risk of manic symptoms. Research
For example, the prevalence of manic symptoms examining the prevalence of mania in rural and
is higher in Indonesia and among the Hutterites urban areas and that has been conducted in
in North America. Similarly, higher rates have various cultures has found that the incidence of
been identified in individuals of European Jew- mania is more common in urban areas compared
ish decent, compared to those from North Africa. to rural areas. Researchers have also found that
Migration is one factor that has been thought to the prevalence of mania is significantly lower in
lead to an increased risk for mania. It is unclear the Netherlands relative to other countries; how-
whether those with a predisposition to mania and ever, the reasons for this are not yet known.
bipolar illness are triggered by the migration pro-
cess, or if individuals prone to mania are more Etiology, Epidemiology, and Treatment
likely to migrate in the first place. A precise cause of mania is unknown. However,
There are several other cultural factors that several risk factors for mania have been identi-
affect the incidence of mania. Although there fied. The onset of manic episodes typically occurs
seems to be a similar prevalence of bipolar disor- around age 30. Studies suggest that patients
der among genders, episodes of mania are more with mania usually have relatives with bipolar
prevalent in men. Black males tend to present or schizoaffective disorder. Mania is more com-
with more manic episodes than white males, and mon among higher socioeconomic classes, while
482 Marginalization

a diagnosis of psychosis is more common among because medications often have dangerous and
people in lower socioeconomic brackets. However, unpleasant side effects, pharmaceutical treat-
the diagnosis of psychosis is often given before ments for this condition need to be monitored
considering bipolar symptoms, which may skew closely. Lithium, the most common mood stabi-
data on the actual prevalence of mania. Individu- lizer for mania, balances affective systems, which
als who have never been married are more likely ultimately stabilize both manic and depressive
to experience mania than married individuals. states. Although it is tolerated fairly well, some
Over half of individuals diagnosed with mania patients experience side effects such as decreased
have histories of substance abuse, but it is often kidney function, tremors, hormonal imbalances,
difficult to determine whether changes in mood and cognitive impairment. Mood stabilizers and
are induced by the substance use or mania. After antipsychotic drugs are standard drug treatments
childbirth, women are at higher risk for experi- for mania. These drugs alter dopamine and sero-
encing manic episodes. tonin levels in the brain, so it is common to briefly
In some cases, it has been suggested that there hospitalize patients to reduce the likelihood of
are abnormalities in the brain structure of those neurological effects such as neuroleptic malignant
with mania. Brain-imaging studies have produced syndrome. Anticonvulsants have also been used
claims that those with mania frequently have to treat mania. Drug therapy, in combination
inflated third ventricles. Mania is often present with cognitive behavioral therapy, appears to be
when individuals have brain lesions, where degen- the most effective treatment of mania.
eration of nuclei or tumors are present, suggesting
that there is a pathway of mania that is anatomical Shannon Bierma
in nature. Enlargement could be because of vol- Ryan Shorey
ume loss in the hypothalamic areas of the brain, JoAnna Elmquist
which is of particular interest to mania research- Gregory L. Stuart
ers because this area controls circadian rhythms, University of Tennessee, Knoxville
and individuals with mania experience sleep dis-
turbances. Specific nucleotide repetitions have See Also: Bipolar Disorder; Lithium; Mood
been found in individuals diagnosed with mania, Disorders; Unquiet Mind, An.
and an excessive buildup of calcium in cells has
also been linked to mania in some studies. Further Readings
Once an individual begins experiencing manic American Psychiatric Association (APA). Diagnostic
episodes, further manic episodes will follow 90 and Statistical Manual of Mental Disorders. 4th
percent of the time. Depressive states often fol- ed. Washington, DC: APA, 2000.
low manic episodes, creating a cyclical pattern Tsuang, M. T., M. Tohen, and P. B. Jones. Textbook
for individuals suffering from bipolar disorder. in Psychiatric Epidemiology. 3rd ed. New York:
Manic episodes often occur for shorter intervals John Wiley & Sons, 2011.
of time, typically present for about four months, Winokur, G. and M. T. Tsuang. The Natural History
compared to the depressive states that can last of Mania, Depression, and Schizophrenia.
up to six months. Recovery from manic episodes Washington, DC: American Psychiatric Press,
varies from months to years and often results in 1996.
only partial recovery. In the 10 percent of the
patients who experience rapid cycling (i.e., four
or more periods of mania in one year, alternat-
ing with depression), recovery is less likely com-
pared to those who do not experience rapid Marginalization
cycling. Mania cycles are often associated with
seasonal changes and are more likely to occur in Marginalized groups are excluded from full par-
spring or summer. ticipation in mainstream social, cultural, eco-
Because the hypothesized biological mecha- nomic, and/or political activity and thereby are
nism behind mania is still largely unknown, and accorded less power in terms of decision making
 Marginalization 483

or distribution of assets. The concept of margin- Typically, members of the majority group try to
alization is typically linked with the notion of avoid the marginalized group. The marginaliza-
relative deprivation. People with mental illness, tion of people with mental illness can take several
especially serious and persistent mental illness, forms, including social distancing, outright rejec-
often report that they feel excluded from general tion, or subtle “othering.” In studies assessing
society; objective evidence corroborates their sub- social distancing, researchers ask respondents to
jective reports. People with mental illness suffer rate on a scale how much closeness they would
employment discrimination. A disproportionate accept in terms of a relationship with a hypotheti-
number of mentally ill people are homeless or cal person, and a series of relationship vignettes
imprisoned. There are restrictions on their abil- are described in questionnaire format. Alter-
ity to vote, serve on juries, or otherwise affect natively, some respondents are provided with
the legislative process. Mental illness stigma is a list of groups and are asked to rate whether
the greatest contributor to the marginalization of they would accept a member of that group in a
people with mental illness. Strategies for combat- particular social role (e.g., neighbor, roommate,
ing the marginalization of the severely mentally teacher, or partner).
ill include fighting mental illness stigma, altering Research shows that members of the general
one’s language, and strengthening advocacy. public prefer to maintain their social distance
Mental illness stigma is fairly ubiquitous; from mentally ill individuals. In terms of choice
research documents a relatively low level of of social partners, people tended to rank individu-
acceptance toward people with mental illness in als with mental illness as the least preferred of all
North America (the United States and Canada), people with disabilities. Although they may feel
Europe, Asia, and sub-Saharan Africa. Despite initially positive or even neutral toward the idea
considerable advances made in terms of the scien- of mentally ill individuals living in the general
tific understanding of the etiology and treatment community, many surveyed readily admitted to
of psychopathology, myths, fears, and misunder- feeling uncomfortable having a person with men-
standing about mental illness persist. tal illness as a teacher or day care provider for
their children. Similarly, many respondents were
Stigma reluctant to accept a person with mental illness as
According to the results of the National Comor- a sibling’s life partner, life partner for their child,
bidity Survey and the National Comorbidity or their own life partner. However, they were
Survey Replication, approximately 6 percent of more willing to live near or work at the same job
all U.S. adults have a severe mental illness. For with a hypothetically mentally ill person.
some members of the public, the mass media may
be their primary source of information about Rights
psychiatric disorders and the people who are Despite the passage of the Americans with Dis-
affected by them. Analyses of television portray- abilities Act (ADA) in 1990, which prohibits dis-
als reveal that mentally ill characters are more crimination in the workplace on the basis of any
likely than other characters to commit violence disability, most people with severe mental illness
or to be victimized. Television programs and are unemployed. In-depth interviews and/or focus
movies typically portray mentally ill characters groups with mentally ill employees reveal that
unfavorably, as “bad” or “evil,” unemployed or there is mental illness stigma in the workplace.
unsuccessful, which serves to reinforce prejudi- Mentally ill individuals who return to work fol-
cial attitudes and mental illness stigma. Similarly, lowing a psychiatric hospitalization or an acute
newspapers and magazines frequently emphasize episode of illness frequently report perceiving a
themes of violence and dangerousness when cov- change in how they’re viewed by their cowork-
ering mental illness. Such articles further perpet- ers and/or supervisor. People with mental illness
uate stigma. This stigma provides the basis for are overrepresented in the lower socioeconomic
the social exclusion of people with mental illness, strata. Some forms of severe mental illness, such as
whether in terms of social networks, employment schizophrenia, may also exert a deleterious effect
settings, or neighborhoods. on a person’s socioeconomic mobility, resulting in
484 Marginalization

“downward social drift,” which may contribute behalf of their affected relatives because of the
to the marginalization of this subgroup. stigma associated with the disorders. Increasingly,
Whereas marginalization would be something mental illness advocacy organizations such as the
that others do toward people with mental illness, National Alliance on Mental Illness have lobbied
social isolation is the behavior that people with for such policy issues as mental health parity in
mental illness may perform, either proactively or insurance coverage, greater government funding
reactively. Individuals with mental illness may for social services for mentally ill people, and
withdraw from social interactions and settings more research funding for the National Institute
(including employment opportunities) in antici- of Mental Health. In addition to these actions,
pation of negative reactions from others; this is greater democratic participation of its constitu-
known as self-stigma (i.e., internalized stigma). In ents on various levels of government will be key.
order to avoid anticipated rejection, some people When a group is marginalized, it is regarded
with mental illness may prefer not to apply for a and treated as “other” or “not us.” Language
position or housing for which they may otherwise can be used as a way of further marginalizing
be qualified. a group. Mental health advocates have pointed
The disproportionate number of people with out that the differential way in which language is
serious mental illness among the homeless popula- used to refer to people with serious and persistent
tion is a reflection of the extent of this group’s mar- mental illness is both a reflection of the extent of
ginalization. According to the Federal Task Force their difference and a way of further marginaliz-
on Homelessness and Severe Mental Illness, the ing them. Although health professionals and the
percentage of the adult homeless population with public would not think of referring to a person
some form of severe mental illness ranges from with cancer as “a cancer,” until recently, it was
25 to 37 percent. The National Coalition for the not uncommon to hear the same professionals
Homeless estimates that approximately 6 percent refer to a person with schizophrenia as “a schizo-
of the severely mentally ill population is homeless phrenic.” Mental illness is not all that defines that
at any point in time. person, any more than cancer is all that defines a
Individuals with severe mental illness have tra- person with that diagnosis.
ditionally been excluded from participating in the One way of combating the marginalization of
political process. There are some barriers to peo- people with mental illness is to use “people first”
ple with severe mental illness having full access to language, that is, referring to someone as a per-
voting. In the United States, there are disability- son with schizophrenia because in doing so, the
related restrictions on the right to vote in all but speakers acknowledge that although the person
15 states. Although only a court can decide that is affected by an attribute (the mental illness),
a person is not competent to vote, election offi- they are still part of the community, rather than
cials and/or service providers may impose voter becoming the attribute (the mental illness).
competence requirements. In addition, some per-
sons with mental illness may be barred from vot- Diane C. Gooding
ing because of a conviction history. A person with University of Wisconsin, Madison
severe mental illness is more likely to be arrested
than someone without mental illness in similar See Also: Acculturation; Antisocial Behavior;
circumstances (e.g., drunkenness, disorderly con- Mass Media; National Alliance on Mental Illness;
duct, and/or assault), and they are more likely Neighborhood Quality; Social Isolation; Stigma;
to be remanded for lesser offending when the Vulnerability; Welfare.
offending is associated with mental illness. More-
over, people with severe mental illness are dispro- Further Readings
portionately represented in prison populations. In Kelly, B. D. “The Power Gap: Freedom, Power and
many states, once convicted of a felony, a person Mental Illness.” Social Science & Medicine, v.63
loses their voting privileges. (2006).
Families of people with severe mental illness Morgan, C., T. Burns, R. Fitzpatrick, V. Pinfold, and
may feel limited in their ability to advocate on S. Priebe. “Social Exclusion and Mental Health:
 Marital Status 485

Conceptual and Methodological Review.” British separated individuals experience the highest levels
Journal of Psychiatry, v.191 (2007). of psychological distress and report more depres-
Wahlt, O. F. Media Madness: Public Images of Mental sive symptoms than happily married adults.
Illness. New Brunswick, NJ: Rutgers University While previous research suggested that the
Press, 1995. benefits of a healthy marriage were greater for
men than for women, contemporary research
shows that married men and women experience
better mental health at similar levels. However,
men and women are susceptible to different
Marital Status mental illnesses in varying degrees: Depression
and anxiety disorders are more common among
Marital status has frequently been studied in rela- women, whereas the prevalence of alcohol
tion to the mental and physical health of men and dependence and antisocial personality disorder is
women. Single classifications include divorced, higher among men. These rates also vary based
separated, widowed, cohabiting, or in a civil on the marital satisfaction of men and women,
union or domestic partnership. In many cultures, with happily married people reporting the fewest
marital status has symbolic meanings, such that distressing symptoms.
being married is often valued or preferred because Marital status relates to differences in mortal-
it is in line with many cultures’ values and because ity rates of men and women. Married men and
of its perceived social and economic benefits. women have a lower mortality rate than unmar-
ried men and women. Marital status has a much
Marital Status and Its Connection to Health larger effect on the life expectancy of men than
A large body of research has shown a connection women, in part because of the emotional connec-
between marital status and mental and physical tion that men feel to their partner. While women
health. Married people are mentally and physi- more easily form emotional relationships with
cally healthier and have longer life expectancies friends and family members, men are likely to
than those classified as single; this association is share emotions with their partner more than with
much stronger for those who are very satisfied others. Thus, having a confidante in a partner
with their marriage. This relationship is explained provides an emotional outlet for men and encour-
by the factors of protection and selection. Protec- ages psychological well-being.
tion means that marriage provides social support Because of the social support and emphasis on
and resources that improve mental and physical health and longevity within marriage, happily
health, while selection asserts that mentally and married men and women are more likely than
physically healthier men and women are more single or divorced men and women to seek help
likely to marry. Regardless of the explanation, for distressing psychological or physical symp-
the social support and stability provided through toms. In addition to seeking help from a spouse
marriage is a key aspect of mental health. or other nonformal resource, married men and
Happily married people live longer and are women are more likely to seek help from psycho-
more resilient to mental and physical illnesses logical or medical professionals. The psychosocial
because of the emotional connection with an inti- support experienced by those in happy marriages
mate partner, access to resources, and social sup- helps lessen the impact of negative emotions and
port provided by a spouse. Regardless of gender, creates an environment in which health is valued;
single people experience poorer mental health thus, seeking help is encouraged. Because women
and are more susceptible to mental illnesses than commonly assume the role of caretaker and more
married couples. Simply being married is not commonly seek help than men, women encourage
enough to boost overall health. Quality of mar- male spouses to seek help. Married men exhibit
riage is significant in determining the effect of the greatest increases in help-seeking behavior
marital status on mental health. Unhappy mar- compared to single men or to single or married
riages tend to increase stress and lessen positive women because of the emphasis that women
mental health benefits. In addition, divorced and place on the well-being of male partners. Married
486 Marketing

couples also have greater financial resources and See Also: Children; Family Support; Gender; Help-
often have increased access to health insurance Seeking Behavior; Women; Work–Family Balance.
through a spouse, which makes help seeking more
feasible. Further Readings
Socioeconomic status (SES) increases with mar- Katz, Alfred. Self-Help: Concepts and Applications.
riage, with an increase in economic resources, Philadephia: Charles Press, 1992.
decrease in separate expenses, and benefits pro- Schoenborn, Charlotte A. “Marital Status and
vided to married couples (e.g., tax benefits and Health: United States, 1999–2002.” Advanced
health insurance coverage). Happily married Data From Vital and Health Statistics. Hyattsville,
couples experience higher SES throughout their MD: National Center for Health Statistics, 2004.
lives and lower mortality rates. Marriage, com- Wood, Robert G., Brian Goesling, and Sarah Avellar.
bined with the added resources of two sources of The Effects of Marriage on Health: A Synthesis of
income, is responsible for better mental health out- Recent Research Evidence. Washington, DC: U.S.
comes relative to those who are single or divorced. Department of Health and Human Services, 2007.
Approximately 10 percent of low-income adults
who are widowed, divorced, or separated expe-
rienced serious psychological distress, while
about 5 percent of low-income married adults
reported similar distress. For low-income couples, Marketing
a healthy marriage serves as a protective factor
by providing health benefits comparable to those Demand for psychopharmaceuticals to treat men-
experienced by higher-income couples. However, tal health problems has never been higher, with
despite the benefits of marriage, low-income mar- pharmaceutical corporations expending consid-
ried couples are more likely to divorce or separate erable sums to market both products and men-
than high-income couples because of the stress of tal health disorders to the public. About 27 mil-
having fewer resources. lion Americans have taken antidepressants since
Marital status is associated with hospitaliza- 2005, according to a study in the Annals of Inter-
tion and healing time for those with distressing nal Medicine, with demand propped up by bil-
psychological and physical symptoms. Those in lions of dollars of marketing aimed directly at the
happy marriages tend to recover faster than their consumer. Rules prohibiting direct to consumer
unmarried peers. As a result, unmarried individu- advertising are in place in nations such as Japan
als spend more time in hospitals, thus incurring and the United Kingdom. In contrast, the U.S.
higher health care costs. In addition, unmarried Food and Drug Administration (FDA) allows this
single men are about five times more likely to be practice and has relaxed rules over time, leading
admitted to a psychiatric facility than married to a transformation in popular beliefs about men-
men. Marital status has a large influence on mental tal conditions and treatment practices.
health. Individuals in happy marriages are believed Other marketing strategies employed by the
to have the best outcomes, while divorced or wid- psychopharmaceutical industry include sales
owed individuals are found to have the worst out- visits to doctor’s offices and free drug samples,
comes. Socioeconomic status is strongly related the financial support of mental health advocacy
to marital status, with married couples tending to groups, the promotion of positive clinical trial
have more resources than single individuals. outcomes to the mass media, and the financial sup-
port of many of the physicians who define mental
Lindsay Labrecque health disorders in the Diagnostic and Statistical
Andrew Ninnemann Manual of Mental Disorders (DSM), a diagnosis
Brown University and treatment guidebook widely used around the
Joanna Elmquist world by health care professionals, as well as legal
University of Texas–Pan American institutions and insurance companies.
Gregory L. Stuart Advertisements for psychopharmacological
University of Tennessee, Knoxville drugs to treat the most common mental health
 Marketing 487

conditions, such as depression and anxiety, have premenstrual dysphoric disorder. While the man-
become a regular feature in the mass media in the ner in which SSRIs work is still little understood,
United States since 1997, when the FDA allowed they remain one of the most commonly pre-
pharmaceutical companies to market products scribed classes of drugs in the psychopharmaco-
directly to the consumer (DTC). Drugs promoted logical tool kit. However, disturbing withdrawal
DTC sell better than those that are not heavily symptoms appear in as many as a quarter of
advertised, affecting both spending and use, so patients taking these drugs, and suicidal ideation
that between 1999 and 2000, the rate at which and behavior was discovered to be twice as high
prescriptions for all drugs were dispensed rose in young patients taking SSRIs as in those tak-
25 percent for advertised drugs, but only 4 per- ing a placebo. In 2003, the United Kingdom (UK)
cent for those not heavily advertised in the same Department of Health banned the prescribing of
period, according to the U.S. General Accounting SSRIs to children and adolescents under the age of
Office. Regulatory requirements for DTC adver- 18. The American FDA issued a similar warning
tising were relaxed in 1999, so that product claim the following year and published a violation letter
ads no longer have to list all the product risks; to drug manufacturer GlaxoSmithKline (GSK) in
and in 2004, they were further relaxed by the response to “false or misleading” television com-
FDA, allowing for simplified language and brief mercials for the SSRI drug Paxil CR (paroxetine
summaries about prescribing information and hydrochloride) that sought to expand the use of
major risks. Spending on all DTC pharmaceuti- Paxil CR beyond the conditions for which it was
cal advertising approached $4 billion in 2011, originally approved. GSK also agreed in 2004 to
according to Nielsen, with over 60 percent of the settle charges of consumer fraud over the way
expenditure allocated for television advertising. that they systematically suppressed unfavorable
research results from the public as part of their
Aggressive Advertising of Drugs overall marketing strategy.
Claims made by drug companies in advertising While the marketing of psychopharmaceuticals
campaigns for psychopharmaceuticals have long purports to be tightly governed by government
been the focus of scrutiny, leading in some cases agencies, there are no such guidelines for the mar-
to lawsuits and the withdrawal of drugs from sec- keting of mental health diseases. In Japan, where
tions of the market. In the early 1970s, advertis- Western concepts of depression were unheard
ing by the drug company Sandoz for a new drug, of prior to World War II, drug companies such
Serentil (mesoridazine), led to scrutiny in the U.S. as SmithKline Beecham (now GlaxoSmithKline)
Senate both because of the way that it redefined had to influence Japanese cultural conceptions of
common behaviors as disordered and the broad- sadness and depression before they were able to
ness of symptoms that the drug purported to successfully market drugs such as Paxil. Psycho-
treat. Promising pharmacological relief from the pharmaceutical companies sponsored the dissem-
“disordered personality” that results in “anxiety ination of new ideas about depression into Japa-
that comes from not fitting in,” even the name of nese culture through newspaper articles, popular
the drug had been carefully constructed to evoke lectures, self-diagnosis guides in magazines with
a positive emotional response. Following the rul- generalized symptoms such as fatigue, and the
ing that the advertisement was guilty of over- sponsored translation of best-selling American
reach, drug manufacturer Sandoz subsequently books on depression that advocated the use of
withdrew it. antidepressants. Suicides, which claimed the lives
New classes of mental health care drugs have of over 30,000 Japanese a year in the early 1990s,
been accompanied by innovative definitions of were reframed by drugs companies as cases of
disorders, but also new risks for patients. Selec- untreated mental illness.
tive serotonin reuptake inhibitors (SSRIs) were Unable to advertise drugs directly to the con-
marketed in the late 1980s for use in treating sumer in Japan, drug trials were used as adver-
depression, and their use would be expanded in tisements that promoted mental illness as a com-
the following decades to treat newly defined dis- mon complaint. The metaphor kokoro no kaze,
orders such as generalized anxiety disorder and likening depression to a “cold of the soul,” was
488 Mass Media

promoted in popular narratives, implying that dramatically broadening the reach of such claims,
depression was a physical condition as ubiqui- until social anxiety disorder became a widely
tous as a cold, for which a medical treatment accepted condition and one of the most widely
was only a doctor’s visit away. Falling into the diagnosed conditions in the Western world.
marketing strategy, celebrities started to talk An analysis of the process by which mental
about their experiences of depression, and in disorders and their associated palliative drugs
2004, the Imperial Household Agency acknowl- are marketed to the public does not fully explain
edged that Crown Princess Masako was taking why people experiencing mental health problems
antidepressant medication. Doctor visits related are willing to accept a diagnosis and its associ-
to depression jumped by 46 percent from 1999 ated stigma. What is certain is that the marketing
to 2003, and both sales and advertising expen- of mental health disorders as extremely common
ditures on psychopharmaceuticals continue to among the population, and the number of celeb-
grow in Japan. rities willing to make public confessions about
their mental health struggles, reduces the stigma
Marketing of Mental Illness associated with mental ill health and increases the
The marketing of mental health diseases can also likelihood of a person accepting a diagnosis and
be seen in the manner in which mental health its associated treatments. That mental health con-
care professionals, frequently sponsored by drug ditions are often defined behind closed doors by
companies, define, revise, and expand concepts psychiatric professionals partnered with or spon-
of mental ill health. This is most apparent when sored by psychopharmaceutical corporations,
looking at successive editions of the DSM. The however, raises serious ethical concerns.
manual, which lays out detailed criteria for diag-
nosing mental disorders, as well as the recom- Holly Sevier
mended forms of treatment, is updated by task University of Hawai‘i, Manoa
force panels of experts, many of whom are either
paid spokespeople or scientific advisers for the See Also: DSM-III; Food and Drug Administration,
same drug companies that offer pharmacological U.S.; Japan; Mass Media; Pharmaceutical Industry;
treatments for the disorders that they are defin- Television.
ing. The third edition of the DSM, for example,
created seven new anxiety disorders, both mir- Further Readings
roring cultural conceptions about the rise of anx- Kato, Takashiro, et al. “Introducing the Concept of
iety as a medicalized, labeled problem but also Modern Depression in Japan: An International
increasing the number of people who could be Case Vignette Survey.” Journal of Affective
labeled as suffering the disorder, and widening Disorders, v.135/1–3 (2011).
the corresponding market for drugs to alleviate Kirk, Stuart A. and Herb Kutchins. The Selling of
their suffering. DSM. New York: Aldine, 1992.
The low burden of proof needed for diagno- Lane, Christopher. Shyness: How Normal Behavior
sis of mental health disorders has led to a vast Became a Sickness. New Haven, CT: Yale
increase in the rate of incidence of the disorder. University Press, 2008.
Social anxiety disorder, for example, unheard
of prior to 1980, is defined in the DSM-IV with
such a broad range of symptoms, including avoid-
ance of performance situations and fear of being
embarrassed or humiliated, that large swathes of Mass Media
the population could be conceived of as having
the disorder. Public relations firms marketed the Mass media are communications intended to
idea of social anxiety, persuading many people reach large audiences. Mass communication may
that common behaviors or emotions were in fact be written, spoken, and broadcast. Mass media
incapacitating medical disorders. The mass media include television, radio, film, movies, CDs,
readily picked up on such pronouncements, DVDs, the Internet, newspapers, magazines,
 Mass Media 489

books, brochures, newsletters, and pamphlets, In Horkheimer and Adorno’s critical assess-
among others. Representations of mental illness ment of industrial mass society, the culture indus-
by mass media can significantly inform popular try thrived on mass media to enforce and perpetu-
and lay conceptions of mental disorders. It can ate standardization in thought at the day-to-day
also stigmatize and marginalize the mentally ill to level. In such fashion, mass media was theorized
a greater degree. Mass media theory employs cer- as part of a skill set that authoritarianism could
tain metaphors in its description of media experi- employ in the everyday life of consumer-driven,
ence as mental illness and health, using techniques modern societies. Horkheimer and Adorno’s
such as psychoanalysis, diagnostic critiques, and Frankfurt school colleague Herbert Marcuse
symptomatic readings of media texts. The impact argued that the mass media defined the very terms
of mass media on the mentally ill is not to be in which one may think about the world in such a
understated, as in clinical cases mass media’s modern society, defining the basis for a new sort
social reach can stretch to inform elements of of rationality and producing a theoretical, one-
content-specific symptoms that are usually associ- dimensional man in the process.
ated with severe psychosis, namely schizophrenia. Representing the next generation of Frankfurt
school critical theory, sociologist and philoso-
Mass Media Representations pher Jürgen Habermas theorized the role of mass
of Mental Illness media in the context of his theory of communi-
Representations of madness and stereotypes of cative action. His approach entails a theory of
insanity, psychosis, neurosis, disease, and disabil- rationalization in modernity that, on one hand,
ity by mass media significantly contribute to the unleashes the emancipatory potential of commu-
marginalization of the mentally ill in society. The nication for democracy that, on the other hand,
sociological study of stigmatization has shown remains permanently challenged by social sys-
that stereotypes about devalued groups such as tems such as a capitalist economy and bureau-
the mentally ill tend to be exceptionally pervasive. cratic administration. The “steering media” of
The sociology of stigma has proven that visual efficiency and power thus threaten the open,
and print media tend to have significant impacts intersubjective use of communicative reason,
on modern societies, allowing for such pervasive- which is exemplified in the lifeworld and public
ness of stereotypes in media-driven cultures. Popu- sphere. Thus, mass media may either serve the
lar conceptions of mental illness are often derived finding of an ever-wider consensus in the public
from mass media representations. These represen- sphere or become subsumed under a consumerist
tations may also perpetuate or reinforce pre-exist- and functionalist logic.
ing conceptions of illness across wider markets of The recent work of Slovenian cultural critic
media consumers. Finally, mass media also have Slavoj Žižek has employed the psychoanalytic
the capacity to inform the lay conception of illness theory and methods of the 20th-century French
and mental health norms across cultures. poststructuralist thinker Jacques Lacan. Žižek
has been successful at incorporating such Laca-
Media Theory: Mass Media as Mental Life nian theory and methods in popular portrayals of
Frankfurt school critical theorists Max Hork- madness found in film, cinema, and Hollywood
heimer and Theodor Adorno pessimistically theo- motion pictures. The most frequent filmmaker
rized mass media’s broadcasting of entertainment used in his cultural criticism and theory has been
as part of a deceptive “culture industry,” one that Alfred Hitchcock and his depictions of insanity
standardized thinking and rationality. A recur- found in his films. Žižek’s work can be thought
rent theme in their social research had been the of as psychoanalytic treatments of madness and
dialectic between a critical, resisting, rebellious, neuroses in movies, film, and cinema intersecting
and emancipatory function of mass media versus in the academic fields of literary theory, the social
its normalizing function. This was expressed as sciences, and the study of popular culture.
a dialectic, or a tension, for critical theory and Postmodern theories of society take for granted
as a framework within the way critical theory the saturation by communication technologies.
expressed itself. The general claim from theoreticians and cultural
490 Mass Media

sociologists is that such saturation contributes to media user, in terms of the lay and popular con-
fragmentation in the postmodern, mass media ceptions of schizophrenia.
theory of contemporary culture. What emerges in Formative media studies thinker Marshall
the theoretical sense is a social identity resembling McLuhan theorized that the book was the first
a schizoid-type structure. For instance, the theory commodity manufactured under conditions rec-
of an online existence forms part of a postmod- ognized as modern mass production. He theo-
ern theory of society, where information has been rized about “hot” and “cool” media that involved
digitized into small bits rather than for a broad- different degrees of participation by mass media
based, coherent display of knowledge. Classical users. Accordingly, hot media are low in partici-
print culture is equated with the rational individ- pation and cool media involve much more audi-
ualism of modernism, whereas postmodern theo- ence participation because media users must fill
ries of society and online media culture generally in the missing content. In theory, those clinically
involve connotations of irrationality. diagnosed with ADHD should be more receptive
A theory of media overload and saturation to the cool media proposed by McLuhan.
is common in postmodern conceptions of soci- The interdisciplinary field of media studies
ety. Cultural sociologist Zygmunt Bauman has generally employs semiotics in theories of mass
depicted a personal and social life in his sociologi- media. Semiotics, the formal science of signs,
cal scholarship where the postmodern mass media primarily studies how signs communicate. In the
dominates the private pleasures of its users. Bau- 1950s, cultural theorist Roland Barthes began
man has theorized on such as grounds for encour- to apply the theoretical principles of semiotics
aging a schizophrenic identity of multiple per- to various aspects of French popular culture,
sonalities in the everyday life of the postmodern including media and print culture. Semiotics
employed in the methodologies of the scholarly
field of media studies involves approaches that
can also study the very rules that regulate the
operation of each system of signs, forming a sort
of cultural semantics. In studies of mass media,
it has represented an approach that analyzes
how meaning is produced by media texts from a
diverse range of sources. In this sense, the mean-
ings produced by mass media form a basis for
rationality in the subjective experience of con-
temporary culture.
Critical social theorist Jean Baudrillard theo-
rized that media reality is in essence a “hyperreal-
ity,” or a world of artificially constructed experi-
ence that is realer than real. Such a media reality
is intended to provide an escape from the banality
of everyday life and create a much more exciting
and entertaining world of mass-mediated, techno-
logically processed experience. The result of such
simulation is an experience that is often far more
involving and intense than ordinary life. In such
an artificially and socially constructed environ-
ment, Baudrillard finds that society is essentially
under surveillance by ubiquitous media. He finds
During a psychotic episode or when unmedicated, an individual that in a media culture with such a reality, the
suffering from a thought disorder such as schizophrenia may private sphere of its users disappears and intimate
have a content-specific hallucination of auditory voices from details of everyday life are revealed by omnipres-
media such as a television announcer speaking directly to them. ent mass media. In this way, Baudrillard attempts
 Mass Media 491

to make sense of and explain the phenomenon of academic movement known as critical peda-
media such as tabloids in contemporary culture. gogy. One of the aims of the scholarly field is
Cultural theorist Stuart Hall, a representa- to teach how to read, analyze, and learn how
tive figure of the United Kingdom’s Birming- media present a version of reality. Another aim
ham School of Cultural Studies, has addressed involves deciphering the ways it can be used to
issues and notions of representation and the learn how the media present a version of real-
mass media, particularly the use of stereotypes in ity as well as be used to learn about social real-
media making and, more importantly, in making ity. Accordingly, the texts of media culture help
sense of media. On the other end, and in direct provide material for a diagnostic critique of the
relation to the user, he adopts a general stance contemporary era, whereby critical readings of
of mass media meaning as essentially interpre- media-saturated popular artifacts and spectacles
tations that inform social reality and discourse. are interrogated in an effort to provide knowl-
In his mass media theory, media may appear to edge of the contemporary era.
reflect reality but in fact they construct it. Never- In the traditional Marxist interpretation of
theless, he contests that there are limits to media mass media ubiquitous in critical theory discus-
interpretation and the experience in itself cannot sions, one typical argument is that there have
be completely private and individual. In gen- been crises of control in the information age that
eral, Hall’s theory has addressed how individuals have emerged over the last few decades. Rational-
make sense of media texts. The social situation ization is attributed as an information-dependent
of the mass media reader, viewer, or listener plays process. It requires excessively more workers to
a significant role in the stance each person takes produce the very information and provide analy-
in the meaning of their specific media. In a media sis. The product of such mental and intellectual
experience as such, the implications for the stig- labor is the utilization of information technol-
matized and marginalized mentally ill individual ogy to such a capacity that it stores and transmits
are obvious, as is also the case of the symptom- bulks of such information. In the Marxist sense,
atic mental patient. ominous themes of surveillance and rationaliza-
Across cultures, there was a critical public tion imply an increase in the ability of capital-
engagement with mass media and its social pro- ists to exercise control over individuals in their
cesses in 1930s Britain. The stance that media roles as employees, consumers, and citizens. In
studies scholars have used to define the incident the power relations that follow, audiences are in
typically employs diagnostic methods. The criti- essence the products of an industrial or manufac-
cal result revealed by such diagnostics is one that turing process, whereby mass media equates to
attempts to understand, situate, and support the common knowledge that manufactures consent.
argument about the role of media in mass culture.
In essence, interpretations of such critical pub- Impact of Mass Media on the Mentally Ill
lic engagement provided what was a secondary- In clinical psychology and psychiatry, thought
source documentation of clear symptoms within insertion is a common hallucination of individuals
what has been deemed by many to represent a diagnosed with thought disorders such as schizo-
pathological construction of modern society and phrenia and schizoaffective disorder. Another is
its mass media. Such a symptomatic reading of thought broadcasting. During a psychotic epi-
mass media in modern culture supports a diag- sode or when unmedicated, an individual suffer-
nosis, in this particular incident, chronic debase- ing from schizophrenia or another closely related
ment of public sensibility, and consists of general thought disorder may have a content-specific hal-
and standardized accounts of contemporary val- lucination of auditory voices—running commen-
ues and norms in a media-driven mass society. tary by a television newscaster or radio announcer
delivering specific content. On a more formal
Media Pedagogy level, the individual suffering from psychosis may
Critical theorist Douglas Kellner is a leading have the false belief that a specific medium such
figure in a field of scholarship that has become as television or radio is inserting thoughts into
known as media pedagogy, a subset of an their thought process.
492 Measuring Mental Health

The mentally ill individual may be convinced Further Readings

that his or her very thoughts are being transmit- Corner, John. Studying Media: Problems of Theory
ted to the television or radio and broadcast over and Method. Edinburgh, UK: Edinburgh University
such medium. The individual may believe that Press, 1998.
a song on the radio or on an album he or she Inglis, Fred. Media Theory: An Introduction. Oxford,
has purchased contains a secret message that UK: Basil Blackwell, 1990.
is being transmitted to them with each listen. Kellner, Douglas. Media Spectacle. London:
The individual may listen to the song over and Routledge, 2003.
over again, reinforcing the specific delusion with Ott, Brian L. and Robert L. Mack. Critical Media
every play. Studies: An Introduction. Malden, MA: Wiley-
Psychotic individuals may believe that news Blackwell, 2010.
broadcast in print, online, by television, or by Real, Michael R. Exploring Media Culture: A Guide.
radio refers directly to them. The same is true of Thousand Oaks, CA: Sage, 1996.
advertisements. A mentally ill individual suffering Smith, Joel. Understanding the Media: A Sociology
from untreated psychosis will often show symp- of Mass Communication. Cresskill, NJ: Hampton
toms in which he or she believes the content of Press, 1995.
advertisements contains a special message that is
being delivered directly to them, rather than to a
market, demographic, or segment of people.
Positive symptoms of psychotic individuals
include suspicions and paranoia that incorpo- Measuring Mental
rate mass media in their content. Content-specific
paranoid delusions may include the mentally ill Health
individual believing that he or she is being moni-
tored by a video camera equipped on a computer, Recent epidemiological studies have produced
tablet, or mobile phone. Mobile phones represent startling findings. They indicate that at the time of
new mass media. The mentally ill may have the being surveyed, over one in five Americans have
false belief that their thoughts are being transmit- experienced some mental illness over the previ-
ted over a mobile phone. ous year and that more than half had a mental ill-
Mass media can also have a positive impact on ness at some point in their life. Some studies show
the mentally ill. Mental patients’ accounts of their even higher rates, finding that three-quarters of
illnesses are shared on blogs and message boards the population report some mental illness by the
on the Internet. On a more mass media level, self- time they are 30 years old. In addition, these rates
help programs on television may feature such appear to be growing over time: respondents in
accounts of illness and be used by the mentally ill more recent studies report higher rates of mental
as a solution and incentive for self-help, mental illness than those in earlier research. Moreover,
hygiene education, or recovery. Medications that younger people display higher levels of mental ill-
treat mental illness such as depression and other ness than older groups, also suggesting that the
more serious mental disorders form a basis for the number of mentally ill people is increasing. In
content of advertisements displayed on network fact, however, the apparent growing numbers of
television, in print magazines, and online. mentally ill people are far more likely to reflect
changes in the methods and definitions that epi-
Dustin Bradley Garlitz demiological studies use than any actual growth
University of South Florida of mental illness.
Epidemiology is the study of the amount, distri-
See Also: Critical Theory; Delusions; Internet and bution, and determinants of disease in a commu-
Social Media; Marginalization; Popular Conceptions; nity. Its distinctive contributions to understanding
Psychoanalysis and Popular Culture; Public Education mental illness lie in its ability to show how the
Campaigns; Schizophrenia; Self-Help; Stigma; number of people with mental illnesses extends
Television. beyond those who seek professional help and
 Measuring Mental Health 493

how those who enter treatment differ in signifi- past year and about 11 percent at some point in
cant ways from those with similar conditions who their lives. About 10 and 14 percent, respectively,
remain untreated. In these ways, it can inform were diagnosed with past-year and lifetime anxi-
policy discussions about the best ways to manage ety disorders.
and possibly prevent mental illnesses among the The National Comorbidity Survey (NCS) was
broadest range of people. the second major community study of the preva-
The measurement of mental illness in American lence of specific psychiatric disorders relying on
community populations has a long history. How- the DSM diagnostic categories. The NCS was a
ever, the absence of a reliable diagnostic system U.S. representative sample of about 8,100 persons,
before 1980 meant that psychiatric epidemiologi- fielded in 1991 with a 10-year follow-up beginning
cal studies prior to that time were limited to study- in 2001. The initial NCS produced higher rates of
ing either treated populations or general states of mental disorder than the ECA. It estimated that
distress rather than specific disorders. Modern nearly half (48 percent) of the population had some
psychiatric epidemiology was only established lifetime disorder and that 29 percent had some
when the American Psychiatric Association’s third disorder over the past year. The results from the
edition of the Diagnostic and Statistical Manual NCS re-study conducted in the early 2000s showed
(DSM-III) created a diagnostic system that could comparable findings. Overall, about 29 percent of
be used in population and clinical studies to mea- the population experienced an anxiety disorder, 21
sure rates of particular mental illnesses. The DSM- percent a mood disorder, 25 percent an impulse
III used the overt symptoms of each mental ill- control disorder, and 15 percent a substance use
ness—rather than the underlying psychodynamics disorder. These rates were all considerably higher
or causes of each condition—as the basis for their than those found in the earlier ECA study.
definitions. While this made the measurement of The major social correlates of higher rates of
each illness category easier, it also relied on the mental disorder in these studies were lower lev-
assumption that the same symptoms had equiva- els of income and education. Rates of depression
lent meanings for different individuals. Current and anxiety were far higher among women than
claims about rates of mental illness depend on the men, while the reverse was true for substance use
validity of the DSM categories and their applica- and impulse control disorders. In addition, both
bility to people who have not sought clinical help. the ECA and the NCS found that younger peo-
ple reported higher rates of both past-year and
The Findings of Epidemiological Studies lifetime disorder. The latter finding was anoma-
The first epidemiological study to use DSM cat- lous because, all else equal, older people should
egories of mental illness was the Epidemiologic have higher lifetime rates than younger people
Catchment Area (ECA) study launched in the because they have passed through longer peri-
early 1980s. It surveyed more than 18,000 adults ods of exposure to illness-producing factors. The
in five sites (New Haven, Connecticut; Durham, results for age, along with the general increase of
North Carolina; Baltimore, Maryland; St. Louis, the rate of mental illness from the ECA and NCS
Missouri; and Los Angeles, California) to gen- studies, seemed to show that rates of mental ill-
erate nationwide estimates of the prevalence of ness were growing at an alarming rate over time.
mental illness. The ECA estimated that about 16 The findings from the ECA and the NCS pro-
percent of the population had at least one current vide the basis for the statements by the surgeon
psychiatric disorder and that about 20 percent general and others that huge and increasing pro-
had experienced some disorder over the past year. portions of the population suffer from mental
About a third reported a lifetime history of dis- disorders. These claims are now widely cited in
order. When the results of a second ECA survey the scientific and popular literature, pharmaceuti-
conducted with the same subjects one year after cal advertisements, and advocacy documents. Do
the original survey were taken into account, the they reflect an actual growth in the rate of mental
estimates of lifetime prevalence increased from 32 illness or are they an artifact of the changing ways
to 44 percent of the population. Nearly 7 percent that epidemiologists have defined and measured
of respondents reported being depressed over the mental illnesses?
494 Measuring Mental Health

Problems With Measuring Mental Illness in misclassifying normal and transitory experiences
Epidemiological Studies as mental disorders.
The basic assumption of psychiatric epidemio- The failure of epidemiological studies to sepa-
logical studies is that the same definitions that are rate ordinary distress from mental disorders and
used to diagnose various mental illnesses among consequently classify both as “mental illnesses”
people who have sought clinical treatment can likely accounts for the extraordinarily high rates
also accurately diagnose those who have not of pathology these studies find. Why, however,
sought professional treatment. To this end, they have these studies shown such extraordinary
translate the clinical criteria for each disorder increases in the rates of mental illness over the past
into a checklist of symptoms that lay interview- 30 years? One reason for these growing numbers
ers can administer in community studies. They lies in changes in the wording of questions and in
ask identical questions of each respondent. For decision rules about how to separate mental ill-
example, those who affirm experiencing enough ness and normality. For example, just changing
of certain symptoms such as, “Have you ever had a single question about social anxiety from the
two weeks or more when nearly every day you ECA wording of having extreme distress “when
felt down in the dumps, low, or gloomy?” or “Did speaking in front of a group you know” to the
you ever have a time lasting one month or longer NCS inquiry about “speaking in front of a group”
when you were anxious and worried most days?” increased affirmative responses from 6.5 to 14.6
receive diagnoses of major depression and gen- percent. This and other, seemingly minor changes
eralized anxiety disorder, respectively. There are, in the criteria for social anxiety disorder resulted
however, major differences in making diagnoses in a nearly sixfold increase in lifetime prevalence
in clinical and community samples. from 2.5 percent in the ECA to 13.3 percent in the
First, people who enter treatment have already NCS over the course of just one decade.
judged that their symptoms go beyond ordinary In another study, changing cut points in how
and temporary responses to stressful events and much interference was created by symptoms,
signal the need for professional help. In addition from “a great deal of interference” to “a great
to patient definitions, clinicians also make contex- deal of interference or distress” to “moderate
tual judgments that a given group of symptoms interference or distress,” resulted in increases in
are not just natural responses to life situations. the prevalence of social anxiety disorder from 1.9
Neither patient nor clinician judgments, however, to 7.1 to 18.7 percent, respectively. The sensitiv-
enter into diagnoses in epidemiological studies. ity of prevalence rates to changes in the particular
Instead, answers to standardized questions with- wording of questions and diagnostic cut points is
out reference to context provide the sole resource also a likely reason why another large epidemio-
to make these diagnoses. logical survey of over 43,000 persons found that
For example, a respondent might recall having rates of depression increased from 3.3 percent
a number of depressive-type symptoms that per- from 1991 to 1992 to 7.1 percent from 2001 to
sisted for two weeks after a physician informed 2002 to 10 percent from 2004 to 2005.
them that they had a malignant form of cancer. Problems also plague the epidemiological mea-
Although these symptoms might have quickly surement of mental illness among people of dif-
dissipated once the person was informed the ferent age groups. Survey questions ask respon-
cancer was not malignant, their response would dents to retrospectively recall their experiences
nevertheless indicate that they had an episode of of particular symptoms over the course of their
major depression. As another example, an indi- lifetimes. Most people, however, can only accu-
vidual who was surveyed soon after losing his rately recall experiences of symptoms in the fairly
job might report a period of anxiety and worry recent past. Older people are far more likely to
that lasted for at least a month. Even if these forget symptoms that they might have had a num-
symptoms disappeared as soon as the respondent ber of years before the interview was conducted,
was re-employed, he would be counted as hav- accounting for the consistent epidemiological
ing had an anxiety disorder. Thus, psychiatric finding that elderly people report lower lifetime
epidemiological studies are highly vulnerable to prevalence rates than younger people. In contrast
 Measuring Mental Health 495

to retrospective studies, prospective research fol- that deal with mental health, the legitimacy of the
lows the same groups of people forward in time problems that mental health researchers study,
so that problems of memory are far less likely to and the size of the market for clinical help.
affect results. Such prospective studies find strik- Mental health advocacy organizations also
ingly higher rates of conditions they classify as embrace claims about the prevalence of mental
“mental disorders.” disorders, which allow them to equate the mil-
One prominent study, for example, indicates lions of people that community surveys identify
that 75 percent of a group of 32-year-olds who as mentally ill with the far smaller number of
had been repeatedly interviewed since they were people who have truly serious mental disorders.
18 years old reported at least one mental illness They believe that this reduces the social distance
by this age. It is likely that virtually everyone between the mentally ill and others, lowers the
would have reported some mental illness over stigma of mental illness, and aids their efforts to
their entire life course. Likewise, accurate studies obtain more funding for treatment.
of symptom recall ought to show higher lifetime Finally, claims that mental illness is extremely
prevalence of mental illness among older groups common are not foisted on a resistant public.
of people. Paradoxically, because epidemiologi- Instead, over the past 30 years, cultural concep-
cal studies use diagnostic criteria that embrace tions of mental illness have become more medical-
ordinary distress as well as mental disorders, the ized as problems that used to be viewed as natural
application of better methods results in less valid results of life stressors are now seen as diseases in
estimates of the rate of mental illness. need of medical treatment. Epidemiological esti-
mates are deeply grounded in changing cultural
Why Are High Estimates of the Rate of conceptions regarding when distress is normal
Mental Illness Widely Accepted? and when it indicates a mental illness.
Epidemiological studies of mental disorders result
in gross overestimates of the rate of mental ill- Allan V. Horwitz
ness because they use diagnostic criteria that con- Rutgers University
sider distressing, but not disordered, emotions of
enough intensity as signs of mental illness. Their See Also: Assessment Issues in Mental Health;
criteria take neither patient nor clinician judg- Cross-National Prevalence Estimates; DSM-
ments of symptom context into account and so III; Epidemiology; Incidence and Prevalence;
are far less valid than clinical studies. Neverthe- Medicalization, History of; Mental Illness Defined,
less, they have been widely accepted as accurate Psychiatric Perspectives; Popular Conceptions.
indicators of the rate of mental illness in the com-
munity. This acceptance results from the benefits Further Readings
that a number of vested groups receive from high Horwitz, Allan V. and Jerome C. Wakefield. All We
prevalence estimates of mental illness. Have to Fear: Psychiatry’s Transformation of
The pharmaceutical industry most directly Natural Anxieties Into Mental Disorders. New
profits from expansive estimates of mental illness York: Oxford University Press, 2012.
because a broader market is created for their prod- Horwitz, Allan V. and Jerome C. Wakefield. The Loss
ucts. Their ads focus on such common symptoms of Sadness: How Psychiatry Transformed Normal
as sadness, fatigue, and anxiety that are widely Sorrow Into Depressive Disorder. New York:
present in the population. The explosive growth in Oxford University Press, 2007.
sales of psychoactive medication since the 1980s Moffitt, T. E., et al. “How Common are Common
indicates the effectiveness of this appeal. Mental Disorders? Evidence That Lifetime
Mental health researchers, policy makers, and Prevalence Rates Are Doubled by Prospective
clinicians are also beneficiaries of views that men- Versus Retrospective Ascertainment.” Psychological
tal illness is extremely widespread in the popula- Medicine, v.40 (2009).
tion. The idea that they are dealing with very com- U.S. Department of Health and Human Services
mon diseases as opposed to ordinary life stressors (HHS). “Mental Health: A Report of the Surgeon
helps boost the budgets of government agencies General.” Rockville, MD: HHS, 1999.
496 Mechanical Restraint

Mechanical Restraint ways. In the atmosphere of the late Enlighten-

ment, lay and medical people envisioned a large-
Throughout history, mechanical restraints in the scale reform of the care of the insane, which
form of chains, manacles, shackles, and other emphasized two things: (1) bringing the men-
instruments have been widely applied on those tally ill out from their houses and nonmedical
suffering from mental illness. The practical pur- institutions such as gaols to specialist hospitals
pose of restraint was to prevent the patients from or asylums; and (2) reforming the asylums into
damaging properties and harming others and a benevolent, humanitarian, and rationally con-
themselves. The practice of restraint, in turn, was structed therapeutic space. In the new approach,
integrated into the cultural images that equated the minimization or abolition of mechanical
patients of mental diseases with wild beasts. The restraint assumed a symbolic meaning. Mechani-
removal of restraints from patients of mental ill- cal restraints stood for the bad old days, and lib-
ness, which started in Europe around 1800, was erating patients from chains and manacles was
thus a transformation of the images of madness a crucial part of the self-image of the newly cre-
and psychiatry as well as the creation of new ated discipline of psychiatry.
types of patient management. The revolution constructed around the aboli-
tion of chains was best represented by Philippe
Early History of Restraint Pinel (1745–1826), who developed the reforms
In many places and cultures in the world, at the Salpêtrière and Bicêtre Hospitals in Paris
mechanical restraints were put on mentally sick during the 1790s during the French Revolution.
persons, especially when they were violent, sui- Pinel’s deeds of liberating patients from mechan-
cidal, and wandering. People in primitive societ- ical restraints, represented as the revolutionary
ies commonly used restraints on the mentally ill, physician fighting the ancien régime, were com-
a practice that was regularly reported by visitors memorated in words and images, most famously
from “civilized” cultures. Controlling a mentally by Tony Robert-Fleury’s painting, Pinel at the
ill person at his or her home, which had been an Salpêtrière, which hangs at the library of the
ordinary form of care before the arrival of men- hospital.
tal hospitals, often relied on restraints because of In England, social reformers took the lead and
the lack of special resources and facilities such leveraged the examples of mechanical restraint
as experienced keepers. The hospitals or special they had discovered during their investigations
wards for the insane, which were first established into old institutions. They reported their findings
in the medieval Islamic world, did not greatly during the parliamentary inquiry into madhouses
change the situation in terms of restraint. In hos- in 1815 and 1816, which set in motion the reform
pitals in Bagdad, Damascus, Cairo, and other in lunacy and a series of legislations. At the Beth-
major cities, violent patients were chained or even lem Hospital, reformers were horrified that many
whipped when deemed necessary, although they patients were under mechanical restraints in a
were not indiscriminately restrained and the hos- shocking state of neglect, misery, and filth. Partic-
pitals were regarded by their contemporaries as ularly outrageous was the situation of James Nor-
providing good therapies and charitable care. The ris, who had been restrained for about 10 years by
principle of the occasional use of restraint in dif- a specially constructed apparatus and chained to
ferent degrees continued in hospitals and institu- an iron bar with a ring on his neck and a cage on
tions for lunatics in early modern Europe, such his body. A picture of Norris under the restraint
as the famous Bethlem Hospital in London, long was drawn on the spot, later mass-produced in
called Bedlam (from which the term bedlam was prints by reformers as the symbol of the cruelty of
coined in the 1500s). the old regime.
In England, reformers and doctors pushed
Building a New Psychiatry for the minimization of mechanical restraint to
In European countries around 1800, the situ- an extreme form of “nonrestraint” or the com-
ation of mechanical restraint and its ideologi- plete abolition of restraint for the inmates of asy-
cal meanings started to change in fundamental lums. The first success of nonrestraint is credited
 Mechanical Restraint 497

credo of alienists in England and the Lunacy Com-

missioners in the 1840s, although it continued to
be the focus of debates throughout the century.
Minimization of mechanical restraints spread
to other countries and adapted to their asylums’
regimes. In the United States, the extremism of
nonrestraint was rejected in favor of the modest
and controlled use of restraint. In Germany, non-
restraint was set in a different context of scientific
psychiatry taught and practiced at universities.
When Conolly’s work on nonrestraint was trans-
lated into German in 1860, Wilhelm Griesinger
(1817–68) took up the issue, calling it frie behan-
dlung (free treatment) and installed a nonrestraint
system at Zürich and the Charité in Berlin in the
1860s. Griesinger and academic psychiatrists
maintained that mechanical restraints hindered
scientific clinical observation through their dis-
tortion of the natural course of symptoms. They
discarded all instruments of restraint with the one
exception of a straitjacket, which was to be dem-
onstrated to the students as a pedagogic relic of
the former carceral psychiatry.

What Has Substituted for

Mechanical Restraint?
A straitjacket made from mattress ticking by patients at State The use of mechanical restraint was greatly
Hospital No. 2 in St. Joseph, Missouri. In the mid-1800s, official reduced in the 19th century in psychiatric insti-
opinion at this mental hospital differed in respect to restraints; tutions as countries adapted the abolition of
one superintendent particularly favored restraint for females. restraint into differently construed ideologies.
From the mid-19th century, patients had to be
controlled through other means, such as moral
treatment, rational classifications, carefully
to Robert Gardiner Hill (1811–78), an assisting planned architecture of the asylum, efficiently
surgeon at the Lincoln Asylum. Hill dramatically managed attendants, chemical sedatives, shock
decreased the number of the instances of restraint therapies, or even psychosurgeries.
there. For example, in 1829, prior to his inter-
vention, 39 of 72 total patients were put under Akihito Suzuki
restraint (1,727 times and for a total of 29,424 Keio University
hours), while by 1838, no patients of 148 expe-
rienced any mechanical restraint during their stay. See Also: Architecture; Asylums; Delirium;
The success at Lincoln was quickly followed at Electrotherapy; Ethical Issues; France; Germany;
the Middlesex County Asylum at Hanwell, super- Human Rights; Imperial Psychiatry; Mental
intended by John Conolly (1794–1866). Non- Institutions, History of; Patient Rights; Trade in
restraint at Hanwell became much more famous Lunacy; United Kingdom.
than its predecessor at Lincoln because of its larger
size and much better publicizing by the lay gover- Further Readings
nors and influential journalists in important papers Dols, Michael and Diana E. Immisch, ed. Majnun:
such as Times in the early 1840s. The nonrestraint The Madman in Medieval Islamic Society. Oxford:
of Conolly, rather than that of Hill, became the Clarendon Press, 1992.
498 Medicalization, History of

Engstrom, Eric J. Clinical Psychiatry in Imperial that medicalization “is one of the most effective
Germany: A History of Psychiatric Practice. means of social control and that it is destined
Ithaca, NY: Cornell University Press, 2003. increasingly to become the main mode of formal
Lederer, David. Madness, Religion, and the State social control.” Sociologists were central to the
in Early Modern Europe: A Bavarian Beacon. early expansion of the term medicalization in the
Cambridge: Cambridge University Press, 2006. 1970s. Notable are Irving Kenneth Zola (1935–
Porter, Roy. Mind-Forg’d Manacles: A History of 94), and Peter Conrad (1945– ), who continues
Madness in England From the Restoration to the to be a major figure within the contemporary
Regency. London: Athlone Press, 1987. discussion. Conrad has discussed how medical-
Scull, Andrew. The Most Solitary of Afflictions: ization is a sociocultural process that may not
Madness and Society in Britain, 1700–1900. New necessarily involve the medical profession, but
Haven, CT: Yale University Press, 1993. that medicalization necessarily indicates a prob-
Suzuki, Akihito. “Politics and Ideology of Non- lem that has been defined, described, understood,
Restraint: The Case of the Hanwell Asylum.” and/or treated medically, which means that medi-
Medical History, v.39 (1995). calization potentially offers a cross-cultural vari-
Tomes, Nancy. “The Great Restraint Controversy: ant, although standardization of cultural com-
A Comparative Perspective on Anglo-American parative health classification manuals helps make
Psychiatry in the Nineteenth Century.” In The some medicalized constructions culturally blind,
Anatomy of Madness: Essays in the History of although practical applications may still have
Psychiatry, W. F. Bynum, et al., eds. London: strong cultural influences.
Tavistock, 1985. One of the earliest and most extensive treatises
to specifically use the term medicalization came
from philosopher Ivan Illich (1926–2002), who
in his 1975 book describes the process whereby
medical practitioners create worse outcomes as a
Medicalization, result of their medical interventions in a phenom-
enon he called iatrogenesis. Illich identified three
History of levels of iatrogenesis in action: clinical, social,
and structural. Clinical iatrogenesis creates side
Medicalization is a historicized and historiciz- effects that are worse than the original condition
ing term because it implies that certain physical treated. Social iatrogenesis describes a condition
processes that were formerly considered in terms of harmful docility and complacency concerning
of different categories of experience (e.g., ethi- exaggerated reliance upon medical professional
cal, social, and religious) become reconceived and authority. Structural iatrogenesis describes the
reconfigured in terms of medical categories and larger cultural process whereby once “natural”
structures of authority. Early sociological discus- life (and death) changes become monopolized by
sions argued that medicalization involves a new medicalized meanings and interpretations. All of
sense in which medical intervention is appropri- these levels of iatrogenesis capture implications
ate in cases where the medical gaze had never and potential harms associated with the process
previously been prioritized or assumed. Research- of medicalization.
ers continue, particularly within sociology, to
investigate how medical authorities have been History of the Process of Medicalization
engaged in the work of de-normalizing behaviors, The process of medicalization has a much longer
rebadging them as conditions. history than the actual term in sociology and a
The term medicalization means “to make med- number of other disciplines, including philoso-
ical.” The first time that the term was used was phers and internal critics from the medical pro-
in 1968 by seminal sociologist Jesse Richard Pitts fession of psychiatry. Many recognize that there
(1921–2003) in his discussion of social control is no medical subfield more medicalized than
as a concept for the International Encyclopedia psychiatry, no field that has absorbed so many
of the Social Sciences. Pitts specifically argues discourses, practices, and structures of authority
 Medicalization, History of 499

previously under the jurisdiction of nonmedical was to coincide with the antipsychiatry move-
sources. Pitts and others trace the origins of mod- ment of the 1960s and 1970s are part of the his-
ern medicalization within the work of Sigmund tory of medicalization.
Freud (1856–1939). Freud’s linking of mental Thomas Szasz (1920–2012) is one of the key
illness, particularly noninstitutionalized forms, figures who continued throughout his long life to
with conflicts between the biogenetic drives such be identified with the antipsychiatry movement
as aggression and sex and sociocultural forces, and was eulogized in the Lancet under the title of
continues to have a seminal influence. He did not “rebel with a questionable cause.” In 1960, Szasz
see madness as a disease of the brain, contracted published his paper titled “The Myth of Mental
or inherited, but rather as a series of conflicts Illness,” which was delivered for the readership
between individuals and the worlds they live in. of legal scholars, and was specifically linked to
According to Michel Foucault (1926–84), Freud the involuntary institutionalization and treatment
was the first to reopen a dialogue with madness. of the mentally ill. In 1961, Szasz testified before
In one of Foucault’s earliest papers (1954), it a U.S. Senate committee that the incarceration
is argued that the complexity of Freud’s ideas of the mentally ill violated general principles of
was heavily influenced by the evolutionary ideas doctor–patient relationships, turning doctors into
of Darwin, and each stage of neurosis is seen as wardens because these institutions were the same
an evolutionary stage of the libido, thus allowing as prisons for the involuntarily institutionalized.
him to write about a psychology of a child that Szasz continued to be a vocal presenter of these
details a disease of an adult. Connected to this ideas throughout his life and extensively pub-
work and to interpretations of Freud at the time, lished regarding medicalization, mental illness,
there is reference to Freud’s work being applied to and sociocultural implications.
noninstitutionalized patients, those who came to Legal scholars (in particular Nicholas Kitt-
him voluntarily to seek treatment. The divisions rie) argued early in the 1970s that a number of
between institutionalized versus noninstitutional- mental illnesses were thought originally as moral
ized, and voluntary versus involuntary, construc- failing, then as legal issues or crimes, and now
tions of mental illness were factors underlying are thought of as within a medical framework,
many of the arguments regarding medicalization moving from sin to sickness with a stop regarding
that later developed. crimes in between. Whereas a legal punitive para-
In the same year, Erving Goffman (1922–82), digm exacts a fixed and finite period of confine-
shortly after being awarded his doctorate in soci- ment as deterrent and atonement for specific hos-
ology from the University of Chicago, took up a tile actions, a medicalized paradigm can impose
visiting membership at the laboratory of socioen- an indefinite period of confinement that removes
vironmental studies of the National Institute of any sense of final agency from its victims. The
Mental Health in Bethesda, Maryland. Goffman Soviet Gulag Archipelago justified its forced labor
conducted a year of fieldwork at the St. Eliza- prison camp regimes along medical rather than
beth’s Hospital in Washington, D.C. This was punitive grounds, and psychiatric “re-education”
to later culminate in the publication of his influ- has formed part of the self-justifying political
ential text Asylums (1961, although one of the rhetoric of a number of totalitarian regimes in the
chapters was originally published two years ear- 20th century. In a Western context, the antipsy-
lier in a psychiatric journal). Within this paper/ chiatry movement found a powerful narrative in
chapter, Goffman gives a sociological definition Ken Kesey’s One Flew Over the Cuckoo’s Nest
of the mental patient, and argues that he is look- (1962, filmed 1975), which presents medicalized
ing at the institutional approach to the study authority in the guise of a stifling and somatizing
of the self. The psychiatric view of the mental conformity.
patient, Goffman argued, is significant because In 1974, Michel Foucault gave a lecture in
it results in hospitalization in the first place, but Brazil titled “The History of Medicalization.”
his study was interested in the changes associ- Foucault argued that medicalization should be
ated with identity that resulted from this diag- studied in terms of a historical process; in other
nosis. The deinstitutionalization movement that words, investigate how phenomena become
500 Medicalization, History of

medicalized, which he linked to his concept of questioning of the demedicalization of the disease
governmentality. The evolutionary changes asso- of masturbation.
ciated with societal constructions of various ill- More recently, there has been a demedicaliza-
nesses have often been traced to the 18th century, tion and controversial remedicalization based on
although many took more formalized medical- the dominance of biomedicalization of psychiatry
ized shapes in the 19th century. with regard to homosexuality. Peter Conrad has
Foucault’s work often concentrated on this extensively discussed the controversial medical-
historical medicalization in France. A number of ization and demedicalization of homosexuality.
sociological discussions of medicalization have Considered a sin for centuries, it was criminalized
tended to have similar cultural bias associated in the 18th and 19th centuries, after which it was
with the origin countries of specific researchers. increasingly medicalized, despite Freud’s compar-
There have been more recent arguments that atively tolerant attitude regarding same-sex issues.
cross-cultural comparative discussions of specific Homosexuality appeared in the earliest diagnostic
medicalized problems should be undertaken more manuals, including both the official classification
often. Postcolonial influences on the medicaliza- of psychiatric disorders of the American Psychi-
tion of problems in places such as India, Africa, atric Association, the Diagnostic and Statistical
southeast Asia, and parts of Central and South Manual of Mental Disorders (DSM), and the
America might help clarify more of the underly- World Health Organization’s International Clas-
ing power structures associated with this process sification of Diseases, which listed homosexuality
across space and time. from their inception in the 1950s, although it was
Connecting historical social changes with ideas moved and then removed in later publications,
about illness continues to produce a large body beginning with DSM-III.
of literature in sociology but also in a number Social dynamics surrounding the HIV/AIDS
of other related fields, with two key examples of epidemic fueled widespread prejudice and nega-
demedicalization: the uncontested onanism, or tivity toward homosexuality, which has also been
masturbation, and the contested demedicalization argued to have led to its remedicalization. Con-
of homosexuality. Processes of both medicaliza- nected to this has been the genetic movement that
tion and demedicalization depend upon both the emerged in the 1990s and has contributed to the
iteration and the realignment of societal norms. split among activists of whether homosexual-
When certain behaviors are no longer subject to ity should be considered a sexual preference or
corrective medical scrutiny, these behaviors shift orientation. The “born gay” philosophy became
from being regarded as deviant to being regarded popular within the gay and lesbian community
as variant. and has given additional support for the biomedi-
calized search for the illusive gay gene. The posi-
History of Demedicalization tive benefits of a proven “natural” genetic dispo-
In 1974, H. T. Englehardt detailed the history of sition have been partially offset by fears that such
masturbation as a disease, showing how it moved a gene, if discovered, might be “bred out” as a
from being classified as a “male disease of genera- result of parental or societal pressures.
tive order” to being a “disease of the nervous sys- Another key example of a term that is variously
tem” to a “cerebral-spinal disease” and then back medicalized and demedicalized is alcoholism,
to a “disease of the nervous system” in 1890, where which historically represents a shift from pun-
it remained until 1906, when it classified mastur- ishing behavior to treating a condition. Dissatis-
bation under the “genito-urinary system, diseases faction with a biomedical definition of alcohol-
of,” where it remained until 1933. Throughout the related problems has created a reaction against
lifespan of masturbation as a disease, there were the term alcoholism while retaining much medi-
widespread moral fears concerning sexual activity, calized rhetoric and many medicalized structures.
becoming increasingly associated with potentially A key transitional term used to describe a variety
increased attraction to someone of the same sex, a of transitional or liminal conditions on their way
disease particular constructed in relation to males. to being either medicalized or demedicalized is
The history of medicalization is marked by the the term syndrome, which reinforces medicalized
 Medicalization, Sociology of 501

authority while more modestly claiming to Conrad, Peter. The Medicalization of Society: On
organize symptoms rather than proving causal the Transformation of Human Conditions Into
processes. Medical Disorders. Baltimore, MD: Johns Hopkins
University Press, 2007.
Future of Medicalization Szasz, Thomas. The Medicalization of Everyday Life:
The pervasiveness of medicalization has lived up Selected Essays. Syracuse, NY: Syracuse University
to, if not surpassed, Pitts’s warning almost a half Press, 2007.
a century ago. Many researchers continue to dis- Williams, Arthur R. and Arthur L. Caplan.
cuss the process of medicalization, and increas- “Thomas Szasz: Rebel With a Questionable
ingly more researchers transnationally are look- Cause.” The Lancet, v.380 (2012).
ing at cross-cultural comparisons of the process
of medicalization and/or demedicalization of a
number of problems. In recent years, however,
some commentators have argued that society is
now beyond medicalization, and that now many Medicalization,
social problems are dominated through biomedi-
calization, which adds aspects of science and tech- Sociology of
nology to the discussion. Others have recognized
the increasing role of pharmaceutical companies The term medicalization refers to social processes
and talk about pharmacologization. Others have in which medicine’s ideas and practices have been
argued that these other conceptualizations of pro- extended to additional areas of life such as birth,
cesses of social control may well exist at the same contraception, and old age, which were formerly
time as medicalization, which may be losing some outside the medical terrain. The concept is of
of its prominence but is still present. Physicians’ particular relevance to the field of mental illness
medical hegemony is changing, and doctor– because a range of mental states and behaviors
patient roles have also changed. Underlying these that were not previously viewed as pathological
changes, it is still useful to analyze the process of have been brought into the domain of mental ill-
medicalization. ness and the jurisdiction of mental health profes-
This history of medicalization dates back centu- sionals—changes that are contested. The evidence
ries, while its development is particularly expan- suggests that a number of factors underpin pro-
sive through the end of the 20th century and into cesses of medicalization, and that the term’s value
the beginning of this century. Using a term that is as a description of these social changes; it should
rapidly captured a process that could be applied not be taken to suggest that the changes are the
to an increasing number of problems or issues, product of active medical imperialism, although
Szasz (2007) wrote about the medicalization of the profession’s activities, along with other key
everyday life, meaning that the medical gaze has factors, have often unwittingly contributed to the
become such an integral part of life that one often extension of medicine into new territories.
forgets that it is there; it has become part of the The concept of medicalization first began to be
taken-for-granted world and has become normal. used by sociologists at the end of the 1960s in
the context of discussions of social control and
Tanya M. Cassidy the regulation of human behavior to refer to the
University of Windsor way in which various forms of deviance (rule
breaking) had come to be regarded as illnesses
See Also: Antipsychiatry; Laing, Ronald David; and brought into the medical fold. For example,
Medicalization, Sociology of; Social Control; Szasz, Jesse Pitts, in a 1968 encyclopedia entry on social
Thomas. control, talked of the medicalization of deviance,
referring particularly to processes by which those
Further Readings apprehended for criminal offenses sometimes
Conrad, Peter. “Homosexuality and ended up in mental hospitals. He went on to sug-
Remedicalization.” Society, v.41/5 (2004). gest that Freudian ideas, with their emphasis on
502 Medicalization, Sociology of

unconscious motivation and the attendant reduc- draws on Freidson’s work but explicitly uses the
tion of personal responsibility, had played an term medicalization. Picking up the expansionary
important role in this medicalization. Arguments implications of Freidson’s argument, Zola defines
about the medicalization of deviance built in part medicalization as the process that makes “medi-
on the work of Talcott Parsons, who had intro- cine and the labels ‘healthy’ and ‘ill’ relevant to
duced the concept of the sick role, contending an ever increasing part of human existence.”
that there are clear social expectations attached to Zola contends that medicine has become a major
the role and that these expectations allow for the institution of social control. He uses psychiatry
social control of the sick. They also drew on the as one example of medicalization but argues that
strong critiques of psychiatric ideas and practice the 1960s antipsychiatrists were wrong in focus-
developed in the 1960s by psychiatrists Thomas ing specifically on psychiatry because a similar
Szasz and R. D. Laing and sociologist Thomas process occurs in other areas. However, he differs
Scheff, all of whom emphasized the centrality of from Freidson in his account of what leads to the
deviance to concepts of mental health and illness. extension of medicine’s jurisdiction. He does not
In turn, Eliot Freidson, in his 1970 book Pro- see medicalization as resulting in any way from
fession of Medicine, helped lay the foundations imperialistic propensities but as an insidious,
for a wider view of medicalization (though he did undramatic process, rooted in the increasingly
not specifically use the term) by suggesting that complex technological and bureaucratic charac-
the label illness could be applied to other domains ter of society, which encourages a reliance on the
outside the field of deviance. In a chapter titled expert. Hence, for Zola, the term medicalization
“The Professional Construction of Concepts of offers a description of an important social change;
Illness,” he argues that the label of illness belongs it is not explained in terms of any imperialistic
to medicine’s jurisdiction, regardless of the object tendencies of the profession.
of its application, or of medicine’s capacity to deal Social theorist, activist, and former Catholic
with it. He goes on to contend that once the pro- priest Ivan Illich also gives a central position to
fession had secured jurisdiction over the label, it the concept of medicalization in his highly polem-
tended to create its own notions of what could be ical 1975 book Medical Nemesis, which attracted
called an illness. He further asserts that doctors’ widespread public attention. In it, he focuses on
mission is to find illness, and that if an individual the “medicalization of life,” which he argues is
came with a problem they considered might be evidenced by increased spending on health care,
helped by doctors, then the doctors could label increased dependence on prescription drugs, the
that an illness, regardless of whether it had previ- medicalization of the life span (with medical con-
ously been considered one. This tendency to iden- trol of birth and old age)‚ the medicalization of
tify illness arises, he suggests, because medicine prevention, and the medicalization of expecta-
is a consulting profession committed to treating tions. Medical Nemesis‚ modified and republished
the ills with which it is presented, but this open- two years later as Limits to Medicine‚ also dif-
ness has expansionary implications. Freidson sug- fers from Zola’s and Freidson’s analyses in offer-
gests that doctors are not active imperialists but ing a very forceful critique of medicine, in which
nonetheless somewhat unwittingly, and perhaps Illich asserts that the medical establishment poses
carelessly, extend their terrain (doctors he sug- a major threat to health through various forms of
gested had been given too much autonomy). Not- iatrogenesis—not only from medically generated
withstanding his caution, his arguments could be illness such as adverse drug reactions or surgical
read as viewing medicine as having imperialist mistakes but also from the growing dependence
propensities. on medicine, which he argues undermines indi-
viduals’ autonomy and independence.
Zola and Medicine as Social Control Subsequent sociologists and other social sci-
Irving K. Zola’s 1972 paper “Medicine as an entists have often found the concept useful and
Institution of Social Control” is usually seen as have described a whole range of areas that have
the key text in spreading the sociological use of been medicalized, though not always using the
the concept of medicalization. In the paper, he term. Much of the subsequent work has focused
 Medicalization, Sociology of 503

on specific conditions, many in the psychiatric an important part in the medicalization pro-
field. For example, sociologist Peter Conrad, a cess. For instance, the decision by psychiatrists
leading exponent of the concept, carried out his involved in the development of the DSM-III to
first research on the introduction of the diagnostic adopt a descriptive approach and focus largely on
label of hyperkinesis (soon termed hyperactivity) symptomatology outside its social context helped
that was published in a 1975 paper, followed by extend the boundaries of mental illness. This is
a book two years later, Identifying Hyperactive despite the fact that the DSM-III’s definition of
Children. In turn, Joseph Schneider, in a 1978 mental disorder stated that responses that are
paper, analyzed the transformation of alcohol normal and expectable should not be regarded
problems into a disease, with Alcoholics Anon- as pathological. However, this significant qualifi-
ymous strongly encouraging the change. More cation has not in practice been extended in most
recently, Chistopher Lane, in his 2007 book Shy- cases to the diagnostic criteria for individual dis-
ness, and Susie Scott in her book the same year, orders. Further, the medical belief in the desirabil-
Shyness and Society, examined the transforma- ity of early treatment in part underpins a focus
tion of the personality characteristic of shyness on incorporating milder cases into classifications
into the mental disorder of social phobia, later of mental disorder, as in the addition of a new
relabeled social anxiety disorder. In a similar vein, diagnostic category of mild neurocognitive disor-
Jerome C. Wakefield and Allan V. Horwitz argued der in the DSM-5 and for the inclusion of a new
in their 2007 book, The Loss of Sadness, that disorder of “attenuated psychotic symptom syn-
sadness and misery have increasingly been trans- drome” in the appendix listing conditions requir-
formed into clinical depression and in a further ing further research.
book in 2012, All We Have to Fear, developed a Medicalization has also been encouraged by
similar argument about anxiety. major societal changes such as growing affluence
and improvements in health service provision,
Contemporary Medicalization which change expectations about the availabil-
Feminists have also been influenced by debates ity of health care. When these changes are asso-
about medicalization and have examined the ciated, as they are in many Western countries,
medicalization of certain aspects of women’s with growing secularization, it is more likely
behavior. They have pointed, for example, to the that individuals with problems will turn to doc-
greater tendency to identify women within the tors for help and support, whereas they formerly
criminal justice system as having mental health might have turned to religious figures. Further
problems and have also argued that the higher and importantly, the pharmaceutical industry
levels of depression identified in women are has encouraged medicalization by its very active
linked to the medicalization of ways of handling marketing of new drugs, including psychoac-
problems and feelings that are more common in tive drugs, marketing that helps change ways
women. They have also looked at the medical- of thinking about health and illness. Publicity is
ization of specific complaints such as the discom- directed both at doctors via sales representatives,
fort and distress associated with menstruation, advertisements in medical journals, and support
which has been transformed into “premenstrual for research and conferences and at the lay pub-
dysphoric disorder,” a condition that featured in lic via press releases about new drugs and about
the DSM-IV (1994) under Appendix B: “Crite- conditions they may be used to treat. This mar-
rion Sets and Axes Provided for Further Study.” keting encourages individuals to request specific
This disorder had the same status in the 2000 drugs if they identify particular problems they
revision but has been moved from Appendix B think the drug might help but also to see them as
to the main body of DSM-5, released in 2013. potential miracle cures.
Processes of medicalization are encouraged In addition to the criticism that has been made
by a number of factors. While the argument that of the term medicalization for its suggestion of
medicalization results from medical imperialism medical imperialism, others have argued that the
is rarely heard in its earlier forms, nonetheless, term is usually taken to imply a negative view of
decisions made by medical practitioners can play medicine and ignores the important gains achieved
504 Medicare and Medicaid

by the improved access to medical services and by the administration of Medicaid and the services
medical advances. While many developments in covered vary substantially depending on the par-
medicine have made an invaluable contribution to ticular state plan. Both Medicare and Medicaid
individuals’ lives, such as hip replacements, some are categorical assistance entitlement programs,
have not. In the case of the expansion of medi- which means that a person who meets legal eli-
cine into more and more areas of mental life, there gibility requirements is entitled to the benefit. For
have been some gains, and there have been many people with mental illness, Medicaid usually con-
negative consequences, not least the enhanced ten- nects with eligibility for cash assistance through
dency to see individuals as sick and as somehow the Supplemental Security Income (SSI) program
the source of their problems, instead of focusing for the aged, blind, or disabled. The 2009 Afford-
on the difficulties of the situations they have to able Care Act’s proposes to expand Medicaid to
face and the role of external social factors. additional categories of low-income recipients.
Both Medicare and Medicaid have cost-sharing
Joan Busfield features, meaning that the person receiving care
University of Essex, Wivenhooe Park is expected to bear some of the cost of the service.

See Also: DSM-III; DSM-5; Medicalization, History Medicaid

of; Social Control. Medicaid is a health insurance program for peo-
ple with low income and limited assets. Although
Further Readings the majority of people enrolled in Medicaid are
Conrad, Peter. The Medicalization of Society. young families and children without disabilities,
Baltimore, MD: Johns Hopkins University Press, the majority of Medicaid expenditures pay for
2007. services to people who are aged, blind, or dis-
Freidson, Eliot. The Profession of Medicine. New abled. Medicaid is the largest funder of mental
York: Dodd, Mead, 1970. health services in the United States.
Horwitz, Allan V. and Jerome C. Wakefield. The Loss Medicaid benefits vary substantially from state
of Sadness. New York: Oxford University Press, to state. Only 45 percent of poor Americans are
2007. covered by Medicaid. The federal government
Zola, Irving K. “Medicine as an Institution of Social requires that each state cover certain specific pop-
Control.” Sociological Review, v.20 (1972). ulations, but many states do not choose to cover
every beneficiary category the program allows.
There is a limited menu of mandatory covered ser-
vices as well, such as hospital and nursing home
care. Other than that, each state can choose the
Medicare and Medicaid medical services to be covered from a list of so-
called optional services. States can even custom-
Medicaid and Medicare both originate in fed- ize their Medicaid programs by asking the fed-
eral law but have substantially different enroll- eral government to waive otherwise mandatory
ment processes and benefit menus. Medicare is a program provisions. Many states use Medicaid to
federally administered social insurance program pay for a wide range of optional services, includ-
funded by worker and employer taxes. Its benefit ing community alcohol and other drug addiction
menu is defined at the federal level and, generally treatment services, community mental health ser-
speaking, does not vary state-by-state. Medicare vices, and prescription drugs. Other states choose
usually connects with eligibility for Social Secu- to cover many fewer services. People who need
rity old age or disability benefits, although there services but are not eligible for the state Medicaid
are additional covered groups. Medicaid is a plan must find a way to obtain them on the open
state-administered means-tested program, funded market or through charity groups—or simply go
through general revenues, with costs shared by without care. Needless to say, many Americans
the states. Although there are minimum cover- suffer poorer health because they cannot afford
age and benefit levels across the United States, needed (let alone optimal) medical care.
 Medicare and Medicaid 505

The advent of managed care makes Medicaid entitled to Medicare on account of disability have
even more difficult to navigate for many individu- a mental or cognitive impairment.
als. Managed care organizations require approv- Medicare Part A covers hospital care and some
als for various types of care and limit access to follow-up services, skilled nursing facility care,
expensive medications. Because newer psychiatric and hospice care. For Medicare Part A, which
medications are so expensive, many managed care pays for inpatient hospital, skilled nursing facility,
plans restrict availability of these drugs. Because and some home health care, the deductible paid
people with mental illness have less capacity to by the beneficiary was $1,156 in 2012. The Part A
deal with the stress of navigating complicated deductible is the only cost to the beneficiary for up
systems, their health is put at substantial risk by to 60 days of Medicare-covered inpatient hospi-
these restrictions. tal care. However, for extended Medicare-covered
People who receive SSI are automatically eli- hospital stays, beneficiaries must pay an additional
gible for Medicaid. Many disabled people who do $289 per day for days 61 through 90 in 2012, and
not receive SSI but who have low incomes may $578 per day for hospital stays beyond the 90th
still be eligible for Medicaid. One way is through day in a benefit period. For beneficiaries in skilled
a spend-down technique, which means using a nursing facilities, the daily co-insurance for days
portion of an individual’s income to pay for medi- 21 through 100 is $144.50 in 2012. Most Medi-
cal expenses. After that point, the person would care beneficiaries do not pay a premium for Part A
become eligible for Medicaid coverage for the services since they have 40 quarters of Medicare-
remainder of the month. The local county welfare covered employment. Other seniors and certain
office usually handles applications for Medicaid. people under age 65 with disabilities may obtain
Medicaid is jointly funded by state and fed- Part A coverage by paying a monthly premium set
eral governments. The amount of funding each according to a formula in the Medicare statute.
state receives depends on the actual amount spent Medicare Part B covers doctors’ visits, lab
for Medicaid services. Each state has to provide tests, outpatient services, and medical supplies.
a certain amount of “matching funds” in order Part B is optional insurance and must be paid
to receive the federal reimbursement. Medicaid for by the individual. For most individuals, the
spending is one of the largest categories of spend- 2012 monthly cost of Part B is $99.90 per month
ing in state budgets. Increases in Medicaid pro- (sometimes higher).
gram costs can seriously affect the fiscal condition Medicare does not pay for dental care, eye
of the state. When state budgets are cut, states care, routine check-ups, or medications. There-
reduce the number of optional Medicaid services fore, many recipients also carry private insurance.
they pay for and restrict eligibility to people with Medicare historically has paid a smaller percent-
extremely low income. age of mental-health related costs than it pays for
Medicare and Medicaid programs interact in other types of care. The 2009 Affordable Care
complex ways. Special programs pay some or all Act is equalizing the reimbursement rates over a
of Medicaid beneficiaries’ Medicare premiums period of years until parity is achieved.
and coinsurance costs. So-called dual eligibles Medicaid Part C is known as Medicare Advan-
have been transitioning to maximize the use of tage. Medicare Advantage Plans are offered by
Medicare to fund their health care costs. private companies that contract with Medicare to
provide beneficiaries with both Part A and Part B
Medicare benefits. Medicare advantage plans vary substan-
Medicare is the basic federal health insurance pro- tially and include health maintenance organiza-
gram for people over 65 and for many people with tions, preferred provider organizations, private fee-
disabilities. People age 65 and older who qualify for-service plans, special needs plans, and Medicare
for Social Security retirement benefits are auto- medical savings account plans. For people enrolled
matically eligible for Medicare. After 24 months, in Medicare Advantage plans, services are covered
people who receive Social Security Disability through the plan and are not paid for under origi-
Insurance Benefits qualify for Medicare. One in nal Medicare. Most Medicare Advantage plans
five older adults and nearly half of beneficiaries offer prescription drug coverage. Because the plans
506 Medicare and Medicaid

are so diverse, it is important to choose one with

the proper mix of providers and coverages.
Medicare Part D provides coverage of prescrip-
tion drug expenses. Eligible beneficiaries select
from a variety of vendor plans. The system is
complicated and sometimes difficult to navigate.
People with mental illness have experienced great
difficulty accessing psychiatric medications under
these plans. According to the Medicare Rights
Center, despite instruction from the Centers for
Medicare and Medicaid Services (CMS) to Medi-
care Part D plan providers to cover substantially all
mental health drugs, many plans either have failed
to provide coverage or have instituted utilization
In 2009, Medicaid purchased a new high-level, picture-based,
management techniques that restrict consumer dynamic alternative and augmentative communication device
access to antidepressant and antipsychotic medi- for this Tulsa, Oklahoma, business owner, who has cerebral palsy
cations. Nearly one out of four common antide- and developmental disabilities. Medicaid is the single largest
pressant and antipsychotic medications are subject payer for mental health services.
to utilization management or are absent from Part
D plan formularies. Many plans apply utilization
management differently, depending on whether
the drug is generic or brand-name. Higher-priced all of its citizens. Legislative proposals addressing
drugs often have higher rates of utilization man- these programs have life-or-death implications for
agement. People with mental illness find it more ordinary Americans. Health care financing issues
difficult than others to navigate the bureaucratic are a continuing concern.
process that is required to obtain coverage for From the point of view of people with mental
restricted drugs. The frustration and stress can illness, the most important issues relate to estab-
lead patients with mental illness to abandon their lishing eligibility for benefits, the types of services
medication regimens and decompensate. covered, cost sharing (including so-called parity
The best sources of information about Medi- issues and the effects of managed care), and the
care coverage and benefits are advocacy groups perils of losing coverage. From the point of view
such as the American Association of Retired Per- of medical providers, key issues relate to provider
sons (AARP) and the Medicare Rights Center. enrollment, reimbursement rates, and organiza-
tional cost controls.
Conclusion The Medicare and Medicaid programs have
National health insurance was first proposed by grown extremely complex over the course of
President Harry S. Truman in 1946 but never nearly half a century of legislative and adminis-
adopted. The Medicare and Medicaid programs, trative tinkering. Even the smallest areas of medi-
created in 1965 and amended several times there- cal practice billing are relentlessly analyzed and
after, were the first federal government healthcare tweaked because the economic consequence of
programs to cover substantial numbers of Ameri- every medical choice is magnified by the sheer size
cans. Today, these programs offer key resources of the medical marketplace. The federal govern-
for millions of Americans, including people with ment manages the nation’s healthcare economy
disabilities and people with mental illness, but largely by manipulating Medicare and Medicaid
their cost, as well as issues concerning the role of payment methodologies.
government in the United States, have prevented The 2009 Affordable Health Care Act, lurch-
them from completely solving the problem of ing toward implementation as of the end of 2013,
access to health care in America. will add further complexity to the health care
The United States has had difficulty finding a landscape. Expanded Medicaid coverage, part of
national consensus on providing health care for this legislation, potentially solves access to care
 Melancholia 507

issues for people with mental illness who cannot is blocked and unchangeable and that they are
establish eligibility for Social Security or SSI. unworthy and guilt ridden.
The term melancholia comes from the ancient
Paul Komarek Greek word melankholia, meaning sadness; it is
Independent Scholar actually a composite word, combining the Greek
melas, meaning black, and the Greek khole,
See Also: Community Mental Health Centers; meaning bile. Aristotle, the Greek philosopher,
Costs of Mental Illness; Department of Health and regarded melancholia as a by-product of genius.
Human Services, U.S.; Health Insurance; Legislation; According to Hippocrates and other ancient phy-
National Alliance on Mental Illness; Policy: Federal sicians, personality was determined by the domi-
Government; Policy: State Government; State nant humors in an individual. Thus, someone
Budgets; United States. with too much black bile had a melancholic dis-
position, characterized by fears and desponden-
Further Readings cies. This idea of diseases, such as melancholia,
Center for Medicare Advocacy. “Medicare caused by an imbalance of the four humors held
Premiums, Deductibles and Copays.” http://www sway from at least the 5th and 4th centuries b.c.e.
.medicareadvocacy.org/2011/10/27/2012-medicare through the Romans to the early modern era.
-premiums-deductibles-and-co-pays (Accessed Medieval Arabic physicians and authors such
November 2013). as Al-Kindi (ca. 801–873 c.e.) and Avicenna
Disability Scoop. “States Crack Down on Mental (980–1037 c.e.) wrote about huzn, a disease very
Health Prescriptions (2012).” http://www.disability similar to melancholia. During the Late Middle
scoop.com/2012/08/15/states-crack-down Ages, European court poets and chroniclers wrote
-prescriptions/16257 (Accessed August 2013). of the pervasive sense of gloom and suffering that
Kaiser Commission on Medicaid and the Uninsured. characterized melancholia. In 1621, Sir Robert
Medicaid: An Overview of Spending on Burton wrote a treatise titled The Anatomy of
“Mandatory” vs. “Optional” Populations and Melancholy that covered the topic from both a
Services. Washington, DC: Henry J. Kaiser Family medical and a literary perspective; he suggested
Foundation, 2005. that music and dance were central to the treat-
Medicare Rights Center. “Clearing Hurdles and ment of mental illness, particularly melancholia.
Hitting Walls: Restrictions Undermine Part D In late-18th-century England, physicians and
Coverage of Mental Health Drugs” (2006). others concerned with mental illness recognized
http://www.medicarerights.org/issues-actions/ that the English, as a people, were particularly lia-
publications.php (Accessed August 2013). ble to morbus anglicus, characterized by despair
Medicare Rights Center. “Medicare Drug Plans and suicide, particularly as a consequence of living
Should Lift Restrictions on Mental Health Drugs” in their damp and chilled climate, eating a beef-rich
(2006). http://www.medicarerights.org/issues diet, and working within a fast-paced commercial
-actions/publications.php# (Accessed August 2013). environment. These factors contributed to the vul-
nerability of the national character of the English
to be melancholic. Accordingly, melancholia was
seen as the cost of being a man in the growing mid-
dle class, exercising his public responsibilities as a
Melancholia member of the emerging industrial society.
Melancholia has been a subject of consider-
Melancholia is a term for a specific type of men- able discussion by psychoanalysts. In a 1917 essay
tal illness characterized by depression, brooding, titled “Mourning and Melancholia,” Sigmund
mental and physical apathy, moroseness, mourn- Freud defined melancholia as the loss of a loved
fulness, wistfulness, and inhibition of activity. It object, resulting in a lack of interest in the world
is also referred to as endogenous depression or and a profound sense of dejection. Freud felt that
mental suffering and it results in a state of pes- this was a dangerous condition that threatened the
simism where the individual feels that the future ego with destruction, emphasizing the violent, and
508 Mental Health America

sometimes even sadistic, impulses that can be gen- There are many specific varieties of melancho-
erated from the melancholic state. Freud thought lia that have been recognized. Melancholia agi-
that the superego of the melancholic individual was tate, for instance, is expressed by much motor
a cauldron of the death drive (Thanatos). He con- activity. Affective melancholia is found during the
sidered it an individual affliction, a pathology that depressed phase of bipolar, or manic-depressive,
should be treated, as opposed to mourning, which psychoses. Climacteric melancholia occurs at the
he said was a normal reaction to a significant loss. time of menopause. Involutional melancholia is
In melancholia, the individual refuses to let go of the despondent sense, the feelings of unworthi-
the lost object, whether a person, thing, or ideal, ness, suicidal tendencies, and psychological agita-
maintaining a libidinal desire for it and internal- tion that occur in late middle life. Panphobic mel-
izing the lost object into their ego. According to ancholia is characterized by dread of everything.
Freud, it is the lack of the ability to move on after Sexual melancholia is associated with the fear of
the loss of a loved object that distinguishes melan- impotence, venereal diseases, and unmet sexual
cholia from mourning. According to psychoana- desires. Melancholia simplex is a mild form that
lytic theory, the object relation must be ambivalent expresses without great excitement or delusions.
for melancholia to occur, while the object choice Melancholia stuporosa is when the patient lies
is narcissistic, characterized by a strong fixation motionless and silent, essentially indifferent to
on the lost object with a weak cathexis of it; the their surroundings. Suicidal melancholia involves
cathectic energy is considered by psychoanalysts the impulse to commit suicide, combined with
to be withdrawn into the ego. feelings of melancholia. It is frequently accompa-
Many writers have characterized various nied by hypochondrical ideas and a marked slow-
national characters as tending toward the mel- ing of psychomotor activities, as well as a sense
ancholic. This has been said, for instance, of the of being unable to love. Anorexia nervosa and
Mexican national character, reflecting their sepa- insomnia are often also experienced.
ration from the pre-Columbian gods as well as
from Spain, their colonial mother. The Japanese Victor B. Stolberg
have often been described as having a pervasive Essex County College
melancholic national character. Note has been
made of the relatively high frequency of involu- See Also: Anthropology; Depression;
tional melancholics among individuals of Scottish Ethnopsychiatry; Mood Disorders; Suicide.
ancestry. Modern Swedes talk of the melancholia
of whiteness contrasted with their traditions of Further Readings
antiracism, egalitarianism, and humanitarianism. Jackson, Stanley W. Melancholia and Depression:
Psychoanalytic studies of Latinos and other From Hippocratic Times to Modern Times. New
ethnic groups in the United States and elsewhere Haven, CT: Yale University Press, 1986.
have suggested the presence of a pervasive ethnic- Kristeva, Julia. Black Sun: Depression and
racialized subjectivity of profound self-hatred and Melancholia. New York: Columbia University
impotence typified by a melancholic process that Press, 1980.
has widespread clinical implications. However, Lussier, Martin. “‘Mourning and Melancholia’: The
a melancholic national character is not the same Genesis of a Text and of a Concept.” International
thing as the pathology of melancholia. This point Journal of Psychoanalysis, v.81/4 (2000).
was originally made by Freud, in particular, when
he described what he regarded as a cultural mal-
aise that characterized European societies, which
he in turn said was derived from that of the Jews
that arose from the separation of the Jewish peo- Mental Health America
ple from Moses during the Exodus. Nevertheless,
those living in a society characterized by a melan- In 1909, Clifford Beers, a former psychiatric
cholic national character are at a higher risk for patient, enlisted philosopher William James, psy-
developing melancholia. chiatrist Adolf Meyer, and others to help form the
 Mental Health America 509

National Committee on Mental Hygiene with the create more inclusive communities and develop
goal of reforming the mental health system in the and implement more recovery-oriented treatment.
United States and internationally. Motivated by In the early part of its history, MHA facilitated
his abusive treatment in public and private Con- the creation of model services, programs, and
necticut hospitals, Beers launched the movement statutes to promote mental health, including a
to improve public understanding and acceptance mental “hygiene” program for the U.S. Army and
of mental illnesses as real, treatable conditions; to Navy before World War I and commitment stat-
eliminate abusive inpatient treatment; and to bet- utes that were adopted in several states. In 1930,
ter link psychiatry with evolving science, seeking MHA convened the First International Congress
ultimately to prevent and cure mental illnesses. on Mental Hygiene as Beers sought to expand
Consistent with Beers’s vision, the organiza- the education and advocacy functions through-
tion now known as Mental Health America has out the world. MHA advocated the development
attempted to represent the perspective of psy- of the National Institute of Mental Health and
chiatric patients by focusing on patient empow- promoted awareness and stigma reduction by
erment, civil rights, and full participation in all developing Mental Health Week in 1949, which
aspects of civil life. Further, its emphasis on pre- ultimately expanded to the month of May and is
vention underscores a public health and social now recognized throughout the United States as
justice perspective that features the adverse health Mental Health Month.
and mental health consequences of inequitable In order to promote community inclusion of
access to valued social roles and resources. persons with mental illnesses as well as commu-
nity-wide prevention activities, MHA helped stim-
The National Organization and History ulate the development of community treatment
Mental Health America (MHA), previously programs at both the state and national levels.
known as the National Mental Health Associa- Nationally, the 1963 passage of the Community
tion, has national offices in Alexandria, Virginia, Mental Health Centers (CMHC) Act represented
where it provides national leadership in advo- important advances in community treatment and
cacy and public education. Along with its 240 a step toward MHA’s goal of eliminating inap-
state and local affiliates in 39 states, MHA has propriate institutionalization. In the late 1970s,
advocated for change in institutional care as well MHA participated in President Jimmy Carter’s
as full inclusion of persons with mental illnesses Mental Health Commission that culminated with
in all aspects of their community lives. The latter the 1980 passage of the Mental Health Systems
includes opportunities to find and sustain meaning- Act, further expanding the role of the CMHCs.
ful work; receive humane, patient-centered mental MHA supported legislation such as the Ameri-
health care; and experience personal relationships cans with Disabilities Act and the Mental Health
without the stigma once associated with mental Parity and Addiction Equity Act (MHPAEA) of
illness. While much has been accomplished, much 2008. The latter established parity between medi-
remains to be done to assure access to quality care, cal/surgical and mental health/addiction insurance
reduce discrimination and stigma, and eliminate benefits and was included in the 2010 Affordable
the incarceration and homelessness often associ- Care Act (ACA) insurance expansion provisions,
ated with severe mental illnesses. mandating the inclusion of mental health and
In his 1907 autobiography, A Mind That Found addiction services as essential insurance benefits.
Itself, Beers began the national movement by expos-
ing the continuous human rights violations that Contemporary Challenges
he experienced in Connecticut’s institutional care Today, MHA continues to advocate equal treat-
system. Although he was counseled not to identify ment for mental health and substance use condi-
himself as a mental patient, Beers concluded that tions through the implementation of MHPAEA
he must fight in the open. Consequently, the nation and the ACA. MHA is also working to promote
was exposed to the patient voice, a powerful tool policies that recognize the multiple needs of
used to this day to help better understand the expe- people with mental illnesses. The organization
riences of persons with mental illnesses and thereby seeks to bring awareness and solutions to the
510 Mental Hygiene

early mortality of persons suffering from severe MHA’s National Symbol: The Bell
mental illnesses as well as social exclusion, pov- Beers envisioned a country where each person,
erty, and discrimination—the social determinants and especially those with mental illnesses, would
of health. MHA works with federal and corpo- be treated with dignity and respect. As hospitals
rate partners, advocacy organizations and trade were depopulated in the 1950s, MHA gathered
associations, to promote integrated general and the restraints used to bind patients such as Beers.
behavioral health care, including research to These chains and shackles were melted and cast
understand the development and treatment of into the 300-pound Mental Health Bell that is
these complex medical needs. These concerns housed in the national office. It is designed to sig-
respond to a broader public health concern nify the hope of transformation from oppression
regarding the burden of chronic illnesses. to inclusion and from illness to health as well as
In an effort to promote patient-centered a reminder of the fight for freedom for individu-
research and dissemination, MHA convened the als with mental illnesses and the commitment to
National Working Group on Evidenced-Based promote the worth and dignity of every person.
Healthcare in 2005. This coalition of over 40
patient advocacy organizations works at the David L. Shern
national level to promote the patient’s voice in Mental Health America
all aspects of the health care system. Historically, Sarah M. Steverman
consumers of mental health services have not par- M. S. W. Catholic University
ticipated as equals in treatment or research.
MHA explicitly advocates population-based See Also: Consumer-Survivor Movement; Human
strategies to improve the public’s mental health, Rights; Mental Hygiene; Patient Activism; Patient
thereby seeking to both reduce the prevalence of Rights; Policy: Federal Government; Prevention;
mental illnesses and increase the mental health fit- Stigma; Stigma: Patient’s View; Trauma: Patient’s
ness of the population. Prevention of mental ill- View; United States.
nesses and the promotion of mental health for all
Americans remains a priority. Consistent with the Further Readings
recognition of the importance of social determi- Beers, Clifford Whittingham. A Mind That Found
nants of health, MHA has adopted strategies that Itself. 5th ed. Pittsburgh, PA: University of
emphasize social justice, recognizing the need to Pittsburgh Press, 1921.
fight poverty, racism, violence, discrimination, and Grob, Gerald N. From Asylum to Community:
other barriers to full social participation in order Mental Health Policy in Modern America.
to create healthy communities and individuals. Princeton, NJ: Princeton University Press, 1991.
Grob, Gerald N. and Howard Goldman. The
Affiliates Dilemma of Federal Mental Health Policy: Radical
MHA’s 240 affiliates work in local communi- Reform or Incremental Change? Newark, NJ:
ties, municipal and county governments, and Rutgers University Press, 2006.
statehouses. MHA affiliates are certified by the
national office and are independently incorpo-
rated organizations that are committed to the
mission and values of MHA. They comprise
diverse organizations in size and portfolio but all Mental Hygiene
work to improve the mental health system and
promote the mental health of their communities. The term mental hygiene was coined in 1843
Many affiliates run evidence-based mental health by William Sweetzer, a physician, author, and
treatment and prevention programs, while others advocate for the mentally ill. From its origins, it
primarily focus on advocacy and public educa- embodied the optimistic notion that mental illness
tion. Representing local perspectives, MHA affili- could be prevented by suitable hygienic measures,
ates join the national office in support of federal though precisely what these preventative mea-
legislative and executive branch initiatives. sures might be and how they might act to forestall
 Mental Illness Defined: Historical Perspectives 511

mental illness would remain vague throughout the Rockefeller Foundation and the Commonwealth
history of the term, even after a national organi- Fund. In 1913, the National Committee opened
zation was formed to implement its goals. Mental the first outpatient clinic in the United States and
hygiene was supposed to be a science that dealt under its first medical director, Thomas Salmon,
with the development of healthy mental and emo- began to collect statistics about mental illness and
tional reactions and habits. In 1893, Isaac Ray, to advocate for vaguely defined programs of men-
one of the founders of the American Psychiatric tal hygiene, aimed at early intervention, preven-
Association, offered the initial definition for men- tion, and the promotion of mental health, as well
tal hygiene. He suggested that it was the art of as collecting data that was influential in policy
preserving the mind against all incidents and influ- circles. Beers continued to remain the nominal
ences that would impair its energies or derange its figurehead of the movement into the 1930s, when
quality. Mental hygiene became the precursor to he suffered a relapse and was rehospitalized. He
contemporary approaches to work on promoting died while still a patient at the hospital.
positive mental health. In 2012, the Clifford W. Beers Guidance Clinic
Another important 19th-century figure indi- continues to provide services in New Haven,
rectly associated with mental hygiene was Doro- Connecticut. The National Committee for Men-
thea Dix. Dix was a former schoolteacher from tal Hygiene has evolved since its conception. The
Massachusetts who traveled across the United organization later became known as the National
States during the 1840s and early 1850s, urg- Mental Health Association. It is presently known
ing the construction of state-supported asylums as Mental Health America, with headquarters
for the mentally ill. Despite the fact that women located in Alexandria, Virginia, and 240 affiliate
were excluded from voting and were generally offices located through the United States.
excluded from all forms of political activity, she
successfully lobbied state legislators to raise the Dashiel Geyen
necessary funding to create a network of these Texas Southern University
establishments. For more than a century, insti-
tutionalization became the primary response to See Also: Mental Health America; Mental
major mental illness. Institutions, History of; Self-Help.
Though a number of 19th-century writers on
mental health issues had made use of the term Further Readings
mental hygiene and had spoken in general terms Dain, Norman. Clifford W. Beers, Advocate for the
about programs to prevent mental illness, the Insane. Pittsburgh, PA: University of Pittsburgh
term achieved much greater prominence in the Press, 1980.
early 20th century through the writings and orga- Gollaher, David. Voice for the Mad: The Life of
nizational activities of a former asylum patient. In Dorothea Dix. New York: Free Press, 1995.
1908, Clifford Beers (1876–1943) wrote his auto- Sue, David, Derald Sue, Diane Sue, and Stanley Sue.
biography, A Mind That Found Itself. The book Understanding Abnormal Behavior. 10th ed.
was an account of the harsh and brutal treatment Belmont, CA: Wadsworth, 2013.
that he and other patients received in the early
20th century while confined in a series of private
mental hospitals and the Connecticut state hospi-
tal for the mentally ill.
With some initial support (later withdrawn) Mental Illness Defined:
from a professor of psychiatry at Johns Hop-
kins University, Adolf Meyer, he started the Con- Historical Perspectives
necticut Society of Mental Hygiene. He quickly
moved to expand this organization to form what The historical perspectives of mental illness are
he called the National Committee for Mental illuminated by examining past efforts to under-
Hygiene, attracting support from private philan- stand and find solutions to troubles of the mind.
thropist Henry Phipps and subsequently from the These attempts to understand are traced through
512 Mental Illness Defined: Historical Perspectives

centuries of primal customs and obscure ideas, that the heart, rather than the brain, had control
some of which are entangled in some of the tech- of mental power.
niques and theories of modern thinking. Modern However, over the next 200 years, this view-
conceptualizations of mental illness developed point shifted and Egyptian medical professionals
from the spiritual traditions and rituals that eventually hypothesized that the brain controlled
ancient civilizations utilized to ameliorate human mental action. In addition, Egyptians adopted
suffering. Much of the current understanding and many ideas concerning mental illness originally
techniques used to examine and treat mental ill- posited in neighboring Greek civilizations. For
ness arose centuries ago, when mysticism was a example, the term hysteria, which is a Greek
thriving part of spiritual practice and daily life. word meaning uterus, became indoctrinated into
Therefore, it was not guided by scientific methods ancient Egyptian medical diagnoses. A common
or theory; rather, it arose out of an innate curios- belief was that individuals evidencing symptoms
ity to understand the relationship between feel- of agitation and anxiety were suffering from a
ings and actions. deviated uterus that needed the assistance of a
physician to put it back in place. This definition
Early Perspectives of hysteria carried on until the 14th century, when
There is limited evidence for examining the nature it was finally discredited.
or even the existence of mental disorders prior to In ancient Chinese cultures, mental illnesses
written records. However, there is evidence from were viewed somewhat differently, although treat-
Neolithic periods of the practice of trephining ments were similar to those employed in ancient
(cutting large holes into the skull) as an effort Egypt. Early records of mental illness in Chinese
to cure illness, which may have included men- literature evidence the belief that mental disorders
tal disorders. Evidence of this practice has been were caused by wicked spirits that inhabited the
found in Neolithic human remains and in later air. These views continued for many centuries and
specimens. Cave paintings indicate that people much research was dedicated to understanding
may have believed that the practice would cure these “wind” disorders. Historically, collectivist
epileptic seizures, headaches, and mental issues. Chinese cultures have placed heavy emphasis on
This practice is not entirely outdated, as people social welfare and, as such, caretaking facilities
still undergo modern versions of this procedure were established to care for those impaired by
in medical settings. Today, trepanation in non- “wind in the mind.”
Western culture is intended to restore childhood Within other early societies, determining the
levels of blood flow and decrease brain fluid, dates of initial conceptualizations of mental ill-
leading to more energy and reduced depression ness remains difficult. For instance, it is difficult
and to being more adventurous, spiritual, and to pinpoint ideas about mental illness in ancient
creative. India because of priests’ control over such mat-
There is also evidence to suggest that ancient ters. More written documentation is available
Egyptian cultures developed conceptualizations of following the writings of Susruta, who claimed
physical and mental diseases. In an ancient docu- that elevated emotions of the mentally ill could
ment known as the Ebers Papyrus, dating back cause physical problems. His perspective encour-
to approximately 1500 b.c.e., Egyptian doctors aged more detailed investigations into the cause
detailed over 700 formulas and remedies, even of mental problems and led to the exploration of
addressing mental illnesses such as depression medical treatments for insanity.
and dementia. Because of the belief that physical In early European cultures, superstition fueled
and mental illnesses were caused by bodily dys- judgmental mystical views of mental illness and
functions, their treatments also involved physical led many to believe that demon possession was the
manipulations and primitive surgeries. Temples only explanation for unacceptable behavior. This
were erected to serve individuals mentally suffer- led many physicians to perform torturous proce-
ing after war and times of anguish, wherein they dures to eliminate internal “demons” and relieve
were treated with baths, massages, and food. The the host’s suffering. These conceptualizations of
dominating belief in ancient Egyptian culture was mental illness contributed to a period of inhumane
 Mental Illness Defined: Historical Perspectives 513

psychological treatments such as bloodletting, Individuals in these societies were deemed worthy
exorcism, restraint, and torture. Babylonians also of humane treatments, which included music, art,
attributed any unconventional behavior to inter- and bathing.
ference from the gods or demonic possession and The 16th century in Europe saw a resurgence
used exorcisms to remove the demons and restore of the belief that mental illness was caused by
peace between supernatural beings and humans, demonic possession. Individuals used cruel tor-
often utilizing plant-based medicines and confes- tures, such as shock, surgery, and starvation to
sionals. However, not all civilizations adopted prevent the spread of possession. This era included
this viewpoint, and Judaic and Muslim scholars many records of witchcraft and witch hunts, with
were more concerned with the inner struggles of those deemed to be mentally disturbed often forc-
the mind, which paved the way for the foundation ibly confined in workhouses or asylums. Scien-
for scientific empiricism regarding mental illness. tists of the time were primarily interested in the

The “probable causes of insanity” among the 193 inmates of Missouri’s State Lunatic Asylum are documented in this 1854 report
from Dr. Turner R. H. Smith, the superintendent of the facility in Fulton. Besides the 56 unknowns, other top causes are miasmatic
fevers (25), indigestion (14), and disappointed love (10). In the mid-19th century, the proliferation and overcrowding of asylums
shifted the focus to outpatient care, which was accompanied by a growing belief in the hereditary etiology of mental illness.
514 Mental Illness Defined: Historical Perspectives

functions of the body, and matters of the mind During the 18th century, almshouses became
were not yet well understood or emphasized. As popular for housing mentally ill patients, driven
such, treating those with mental dysfunction was particularly by the rise of large cities and the
not of primary concern. Instead, those evidenc- increase in individuals unable to care for them-
ing mental problems were sent to “mad houses,” selves. In the early 1750s, the first general hospi-
which served primarily to segregate them from the tal, Pennsylvania Hospital in Philadelphia, began
healthy population. Supernaturalism, a belief in a admitting the mentally ill, marking the beginning
supernatural entity that intervenes in the course of the development of a medical model of treat-
of natural laws, subsequently became a primary ing those with psychological illnesses. However,
worldview for comprehending mental distur- it was not until the end of the 18th century and
bances, and priests capitalized on people’s fears beginning of the 19th century that mental institu-
by promising they could undo spells and cleanse tions adopted the idea of widespread humane care.
the minds of the mentally ill. Many societies have Slowly the belief shifted that mentally ill individu-
placed the power to heal individuals with mental als should be strictly confined and removed from
illnesses with religious leaders and magicians at society to the belief that in order to alleviate men-
one point in time or another, and this authority is tal problems, comfort, physical care, and social
still present in many cultures today. interaction were needed.
In the mid-19th century, the movement to estab-
Scientific Thinking lish state institutions for individuals with men-
During the later part of the 16th century and tal illnesses grew in momentum. Several things
throughout the 17th century, the supernatural accounted for this: the evidence that moral treat-
belief system attributed to mental illness began ment seemed to work, the encouragement to phy-
losing vitality when scientific theory and ques- sicians that mental illnesses may be curable, and
tioning of demonic possession emerged. Dur- that the inadequate and limited treatment facili-
ing the Reformation, these views lost a signifi- ties aroused a reform impulse directed at getting
cant amount of control over people’s thinking, government provisions and funding to improve
and several social changes such as industrialism them. This was in large part also driven by the
molded the worldviews of Europeans. The study industrialization occurring in that period. During
of human nature became one of necessity as phi- the decades after the Civil War, the study of men-
losophers challenged ideas in all areas of study tal illness achieved the status of a specialty, and
and the significance of human emotions became those qualified numbered approximately 200 of
apparent in directing intellectual thought. Psycho- the 20,000 physicians in the United States. The
logical disorders began to be humanized and the beliefs during this time were driven in part by John
biology underlying mental processes was taken Locke’s sensationalist psychology, which asserted
into consideration. that if the senses were defective or damaged, the
However, this advancement in thinking mini- mind would receive false impressions that would
mally improved how individuals with mental ill- cause faulty thinking and unusual behavior.
nesses were still viewed and treated. Mental ill- Unfortunately, the proliferation of the asylum
ness was often equated with violent, disruptive, led to some unintended consequences, namely,
and deviant behavior and insanity was equated the resulting overcrowding of these facilities. As
with sin. Such sinful behavior demanded retribu- such, the end of the 19th century saw a movement
tion, and the deviant were whipped, beaten, or toward outpatient care. During this time, more
otherwise terrorized. The intention was to ren- physicians also came to believe in a hereditary eti-
der mentally ill patients harmless by completely ology of mental illness and that debilitating con-
removing any human interaction from them. The ditions could be passed down across generations.
more violent the patient acted, the more he or she This shift was coupled with an increased interest
was isolated from society. Those who suffered in the study of psychiatry as well as the treatment
from schizophrenia or mental retardation were of patients in outpatient clinics or medical hospi-
often outcast by their communities and left to live tals. Community care gained momentum in the
a life of poverty and homelessness. early 1900s and new therapies were developed in
 Mental Illness Defined: Psychiatric Perspectives 515

an effort to treat a wider range of patients. With See Also: Asylums; China; Cognitive Behavioral
psychological science well established as a profes- Therapy; Community Mental Health Centers;
sional field at this time, psychotherapy became a Dangerousness; Deinstitutionalization; Egypt;
widely accepted treatment and mental hospitals Electrotherapy; Environmental Causes; Freud,
associated with larger medical facilities and uni- Sigmund; Hysteria; India; Insulin Coma Therapy;
versities were established, often privately funded Lobotomy; Medicalization, History of; Mental
and well staffed. Focus also moved from treat- Institutions, History of; Mesmerism; Popular
ment to prevention efforts in order to monitor Conceptions; Psychoanalysis, History and Sociology
those at risk of becoming ill. Furthermore, mental of; Religion; Religiously Based Therapies; Social
illness was no longer seen as only a somatic dis- Causation; Somatization of Distress; Spiritual
ease but also as an interaction with environmen- Healing; Sterilization; Stigma; Therapeutics, History
tal and social factors. of; Thorazine and First-Generation Antipsychotics.
In the mid-1930s, as treatments became more
advanced, some medical strategies were used to Further Readings
treat those with mental illnesses. For instance, De Young, Mary. Madness: An American History of
drugs and electrotherapy in the form of insulin, Mental Illness and Its Treatment. Jefferson, NC:
metrazol, or electric shock were thought to reduce McFarland, 2010.
the symptoms of those with chronic and severe Gamwell, Lynn and Nancy Tomes. Madness in
mental illnesses. The practice of lobotomies devel- America: Cultural and Medical Perceptions of
oped around the same time and was used with the Mental Illness Before 1914. Ithaca, NY: Cornell
most dangerous or severe cases. The development University Press, 1995.
of antipsychotic medications eventually led to the Hewitt, K. “Women and Madness: Teaching Mental
decline of lobotomies, and psychotropic medica- Illness as a Disability.” Radical History Review,
tions continue to be used today to treat a wide v.94 (2006).
variety of mental problems. MacSuibhne, S., and B. D. Kelly. “Vampirism as
The late 20th century saw a significant increase Mental Illness: Myth, Madness, and the Loss
in the development of psychotherapeutic tech- of Meaning in Psychiatry.” Social History of
niques, including cognitive and behavioral thera- Medicine, v.24/2 (2011).
pies, typically administered in an outpatient clinic. Millon, T., S. Grossman, and S. Meagher. Masters of
As the medical and psychological fields continue the Mind: Exploring the Story of Mental Illness
to merge and the reciprocal impact of the body From Ancient Times to the New Millennium.
and mind continues to be examined, community Hoboken, NJ: John Wiley & Sons, 2004.
mental health clinics advertising an integrated Porter, R. Madness: A Brief History. Oxford: Oxford
treatment model have developed. The future University Press, 2002.
holds promise that mental illnesses will eventu-
ally be treated in context of the entire well-being
of the individual.
Perspectives of mental illness have vastly
improved over time with the development of com- Mental Illness Defined:
plex philosophical ideas and empirical research.
Great advances have been made toward an under- Psychiatric Perspectives
standing of psychological processes and how
environmental and biological factors can impact Identifying a person as “mentally ill” involves
mental illness. a number of important steps. Depending on the
background, training, and orientation of the pro-
Shannon Bierma fessional working with the individual client, a
Samantha J. Lookatch completely varied perspective on the symptoms,
Kathrin Ritter etiology, and treatment will likely take place. The
Todd M. Moore diagnostics that are involved in assessing mental
University of Tennessee, Knoxville illness include a review of the client’s self-report,
516 Mental Illness Defined: Psychiatric Perspectives

history, and symptoms as well as an assessment illness, a psychological perspective on mental

of the individual’s overall level of functioning in illness also often views the symptoms as either
multiple areas. learned or developed from the environment. A
Diagnosing an individual with a mental ill- psychological perspective supports the treatment
ness is not a simple task. Unlike physical disor- of mental illness from numerous orientations
ders such as diabetes or hypertension, there is and modalities, including cognitive behavioral
no one specific test or assessment tool that can therapy and psychodynamic, humanistic, and/or
be used to conclusively diagnose a client with a integrated approaches that combine one or more
mental illness such as major depressive disorder, orientations. A psychiatric perspective views the
social phobia, or even a personality disorder. symptoms of mental illness as biologically based
While it can be confirmed if a client fits into a and best treated from both psychopharmacologi-
category of mental disorders based on his or her cal and/or biological perspectives.
presentation and reported symptoms, the com- For example, a client with a mood disorder
plexities involved in accurately identifying men- such as depression would receive entirely dif-
tal illness are vast. Still, the psychiatric perspec- ferent treatment based on psychological and
tive of mental illness is widespread, and many psychiatric approaches. From a psychological
professionals hold that mental illness is indeed perspective, an individual would be engaged in
the product of mainly biological, physical, and some type of weekly talk therapy, usually cog-
genetic processes. nitive behavioral therapy. Cognitive behavioral
therapy involves addressing the individual’s neg-
Symptomology ative and maladaptive thoughts and restructur-
One issue that is seen on a consistent basis is that ing those thoughts to make them more positive
the actual diagnosis of mental illness includes a and functional. The relationship between one’s
large group of symptoms that can often cover thoughts and his or her feelings and behaviors
many different disorders. There is also overlap in is also addressed by using cognitive behavioral
symptomology that can lead to a false or inac- treatment techniques. Cognitive behavioral ther-
curate diagnosis. Clinicians most often diagnose apy is consistently supported in the current lit-
specific mental illnesses by the symptoms that are erature as an effective and efficacious treatment
obtained through a client’s self-report, through for depression.
the reports of others, or that are actually observed, From a psychiatric perspective, the same cli-
and presently there is no other option. Patients ent would likely be treated with some form of
diagnosed with the same mental illness are still popular antidepressant medication such as Paxil,
completely unique and have a different etiology Zoloft, or Prozac and meet with a medical pro-
of the disorder, have a different onset, and need fessional or psychiatrist on a monthly rather
different treatment interventions and plans. If than weekly basis. He or she would likely not
mental illness is viewed strictly as a psychiatric explore the origin or meaning of maladaptive
disorder with a biological function only, the prac- thoughts or the connection between thoughts
titioner may miss some very important data that and behaviors, and treatment would focus solely
could assist in both accurate diagnosis and effec- on biological options.
tive treatment planning.
Classification for Mental Disorders:
Psychiatric Versus Psychological Perspective Weighted Toward the Psychiatric Perspective
The psychiatric perspective of mental illness views The classification for mental disorders is based
the mental health disorder as a disease that is most on two main systems: the Diagnostic and Statis-
effectively treated with a biological approach that tical Manual of Mental Disorders (DSM), pub-
directly alters the bodily functions and processes, lished by the American Psychiatric Association,
such as medication or a medical approach such as and the International Classification of Diseases,
electroconvulsive therapy. Clinical Modification (ICD-9-CM), published by
While some psychologists do look at the hered- the World Health Organization (WHO). Both are
itary and genetic factors involved in the mental very large references that are used as diagnostic
 Mental Illness Defined: Psychiatric Perspectives 517

tools for identifying mental illness. The DSM-5 years, 12 states—Alaska, California, Connecti-
was published in the spring in 2013. The ninth cut, Florida, Georgia, Hawai‘i, Illinois, Louisi-
edition of the ICD-CM was developed to address ana, Missouri, Montana, Tennessee, and Texas—
the changes and advances in medicine. In Octo- have rejected legislation to allow psychologists
ber 2014, the ICD-9 code sets will be replaced prescription privileges.
by ICD-10. As medical doctors, by contrast, psychiatrists
The ICD was developed by a joint effort have the legal authority to write prescriptions,
between the World Health Organization and 10 regardless of their state of licensure. Following
international centers, including the WHO Collab- the medical model, they view mental illness under
orating Center for the Classification of Diseases a biological lens and hold that mental illnesses
in North America. The ICD is also the only clas- and disorders are most effectively treated with
sification system approved by the Health Insur- medication and other organic measures.
ance Portability and Accountability Act (HIPAA), However, assessing and treating mental ill-
whereas the DSM is not. Consequently, the ICD ness cannot be conducted with a one-size-fits-all
codes meet all insurer-mandated and HIPAA cod- approach, and the view that mental illness is pre-
ing requirements. These are the only two major dominantly a biological function does not serve
volumes used by clinicians, and all of these stan- all clients. While it is known that some disorders
dards and codes support the psychiatric perspec- such as schizophrenia, autism, and bipolar dis-
tive of mental illness and clearly divide mental order support a biological model, not all condi-
illnesses by symptoms, duration, and specific tions and mental illnesses do. More commonly,
diagnostic criteria. the mental illness is the result of multiple factors,
It is important to note that the DSM-IV-TR and including a combination of biological, genetic,
the ICD-9-CM were written by medical doctors and environmental factors. A great deal more
from more of a medical and biological perspective research is necessary to understand the precise
than a mental health viewpoint. The Centers for interplay of these factors; if care is not taken, too
Disease Control and Prevention (CDC) reports much emphasis can be placed on only the bio-
that the United States is required to use the ICD to logical factors involved in mental illness, which
classify biological diseases. These are important would be a great disservice to both clients and
considerations for mental health workers as well. providers.
Social workers, counselors, therapists, psycholo- While the functions of the brain and biol-
gists, marriage and family therapists, and clini- ogy are involved in the onset of some mental
cians—as well as psychiatrists—use these tools illnesses, genetics and biology are not the only
to diagnose and assess individuals. Each publica- factors involved in all mental illnesses. Even sup-
tion has commissioned its respective task force to porters of the psychiatric view of mental illness
develop and edit the new editions, yet the major- know that some disorders do indeed develop
ity of task force members come from a medical through a combination of situational and envi-
background. This ensures that the criteria will ronmental factors coupled with the individual’s
continue to view the individual’s symptoms as the personality traits. Unfortunately, there is no one
diagnostic criteria necessary for the identification blood test that can accurately diagnose a mood
of mental illness and that the psychiatric perspec- disorder, and there are no brain-mapping tech-
tive will prevail. niques that can conclusively assess schizophre-
nia. Relief from debilitating symptoms that nega-
A One-Size-Fits-All Approach? tively impact an individual’s overall functioning
Psychologists work from a variety of orientations is available from a variety of perspectives, ori-
and treatment modalities, and for the most part entations, modalities, and disciplines. However,
do not apply medication as part of treatment. whether a patient’s problems and disorders are
The National Alliance on Mental Illness (NAMI) viewed as mental illness, psychiatric illness, or
reports that only a handful of states, such as New problems related to life adjustment will be sub-
Mexico and Louisiana, offer prescription privi- ject to the practitioner’s views on psychology,
leges to psychologists. In the past dozen or so psychiatry, and medicine.
518 Mental Illness Defined: Sociological Perspectives

The Debate Continues Mental Illness Defined:

The concepts of mental illness are broad and
include a vast range of behaviors. While a psycho- Sociological Perspectives
logical approach does not identify any one cause
or category for mental illness, the psychiatric per- The examination of mental health in accordance
spective holds that mental illness is a disease with with the laws of social relations provides an
a physical, genetic, and/or biological origin. The important background for examining mental ill-
goal for the clinician in the psychiatric view is to ness. The scholarship within sociological perspec-
identify, treat, and control the symptoms of the tives offers little insight to the trajectory of mental
disease. Once a person is placed in a diagnostic illness but can serve as a significant entry when
category, he or she will be expected to display a assessing epidemiology, etiology, correlates, and
variety of symptoms based on this diagnosis. The consequences within the context of culture. While
medical practitioner will then treat those symp- sociology tries to comprehend trends in outcome,
toms by using medication or other biological the portrayal of mental illness should find the
techniques that directly impact and change bodily expression of a people as the shaping of ordered
functions and neurochemistry. Much debate and disordered behaviors.
continues, however, over whether the psychiat- The following discussion focuses on the rele-
ric focus is too narrow and that without a clear vance of mental illness from a culturecology per-
and accurate identification system, the treatment spective, evaluates health statistics from collectiv-
options are limited. ist/individualist continuum, and presents the need
to transpose the current individualistic paradigm
Alyssa Gilston to a broader cultural paradigm of mental health
University of the Rockies and mental illness.

See Also: American Psychiatric Association; The Culturecology Model

Cognitive Behavioral Therapy; DSM-IV; International The current political climate continues to exac-
Classification of Diseases; Therapy, Individual. erbate the mental health functioning of certain
groups more so than others. This psychic cultural
Further Readings pattern reflects the sentiments of cultural groups’
Goldman, H. H. and G. N. Grob. “Defining ‘Mental feelings and moods toward each other and should
Illness’ in Mental Health Policy.” Health Affairs, be able to contribute to the contextualizing of
v.25/3 (2006). mental illness. However, the context of evaluating
Phillips, James, et al. “The Six Most Essential mental illness continues to be concerned mainly
Questions in Psychiatric Diagnosis: A Pluralogue with the individual level of analysis and is less
Part 1: Conceptual and Definitional Issues in concerned with ecological mental illness. The con-
Psychiatric Diagnosis.” Philosophy, Ethics, and ditions that led individuals to express themselves
Humanities in Medicine, v.7/1 (2012). in a given way in relation to others are likely to
Phillips, James, et al. “The Six Most Essential shape mental health outcomes. As postulated in
Questions in Psychiatric Diagnosis: A Pluralogue the emergence of Western European psychology
Part 2: Conceptual and Definitional Issues in known as volkerpsychologie, mental illness devel-
Psychiatric Diagnosis.” Philosophy, Ethics, and ops because of the confluence of culture and com-
Humanities in Medicine, v.7/1 (2012). munity. One conceptual approach to advance this
Phillips, James, et al. “The Six Most Essential explanation of convergence is the Authentic Cul-
Questions in Psychiatric Diagnosis: A Pluralogue turecology Model developed by Lewis M. King.
Part 3: Conceptual and Definitional Issues in This model is the organized structure for captur-
Psychiatric Diagnosis.” Philosophy, Ethics, and ing the cultural framing of people of color in rela-
Humanities in Medicine, v.7/1 (2012). tion to health. As a general systems theory, it can
Roleff, Tamara L. and Laura K. Egendorf. Mental be used to link stressors at the socioenvironmen-
Illness: Opposing Viewpoints. Westport, CT: tal level with the etiology of mental illness at the
Greenhaven Press, 2000. individual level.
 Mental Illness Defined: Sociological Perspectives 519

Culturecology recognizes the intricacy of the effecting mental illness broadly include non-
human psyche (values, beliefs, and epistemolo- conformity to given social roles, deprived social
gies) and the interaction with the environment identity, systematic exposure to prejudice and
that shape both normal and abnormal behavior. discrimination, and the inability to form healthy
Each individual has an ontological cultural his- relationships with others. The examination of
tory embedded with facilities, ideas, life practices, culture and mental illness requires a broader par-
and prescripted epistemology for survival. King adigm that may offer a more complete cultural
and Wade Nobles claim that the Culturecology analysis and understanding of the social construc-
Model identifies that the nature of the person as tion of health and illness.
cultural agent (their episteme, ontogeny, and phy-
logenetic survival thrust) and the nature of the Health Status
environment (the cultural agency of ethos, rules, Health statistics indicate that collectivist groups
and social norms) require synergistic interplay represent the worst health statistics in the United
between both cultural phenomena. The conflu- States compared to individualistic populations.
ence of cultural agent and cultural agency on the The CDC reported in 2008 that more than 1 of
etiology of mental illness varies as collective per- 20 Americans 12 years of age and older reported
ceptions of personhood and broader social con- depression in 2005 to 2006. African Americans
texts significantly influence functioning, behavior, presented with depression at a rate of 8 percent,
and perceived stressors. Mexican Americans at 6.3 percent, and whites at
4.8 percent. According to the Office of Minority
Defining Mental Health Health, African Americans are 30 percent more
The term mental illness is used in conjunction likely to report having serious psychological dis-
with mental health. While mental health and men- tress compared to white counterparts. African
tal illness are intimately interrelated, they present Americans experience sadness, hopelessness, and
as two distinct psychological states. The term worthlessness on average 1.3 times more than
mental health broadly refers to development and their white counterparts. The U.S. surgeon gen-
functioning. Mental health is the state of mental eral found that from 1980 to 1995, the suicide
functioning that results in productive activities, rate among African Americans aged 10 to 14
fulfilling relationships, and the ability to adapt to increased 233 percent.
change and cope with adversity. The conceptual- It has been argued that African Americans are
ization of mental health involves the individual more likely to experience mental health issues
comprehending his or her own capacities, man- than their white counterparts because of inequali-
aging life stresses, producing quality work, and ties they experience from living in the United
contributing to the community. States. Poverty rates remain twice as high for
The Centers for Disease Control and Preven- African Americans, slightly less than the Hispanic
tion (CDC) estimates that only 17 percent of population when compared to the white popula-
adults in the United States achieve a state of maxi- tion. Factors that contribute to disproportionate
mum health. While the definition of mental health statuses in the United States have shown little
constitutes the presence of having a sound mind progress in the last 50 years. A variety of socio-
and body, a good quality of life, and the promo- cultural variables have been posited as founda-
tion of healthy habits, the lack of this good func- tions of mental illnesses, including acculturation,
tioning therefore suggests an equation to mental urbanization, migration, and poverty.
illness. This may be problematic for individuals Culturecology takes into account the many
with a collectivist orientation who experience factors that impede the health and functioning
such stressors within traditional Western social of certain groups and recognizes the interaction
constructs. between people and their environment. In the
Mental illness is seen as experiencing social United States in 2011, it was estimated that 38.6
or psychological distress established by a cul- percent of black children and 33.7 percent of His-
tural incongruence that exacerbates and alters panic children lived in poverty, compared to less
cognition, disposition, or behavior. Key elements than 18.1 percent of white children. Two-thirds
520 Mental Illness Defined: Sociological Perspectives

of black men were employed, compared to three- existence. However, in collectivistic cultures, per-
fourths of white men. African American males sonality and self are indistinguishable from other
are less likely to complete postsecondary educa- members within the community and contextual
tion, as fewer than 20 percent aged 25 to 29 have conditions are used to explain behavior.
college degrees, compared to 30 percent of white Collectivistic cultures are reciprocal in nature
men. Finally, roughly 16 percent of black men and kinship oriented, valuing cordiality and prox-
have been incarcerated, compared to 3 percent of imity to family, while individualistic characteristics
white men. It is estimated that 75 percent of those include self-dependence, pleasure seeking, antago-
incarcerated have a mental health issue that goes nism, and emotional detachment from same-group
untreated. settings. While this work is well accepted within
Health statistics indicate alarming trends for theories of cultural dimensions, ideocentrism ver-
collectivist groups versus noncollectivist groups. sus allocentrism, and interdependent versus inde-
From 1980 to 2010, life expectancy rates for pendent self, etc., cultural relativity remains fleet-
blacks were 74.5, compared to whites at 78.5 ing in the examination of mental health.
and Hispanics at 81.5. Mean wait time to see a Imagine a perpendicular axis model consisting
physician in an emergency department was 50 of personhood and environmental axes. With the
minutes for whites, 68 minutes for blacks, and 60 person serving as cultural agent, the vertical axis
minutes for Hispanics. When individuals cannot of individualism (VI) versus vertical collectivism
control their equal access to proper education, (VC) reflects the survival thrust by its commu-
health care, certain entry points of society, and nication of how people view themselves, their
respect, the result is social ills—crime, unemploy- content, and their conduct from a competitive,
ment, incarceration, deaths, and mental illness. independent, anything-goes mentality to seek-
The major challenge in examining mental illness ing harmony, interdependence, and achievement
in an unjust, unequal distribution of goods and of balance. An interdependent, similar self-con-
resources only exacerbates the need to effectively strual reflects a strong sense of self (high VC)
diagnose health for less-revered groups. while a high VI is an independent, different self-
Traditionally, mainstream psychology has har- construal that reflects a false sense of self.
bored an individualist ideology where mental The horizontal axis represents the environmen-
illness is seen purely at the individual level. The tal cultural ethos as defined by its content (epis-
long-standing challenge between sociology and teme, ontology, and cosmology) and its nature
mental health remains in the search for an expla- of communication of the prevailing culture. The
nation that may be universal. Attaining health subjective (cultural) agency, horizontal individu-
from an individualist-collectivist continuum may alistic (HI) versus the horizontal collectivist (HC)
offer some explanation. continuum, ethos of self-indulgence, immediate
gratification, and competition reflect strong HI,
Mental Health Continuum while conformity, mutual respect, and sense of
Two well-known methods of examining cul- appropriateness reflect strong HC.
tural contexts of mental health are etic and emic Divided into quadrants formed by the intersec-
approaches. The etic approach involves examin- tion of the person and environmental axes, indi-
ing different cultural populations within the uni- vidualist versus collectivist continuum, and opti-
versality of traditional Western theoretical con- mal health or lack of mental illness would locate
structs, whereas the emic approach allows for the individual in a quadrant where the greatest
in-depth exploration of mental health function- health occurs when that individual experiences
ing within specific cultural contexts. There is an the highest level of cultural congruency. When the
increased appreciation for cultural effects on men- individual experiences the lowest level of cultural
tal health in relation to rules, adaptation, and life congruency it is more than likely they will experi-
meaning. Individualistic societies attribute behav- ence stress overload due to competing forces on
ior to “traits,” in alignment with standard West- the HI/HC scale versus the VI/VC continuum.
ern perspectives in which the concepts of personal- The individual begins to feel less connected, less
ity formation and self are derived from individual competent, and not fully aware of his or her own
 Mental Illness Defined: Sociological Perspectives 521

existence. While the sociology of mental health Psychological functioning has been regulated as
recognizes the value of group patterns analysis a manipulative, independent variable often mar-
toward an understanding of behavior, this can ginalized because of limitations of time and place.
also open the door to acknowledging the need to This sociological review accounts for broader
expand how mental illness is diagnosed. aspects of human experiences as much more con-
For example, there are psychological norms ducive to acknowledging the unique cultural expe-
in which the characteristics of identity of self is riences of the various groups that make up Ameri-
seen through the collective, or a survival-of-the- can society. It challenges the examination of mental
group construct, rather than the traditional sur- health functioning from the cultural congruence
vival of the fittest. It has been noted that different approach compared to the traditional understand-
cultures exhibit common characteristics of com- ing of culture and mental health from the more
munal and collectivist well-being. Cultures that restricting paradigms of Western psychology.
are looked upon as representing a communalistic
theme regardless of their diversities in ancestry, Derek Wilson
place, and religious worship include nations of Veeda Williams
diasporic Africans, Asians, Latinos, and Indians. Prairie View A&M University
For instance, in the Sushrut Indian conceptualiza-
tion for healthy well-being, one must demonstrate See Also: China; Cultural Prevalence; India;
synchronicity with the environment, be it physi- Race; Race and Ethnic Groups, American; Racial
cal, mental, or social (prasannamendriyamanah Categorization.
swastha). In this view, sustaining appropriate bal-
ance is not dictated by materialistic wealth or the Further Readings
manipulation of nature. Centers for Disease Control and Prevention.
Mental and social well-being for Chinese tradi- “Depression: Surveillance Data Sources”
tionalists reflects Confucian philosophy as a col- (2011). http://www.cdc.gov/mentalhealth/data
lectivistic culture. An examination of the Baoulè _stats/depression.htm (Accessed June 2013).
universe suggests a thirst for unity, or the desire Feagin, Joe R. The White Racial Frame: Centuries of
for cohesion as deepest aspiration—to stick as Racial Framing and Counter-Framing. New York:
closely as possible to one another, whether the Routledge, 2010.
“other” is a deity, the universe, or the clan. In the Gregory, Gregory, Kenneth Braswell, Elaine
Akan culture, the human individual is not self- Sorensen, and Margery Austin Turner. The
sufficient; he or she requires the assistance and Moynihan Report Revisited. Washington, DC:
goodwill of others in order to satisfy his basic Urban Institute, 2013.
needs. The well-being of man depends upon his McLeod, Saul. “Social Identity Theory.” Simply
fellow man, or obi yiye firi obi. Psychology (2008). http://www.simplypsychology
For African Americans, black family kinship .org/social-identity-theory.html (Accessed June
strategies are a communal, social-cultural net- 2013).
work of extended family. Healthy psychological National Library of Medicine. “From TIOP to
functioning is the result of experiencing emotional EnHIP: Evolution of Environmental Justice.”
and moral support during complacent times and Proceedings of the Environmental Health
gives individuals a sense of identity and roots as Information Partnership Meeting, National Library
well as the emotional stability of belonging. Thus, of Medicine, Bethesda, Maryland, March 14–15,
the examination of mental illness should incorpo- 2011.
rate a level of analysis that allows accurate under- Nobles, W. W. Seeking the Sakhu: Foundational
standing of mental health issues. The challenge is Writings for an African Psychology. Chicago:
the understanding of what can be gleaned from Third World Press, 2006.
the indigenous episteme for the understanding of Nobles, W. W., L. L. Goddard, and D. J. Gilbert.
mental illness. This collective view poses a signifi- “Culturecology, Women, and African-Centered
cant challenge to the mental health field, particu- HIV Prevention.” Journal of Black Psychology,
larly when diagnosing mental illness. v.35/2 (2009).
522 Mental Institutions, History of

Pratt, L. A. and D. J. Brody. “Depression in the other community-based mental health services
United States Household Population, 2005–2006.” are linked to the rise of the fields of psychiatry,
NCHS Data Brief, v.7 (2008). psychology, social work, and other mental health
Warren, Crystal LaVonne. “A Quantitative Analysis specialties.
of the Synergy Among Self-Reported Faith, Health,
and Health Care Practices of Black Baptists: A Early Christian and Medieval Periods
Culturecology Perspective.” Ph.D. diss., University Persons affected by mental disorders have been
of Pittsburgh, 2006. described since ancient times; however, records
Wilson, D. and V. Williams. “Ubuntu: Development describing the care and treatment of persons with
and Framework of a Specific Model of Positive mental illness are not found until the early Chris-
Mental Health.” Psychology Journal, v.10/2 tian era. In the early 4th century, the city of Con-
(2013). stantinople, known for its wide variety of charita-
Woods, V. D., N. J. King, S. M. Hanna, and C. ble institutes, built a “morotrophium,” a hospital
Murray. “‘We Ain’t Crazy! Just Coping With a for the insane, which was attached to the city’s
Crazy System:’ Pathways Into the Black Population general hospital. A number of other mental hos-
for Eliminating Mental Health Disparities.” African pitals or, more commonly, mental wards attached
American Population Report, North Highlands, to general hospitals were established throughout
CA: California Reducing Disparities Project, 2012. the Middle Ages in the Middle East and Europe.
Jerusalem established a hospital for the mentally
ill in the 5th century, Baghdad in the 8th century,
Damascus and Cairo in the 9th century, Aleppo in
1270, and Fez in 1500.
Mental Institutions, In Europe, a mental hospital was founded in
Mets, France, in 1100. The Tollhaus in the city of
History of Elbing in Poland was founded in 1320; Denton’s
Hospital in the Berking Church area of London
The history of mental institutions is a broad sub- in 1371; and the Het Dolhuys in the city of Haar-
ject spanning thousands of years and involving lem, the Netherlands, was an asylum exclusively
virtually every country around the world. Men- for the mentally ill, built in 1562. The coun-
tal institutions, hospitals, or psychiatric hospitals try of Spain has been particularly noted for its
used to be known under a variety of other names enlightened treatment and care of the mentally ill.
in the United States and Europe, including luna- Valencia opened a hospital in 1409, followed by
tic asylums and madhouses. Although today these Zaragoza in 1425, Seville and Valladolid in 1436,
latter terms are pejorative, they were not consid- and Toledo in 1480. Rome also established a paz-
ered such in past centuries. zarrella in the 14th century, an institution that
The history of mental institutions offers a num- provided care for the mentally ill. Special units
ber of lessons. It demonstrates society’s long-term for the insane within general hospitals became
struggle to accurately define mental illness and increasingly common after the 13th century,
when governments should intervene. Balancing including in Paris, Munich, and Zürich, among
the rights of the mentally ill individual with the other European cities.
need to protect others from potential harm is dif- In the Middle Ages, particularly as the result of
ficult. In fact, history repeatedly demonstrates the establishment of Benedictine and other reli-
alternating cycles of progression and control gious orders, a growing number of monasteries
when, in the former, the goal of care was rehabili- began to care for people with mental disorders.
tation and, in the latter, the objective was to pro- These were the preferred placement for the men-
tect society from the potentially volatile. Further- tally ill among the wealthy and elite classes of
more, the ebb and flow of patient admissions and society. In London, the Priory of Mary of Beth-
mental health services utilization is predicated on lehem, later known as the notorious Crown hos-
financial considerations. The growth of mental pital Bedlam, was founded in 1247, and by the
institutions and the more recent proliferation of beginning of the 15th century, it provided care for
 Mental Institutions, History of 523

both the physically and mentally ill; however, it Newcastle (1765), Manchester (1766), Liverpool
did not provide care to more than 20 to 30 insane (1792), and York (1797). However, charitable
patients until the 1600s. In 1645, the Charenton did not mean free of charge. Some asylums used
Asylum, a religiously run establishment for the the payment received from more affluent patients
mentally ill near Paris, was known for some of its to offset the care of indigent patients. Only in
famous or infamous patients, such as the Marquis extreme cases would local authorities pay for
de Sade (captive 1801–14). the confinement of the mentally ill in an asylum,
During the early Christian and Middle Ages, workhouse, or jail because of the cost, but lim-
despite the establishment of a number of facili- ited financial relief was provided directly to some
ties for the mentally ill, they were insufficient in families for the care of the insane. Consequently,
number to adequately care for the number of some families committed their mentally ill kin
mentally ill individuals in society. Families, and in with other town members or private madhouses.
some cases entire villages, assumed responsibility Records indicate that private madhouses were
for the care of nonviolent mentally ill residents. A established in England as far back as the 1600s,
notable example is the city of Gheel in Belgium, in and by the mid-18th century, private madhouses
which from the time of the 13th century and last- in England flourished. In 1724, London alone
ing for hundreds of years, residents took care of contained at least 15 private madhouses. Records
their mentally ill neighbors, often taking them into indicate that madhouses were also established in
their homes and acting as foster families. Gener- other parts of England, including Wiltshire in the
ally, however, societal attitudes concerning mental 17th century, Oxfordshire in 1725, St. Albans in
incompetence were unfavorable. Writers during 1740, and Bristol in 1766. Most madhouses were
these periods frequently noted how persons with small and provided care to fewer than 20 patients.
mental illness wandered the towns or country- Many madhouses, such as Ticehurst House,
side, begging for food and shelter. The dislike for began as private homes, initially under contract
these unfortunates in some areas was intense, and to board one or two insane persons, and such an
they were mercilessly beaten and evicted from the arrangement eventually became a lucrative busi-
towns. Mental institutions during the medieval ness enterprise by taking in more patients. Like
period were largely custodial in nature, and many the public asylums, however, madhouses were
applied chains and other devices to keep patients places of confinement where patients were physi-
physically restrained. Further, mental illness was cally restrained and received little, if any, medical
largely perceived to be the result of the Devil, and care. Regardless, private madhouse proprietors
women especially were believed to be more vul- frequently made claims of patients cured and dis-
nerable to the Devil’s influence. Between 50,000 charged successfully back into the community to
and 100,000 persons may have been executed as resume a normal life. It is likely that madhouses
witches between the 1400s and 1700, and a good dealt with the same problems of symptom remis-
number of those executed were probably men- sion and readmissions that the mental health
tally ill but misunderstood. community does today.
It was not until the late 1700s that legislative
Growth of Private Madhouses in England mandates were passed to guide local authorities
The dearth of charitably funded asylums until the on whom and under what circumstances individ-
early 19th century left families with few options uals should be committed by reason of insanity.
for the management of mentally ill family mem- While madhouse proprietors had a vested interest
bers. Besides Bedlam, the only other charitable in maintaining the community’s confidence and
asylums were Bethel in Norwich (1713), which preserving their reputations, the opportunities for
housed only 20 to 30 patients, and Guy’s Hos- profit making often outweighed these concerns.
pital in London (1726), which initially had 100 In addition to charges of filthy living conditions,
beds for the incurably physically and mentally ill inadequate food, excessive physical restraint,
but later built a 20-bed facility designated for the and physical abuse, private madhouses provided
mentally ill. Later, other charitable asylums were unscrupulous individuals opportunities for get-
established in London (St. Luke’s Hospital, 1751), ting rid of family members, often female family
524 Mental Institutions, History of

members, who were not mentally ill but were Parliament to pass the Madhouses Act of 1774,
deemed a nuisance. Women were particularly vul- which required that madhouses in London be
nerable because of their limited rights in society. licensed and inspected at least yearly by a special
During this period, a woman could be commit- committee of the Royal College of Physicians;
ted to a mental institution solely based on a hus- outside London, this responsibility fell to provin-
band’s declaration that she was insane. Patients cial authorities. Fines were imposed on propri-
were forbidden any communication with the out- etors who failed to obtain licensure or admitted
side. Moreover, madhouse proprietors kept few patients without a physician’s order.
records of their dealings, making it difficult for
concerned family members to even locate loved Colonial America
ones they suspected had been committed. American colonists labored under the medieval
One particular case, in 1762, that of a Mrs. superstitions of western Europe in the 1600s and
Hawley, garnered public sympathy and anger 1700s. The colonists, believing in demonic pos-
when it was discovered that she had been wrong- session, whipped and/or hanged individuals who
fully committed to a madhouse by her husband. they believed were in league with the Devil. It is
On examination, the proprietor’s agent, Mr. King, likely that some of the individuals punished in
declared that he had not boarded anyone who this way were afflicted by some form of mental
was insane during the six years he had worked illness. There were no institutions in the 1600s
there; money offered by a husband or other fam- in America to treat and care for the mentally
ily member was the only consideration. Abuses ill. Families assumed responsibility for the care
such as these eventually prompted the British of their mentally ill kin. In some cases, families

The interior of Bethlem Royal Hospital (Bedlam) is depicted in the final painting of William Hogarth’s series titled A Rake’s Progress
(1763). According to many contemporary accounts, the atrocities in Hogarth’s depictions of Bedlam were actually commonplace in his
day. For example, the two well-dressed bourgeoisie women would have paid a small sum to be amused by the bizarre antics of the
inmates. Bedlam was one of the few charitably funded asylums until the early 19th century, which left families with few options.
 Mental Institutions, History of 525

received town funding to maintain their mentally institution specifically built for the mentally ill
ill relatives at home. In other cases, those deemed was Eastern State Hospital, located in Williams-
mentally ill and without family to look after them burg, Virginia. Originally named the Public Hos-
were placed in the homes of other citizens who pital for Persons of Insane and Disordered Minds,
were paid for their keep. These early Americans it first began receiving patients in 1773. Life in
did not distinguish between people with mental these institutions was grim. They tended to serve
disorders and people with intellectual disabilities. as places of confinement, with crude methods for
Both of these groups, as well as the poor and the securing patients, including shackles and the use
disabled, were provided with public funding for of depletive treatments such as bloodletting and
their maintenance, continuing the tradition of leaching. Throughout the 18th century, public
the English Poor Laws. However, the criminally provisions for mentally ill persons, especially the
insane were jailed. indigent insane, remained inadequate.
This kind of individual care of individuals
with mental disorders became increasingly dif- Europe and the Moral Treatment Period
ficult to maintain as American cities increased By the end of the 18th century, Europeans gradu-
in size and rural populations dwindled. Various ally came to embrace a more enlightened view of
colonies passed laws allowing town authorities to the causes of mental illness. Physicians looked
assume charge of the estates of the mentally ill. to physical disease processes and environmen-
Like their counterparts in England, the colonies tal conditions as underlying factors in the cause
began building almshouses in the early 1700s to and exacerbation of mental illness. Among these
provide for both the mentally ill and the poor. physicians, Philippe Pinel (1793) is credited with
The latter half of the 18th century, however, saw ushering in the moral treatment period. Pinel
Americans building numerous almshouses, work- believed that mentally ill patients could be cured
houses, and jails to accommodate the mentally ill. through careful observation and individual ther-
These institutions shared a common purpose, that apy. He advocated humane treatment of mentally
is, to serve as places of containment for a growing ill patients and disapproved of physical restraint
population of disabled persons who were becom- of patients at the Bicêtre Hospital near Paris,
ing increasingly difficult to deal with and who where he was employed. Providing patients posed
were considered deviants by the general popu- no threat of harm to themselves or others, they
lation, especially in burgeoning towns and cities were allowed to walk freely within the hospital
where close proximity made the public increas- grounds.
ingly aware and uncomfortable with people who Asylums in this period were grand struc-
exhibited bizarre behaviors. Life for the mentally tures with extensive grounds and gardens where
ill, the poor, and the intellectually disabled was patients could work as part of their therapy. The
very difficult in the almshouses. Generally, no physician was believed to be a key component for
medical care was provided. People who entered the patients’ recovery, a kind but firm father fig-
them generally never left. ure to serve as a soothing mechanism for patients.
The first mental institution in the United States, Pinel and like-minded physicians began to study
the Pennsylvania Hospital, was built in 1751, and categorize mental disorders in earnest, which
established through the efforts of the Quakers. marked the beginning of the profession of psychi-
This hospital cared for both the physically and atry. Alienism was the term soon applied to this
mentally ill. The hospital’s builders considered new branch of the medical profession based on
mental illness a disease and believed that institu- the French term aliénisme, from aliéné, meaning
tional care might provide a cure. Despite the fact “insane,” which was derived from the Latin verb
mentally ill patients were confined to cells in the alienare, “to deprive of reason.”
hospital’s basement, this belief denotes an impor- Despite humanitarian advances in dealing with
tant shift in thinking in the way people at the time the mentally ill, abuse and neglect still occurred.
were beginning to view mental illness and in the Many believed that the mentally ill were impervi-
budding notion that diseases of the mind might ous to heat or cold and so were often left naked in
be cured through medical intervention. The first squalid surroundings, physically restrained, and
526 Mental Institutions, History of

undernourished. In response to the scandalous exacerbated by other physical diseases and envi-
treatment of patients at the recently built York ronmental factors. Life in the American colonies
Lunatic Asylum (1777), especially following the had become increasingly urbane and populous
death of a Quaker woman named Hannah Mills, by the end of the 1700s, making the problems
a Quaker named William Tuke opened the York of mental illness, poverty, and crime more evi-
Retreat in 1796. Tuke, a businessman and phi- dent. Additionally, almshouses had become vastly
lanthropist, espoused the Quaker values of self- overcrowded, and the residents were physically
control, compassion, and respect for others. Like and medically neglected, often leading to disease
Pinel, Tuke believed in the humane treatment of outbreaks that threatened the general popula-
the mentally ill, shunning physical restraint in tion. These concerns, coupled with a growing
favor of constant surveillance of patients. Origi- spirit of reform in the early 1800s, which encour-
nally intended for Quaker patients, the retreat aged Americans to tackle such problems through
eventually accepted non-Quakers for a higher humanitarian activities, sparked interest in build-
maintenance charge. Physicians such as Pinel and ing asylums for the mentally ill. In part stimu-
Tuke inspired excitement among the public, who lated by America’s Second Great Awakening, a
claimed success in curing mental illness with their Protestant revival movement that had swept the
methods. Enthusiasm over the perceived success- country, Americans increasingly embraced the
fulness of moral treatment ushered in an era of principles of justice and social equality, resulting
publicly and charitably funded asylums in Eng- in a population-wide shift in the way Americans
land and the rest of Europe. viewed mental illness.
Abuses such as those at York were an impor- Similar to England, physicians in the United
tant factor in the shift of responsibility for the States became opposed to the use of physical
mentally ill from the religious and private sectors restraints and advocated moral treatment (psy-
to the state. In England, the County Asylum Act, chological therapy). They claimed that their
or Wynn’s Act of 1808, initiated the construction methods were highly effective in curing mental ill-
of county lunatic asylums. Asylums built in Bed- ness. In 1817, the Quakers, who advocated gentle
ford and Nottingham in 1812 were the first built and humane care, established a second institution
as a consequence of this legislation. County asy- specifically for the mentally ill, called the Friend’s
lum building, however, grew very slowly through Asylum at Frankfurt, Pennsylvania. Dr. Benjamin
the early 1830s, with asylums established at Rush, a physician at the Pennsylvania hospital,
Cornwall County (1820), Gloucester County was aggrieved at the conditions there and became
(1823), and Middlesex County (1831), and a an ardent proponent of moral treatment. He suc-
handful of others. cessfully advocated the building of a separate
An important change to asylum admissions facility in Philadelphia to treat the mentally ill,
laws occurred with the Poor Law Amendment Act albeit after his death, in 1841. He also observed
of 1834, which required that any mentally ill indi- that patients who participated in useful tasks,
viduals at public workhouses deemed potentially such as gardening or washing clothes, recovered
dangerous be transferred to public or private asy- more often than patients who did not work. Not
lums. This change created a greater demand for all of Dr. Rush’s treatments were as enlightened,
asylum placements, which raised their censuses. however, as he still applied treatments that even
With the passage of the Acts of 1845, England many of his contemporaries had abandoned as
laid the foundation for what was to become a ineffective or even harmful to patients, such as
national system to aid the indigent mentally ill, bloodletting and sensory deprivation.
including providing a central regulating body to One, if not the most influential and tireless,
monitor the activities of both public and private supporter of moral treatment and the care of the
asylums. indigent mentally ill was Dorothea Dix of Massa-
chusetts. In the early 1840s, when teaching Sun-
Moral Treatment in the United States day school in a Cambridge jail, she was shocked
By the late 18th century, Americans increasingly at the deplorable conditions and treatment of the
believed that mental disorders were caused or mentally ill persons who were incarcerated there.
 Mental Institutions, History of 527

Afterward, she resolved to complete a statewide or resided in city almshouses because asylums
survey of the indigent mentally ill in her state, charged communities for patients’ care and treat-
many of whom lacked family to care for them. ment. Wealthier families had to pay for their men-
These unfortunates were frequently placed by the tally ill relatives, and in general, decisions about
state into the care of individuals who received patient care were decided based on class, race,
payment for their care and treatment. What she and ethnicity. Further, the realization that moral
discovered was often horrific abuse of the patients treatment providers could not make good on their
by their paid caretakers. She sent a report of her claims to effect cures caused Americans to doubt
findings, including numerous instances of patients that it was possible to rehabilitate the mentally
beaten, starved, and chained or placed in cages ill at all. This gloominess shifted public opinion
naked, to the state legislature. Her efforts led to about the causes of mental illness; the public
the expansion of the state’s sole mental institution decided that heredity must be to blame and that
in Worcester. She then traveled the country, lob- deviant behaviors such as excessive alcohol con-
bying other state legislatures to build or expand sumption and lechery could arouse any underly-
state mental asylums including in Illinois, Penn- ing genetic predisposition to mental illness.
sylvania, and North Carolina. She also traveled Asylum censuses increased not only because of
to England and Scotland to effect similar changes the growing numbers of chronically ill patients
in those countries. Dix’s lobbying is credited with but also because the population of the United
the building or expanding of dozens of asylums in States had rapidly grown. In particular, a grow-
the United States and Europe. Besides Dix’s efforts ing number of the mentally ill were foreign-born
to increase support for state asylums, a number of and indigent, which provoked prejudice among
private asylums were also founded in the period native-born citizens. Mental illness was increas-
which, despite their business status, frequently ingly associated with the lower class. In illustra-
admitted indigent patients. tion, Massachusetts’ Worchester State Hospital
Far from being seen as grim places of confine- was opened in 1877, with 500 beds. When it
ment, the mental asylums in this period were con- opened, it had 496 registered patients, which rose
sidered sanctuaries for the mentally ill, a place to 811 patients by 1890, a number far in excess of
where they could escape from the environmental what the hospital could comfortably accommo-
and other factors that were presumed to have date. Some states were forced to open additional
caused their mental illness and where they could facilities or to expand existing ones to accommo-
become rehabilitated and eventually returned to date their growing censuses.
society as cured. The patients in the asylums were Additionally, the passage of local commitment
offered a variety of educational, recreational, and laws required that potentially violent mentally ill
spiritual activities. Emphasis was placed on kind, individuals be sent to state hospitals. This meant
caring, but firm relationships between patients that the patients residing in mental asylums
and caretakers who encouraged patients to exer- increasingly represented chronically ill popula-
cise self-control; the use of mechanical restraints tions such as the criminally insane, older adults
was discouraged. Because Americans did not with dementia, people with tertiary-stage syphilis,
always distinguish mental illness and intellectual and substance abusers. At the same time, under-
disability and boarded persons suffering from funded state asylums began to deteriorate across
either together, people with intellectual disabili- the country, and the care provided to the men-
ties also benefited from the improved conditions, tally ill within them dropped in quality because
medical care, and educational opportunities pro- of an inability to hire and retain sufficient num-
vided by the new asylums. bers of skilled staff. Asylums resorted more often
to using physical restraints, such as straitjackets
Decay of U.S. Asylums in the Late 1800s or tying patients to beds or chairs, and using
Asylums in the United States multiplied through sedative drugs, seclusion, and surgery to con-
the late 1800s. From 1860 to 1890, 77 new trol patients. In 1887, an investigative journalist
state asylums were built. A large number of the working for the New York World named Nellie
mentally ill were still cared for by their families Bly (née Elizabeth Jane Cochrane, 1864–1922)
528 Mental Institutions, History of

feigned insanity to gain admission to the Women’s health approach to mental illness and developing
Lunatic Asylum in New York City’s Blackwell’s advanced psychological and medical treatments.
Island to learn how the patients were treated Advances in treatment included study and clas-
there. Her exposé, later published in a book titled sification of mental disorders and psychoanaly-
10 Days in a Mad-House, caused a public out- sis. The Mental Hygiene Movement (1908) also
cry over the filthy, rat-infested conditions of the sought to improve hospital conditions, treatment
hospital and the contemptible treatment of the and prevention, and post-discharge care. The
patients who were given rotten food and dirty mental health field expanded to include social
water, inadequate clothing against the cold, and workers and psychologists. It was at this time
punishments that included beatings and ice-cold that the term asylum fell out of favor and was
baths. Additionally, she reported that some of the replaced with the term mental hospital. On a
patients at Blackwell’s Island were no more insane much smaller scale, community-based services
than herself but had either been abandoned there for the mentally ill, including short-stay psychi-
unwanted by their husbands or were unable to atric hospitals and outpatient clinics, were estab-
speak English. The series of articles brought lished for the first time.
swift results by improving sanitation at the facil- Notwithstanding these advances, other more
ity, removing abusive staff, the release of wrong- contentious developments occurred in this period,
fully committed patients, added protections for such as the lobotomy and electroconvulsive
patients to prevent wrongful commitment, and therapy (ECT). Additionally, Social Darwinism,
roughly $1 million in appropriations from the which asserted that the weak and unfit in society
state legislature to make improvements. should be allowed to die; and the eugenics move-
The lack of funding and the fact that asylums ment, which advocated the enhancement of inher-
were an expensive proposition for communities ited genetic traits in human beings, were gaining
caused many local governments to place the indi- widespread adherence in the United States and
gent mentally ill in less expensive almshouses. Europe. These led to restrictive marriage laws
These had traditionally been used to house the and forced sterilizations of the mentally ill and
poor, particularly for older adults without means intellectually disabled out of fear that they would
or with dementia. However, growing concern pass on their defective genetic traits to future gen-
about the ability of local communities to provide erations. These ideas culminated in World War II,
quality care for the mentally ill while still protect- when German psychiatrists willingly orchestrated
ing the general public led to the passage of legisla- the deaths of hundreds of thousands of mentally
tion to transfer responsibility for their care to the disabled patients in gas chambers at psychiatric
states. This presented an unprecedented oppor- hospitals throughout Germany in collaboration
tunity for local officials, who immediately began with the Nazis.
categorizing older inhabitants of the almshouses
as demented to shift the costs for their care to Deinstitutionalization and
state-run mental hospitals. Consequentially, the Community-Based Care
number of elderly mentally ill patients residing in To redress the failures of state mental hospitals
almshouses fell from 24.3 percent in 1880 to only and the inability of psychiatry to cure mental
5.6 percent in 1923. illness, in 1946, the federal government passed
the Mental Health Act to discover the causes of
Early Twentieth Century mental illness, develop prevention and treatment
The composition of mental hospital censuses protocols, and train mental health professionals
radically changed with the transfer of chroni- in an effort to reduce hospital admissions. This
cally ill, older adults. The patients who entered was followed by the Mental Health Study Act
were unlikely to ever leave. After the scandals in 1955 to study the epidemiology of mental ill-
of patient abuse in the late 19th century were ness, improve state mental hospital conditions,
revealed and the advent of the Progressive move- and reduce admissions. A key recommenda-
ment (1890s–1920s), psychiatrists desired to tion was to build community outpatient clinics
redeem their reputations by taking a public and other community-based services to reduce
 Mental Institutions, History of 529

hospital admissions. However, outpatient treat- Decentralization of mental health services has
ment would not have been realistic if not for recent also occurred in Europe under universal health
advances in developing psychotropic medication and social insurance platforms over the past
that reduced acute symptoms in the mentally ill. several decades. In England and Wales, mental
The passage of the Community Mental Health health trusts provide inpatient care, community
Centers Act (1963) established federally funded and rehabilitation services, residential care cen-
community mental health centers (CMHCs), tar- ters, day clinics, and drop-in centers. France has
geting underserved racial/ethnic neighborhoods. promoted a sector system to ensure that commu-
These new facilities provided care for individuals nity services are available to residents in every
at risk for hospitalization. community. Germany, Spain, and Italy also have
With the passage of federal welfare programs a variety of public and private inpatient services,
such as Medicare and Medicaid (1965), which community mental health centers, residential and
caused a lateral transfer of the majority of elderly day care facilities, among other services.
and disabled patients from state hospitals to Although the mental hospital still plays an
nursing homes, and other federal social welfare important role for the severely and persistently
programs like the Food Stamp Act of 1964 and mentally ill, it has been greatly overshadowed by
the Supplementary Security Income for the Aged, a vast array of public and private treatment pro-
the Disabled, and the Blind (SSI) in 1972, which viders. The current goal of modern mental health
helped many other mentally ill patients live in the systems in the United States and western Europe
community, mental hospitals had experienced is to place people with mental illness in the least
drastic declines in admissions by the mid-1970s. restrictive settings possible.
This period was also marked by a number of chal-
lenges to state laws involving individual rights Julie L. Framingham
to treatment in the least restrictive settings. The Florida Department of Children and Families
deinstitutionalization movement was not without
some negative unintended consequences. Many See Also: Architecture; Community Mental Health
communities did not have sufficient outpatient Centers; Deinstitutionalization; Policy: Federal
treatment capacity to prevent patient decom- Government; Policy: State Government.
pensation, requiring readmission to the hospital,
and families were unprepared to care for men- Further Readings
tally ill relatives. These circumstances have led to Grob, Gerald N. “Mental Health Policy in America:
increases in homelessness and criminality, the lat- Myths and Realities.” Health Affairs, v.11/3 (1992).
ter resulting in the imprisonment of the mentally Grob, Gerald N. “Mental Health Policy in the
ill where treatment services are extremely limited. Liberal State.” International Journal of Law and
After the passage of the 1981 Omnibus Budget Psychiatry, v.31 (2008).
Reconciliation Act, the Ronald Reagan adminis- Mechanic, David and Richard C. Surles.
tration expanded the states’ authority to coordi- “Challenges in State Mental Health Policy and
nate and integrate mental health services at the Administration.” Health Affairs, v.11/3 (1992).
community level by relinquishing control of the Rochefort, David A. From Poorhouses to
CMHCs to the states and establishing the block Homelessness: Policy Analysis and Mental Health
grant so that states can design mental health pre- Care. 2nd ed. Westport, CT: Auburn House, 1997.
vention, treatment, and recovery services based Smith, Leonard D. Cure, Comfort and Safe Custody:
on their communities’ unique needs, in addition Public Lunatic Asylums in Early Nineteenth-
to other services covered by Medicaid, Medicare, Century England. New York: Leicester University
and private insurance. Community-based services Press, 1999.
in the United States now include crisis stabiliza- Scull, Andrew. The Most Solitary of Afflictions:
tion units in general hospitals, private psychiatric Madness and Society in Britain, 1700–1900. New
hospitals, outpatient clinics, case management, Haven, CT: Yale University Press, 1993.
private therapists, group homes, and community Strous, Rael D. “Psychiatry During the Nazi Era.”
treatment teams. Annals of General Psychiatry, v.6 (2007).
530 Merleau-Ponty, Maurice

Merleau-Ponty, Maurice understanding human experience. In his 1964

work, The Child’s Relations With Others, Mer-
Maurice Merleau-Ponty (1908–61) is heralded as leau-Ponty debunked conventional thinking and
breaking new ground in illuminating the mean- myths about the psyche being inaccessible by oth-
ing of embodied illness. His notion of the lived ers and known only by oneself, and described the
body has increasing significance today for under- way in which consciousness is disclosed in the
standing the social ecology of health and illness, world through the way one interacts with oth-
especially in building community assets to enable ers in the world. In this work, Merleau-Ponty
and support culturally sensitive mental health explains that consciousness is a turning toward,
practice. and a relation with, the world. Merleau-Ponty
Many people around the world are reported to also locates the position of one’s body as a system
have one or more mental disorders. In the United in relation to the environment.
States, data show that the rate of diagnosed men- Merleau-Ponty also redefines what phenome-
tal disorders is one in four Americans. Globally, nologists call “intentionality” or a “directedness”
the World Health Organization (WHO) reports to the world. He defines a type of intentionality
that over 450 million people have some form of called operative intentionality, which occurs at
mental disorder. the precognitive, prereflective level in the move-
The WHO has defined health as “a state of com- ment of the body toward objects that are grasped.
plete physical, mental and social well-being and not Examples of this movement, which cannot be
merely the absence of disease or infirmity.” This separated from intentionality, include the way in
conceptualization establishes the critical nexus of which one turns toward another in greeting or
mental health to the overall health and well-being welcome, or the pianist who carries a repertoire
of the whole person in social ecological and cul- of pieces and needs no music to perform a move-
tural contexts. The focus on social aspects of well- ment of a sonata. Sociologist Alfred Schutz used
being underscores a public health concern with the this metaphor of “making music together” in
health and mental health of persons in an envi- describing the essential nature of intersubjectiv-
ronment and as members of communities. Public ity. Even the experience of pain has a component
health approaches to the continuum of health and of operative intentionality in that once the sensile
mental health care take into account the multiple dimension of pain is felt, operative intentionality
social determinants of health, including population is responsible for the turning of the body to the
health factors such as income, housing, neighbor- felt pain. These are not reflexive actions, but pre-
hood, education, and equitable access to good food reflective movements of the body in relation to
and adequate health and mental health services. the lived world and its objects.
In Sanity, Madness and the Family (1990), R.
Intentionality D. Laing and Aaron Esterson describe their inter-
Phenomenologist Merleau-Ponty has made views with individuals who have been diagnosed
explicit a central problem with existing frame- with schizophrenia. Their accounts of the experi-
works in mental health practice. A well-estab- ences of the identified patients demonstrate that
lished norm among mental health professionals the diagnosed mental disorder had much to do
that has dominated mental health counseling, with the patients’ situatedness in their social ecol-
assessment, and treatment is locating the etiology ogy, especially the family. This situatedness was
of mental illness in the mind, divorced from the multidimensional and had many alterations based
lived body and world. Neuroscientists and neu- upon the particular family, family members, and
ropsychiatrists alike have located mental illness the different social and relational units among the
in the organ of the brain, at the risk of reduc- family members. In each of these situations, the
ing human beings to mere homunculi. Instead, patient had a postural stance and bodily relation
Merleau-Ponty jettisoned Cartesian notions of to the family members and the world. The range
mind–body dualisms that result in polarizing the of mental dysfunction was not located in the mind
mind and the body and returned to the lived body of the patient but in the patient’s relation with the
and its relation to the world as the ground for social world.
 Mesmerism 531

Merleau-Ponty’s work is helpful in appreci- the Philosophy of Art, History and Politics, James
ating more fully the extent to which certain life Edie, ed. Evanston, IL: Northwestern University
experiences may be part of the human condition. Press, 1964.
A good example is suffering, and not simply suf- Merleau-Ponty, Maurice. Phenomenology of
fering associated with serious illness, but suffering Perception. London: Routledge, 1962.
that arises from living in the world with others. Smyth, Bryan. “Generating Sense: Schizophrenia and
When does such suffering become a mental health Phenomenological Praxis.” Schutzian Research,
problem that is a diagnosable disorder? There is v.2 (2011).
a high prevalence of suffering and burden when
one is faced with trauma and detrimentality in life
dislocations, such as what might be encountered
in the loss of a loved one, a home, the self, or of
meaning. One example of such dislocation would Mesmerism
be in the experience of life transitions in growing
old. While a great deal of progress has been made Mesmerism, popularized by French physician
in understanding the multidimensional nature of Franz Anton Mesmer (1734–1815), was devel-
pain and assessing and treating pain, less progress oped in an attempt to treat patients’ psychological
has been made in understanding the depth of suf- and physical symptoms through the realignment
fering that is genetic and developmental in origin. of magnetic forces in their bodies. Mesmerism
Merleau-Ponty’s phenomenology calls for attracted the attention, and ultimately the criti-
reflection on social and developmental origins cism, of important political and scientific figures. A
prior to the development of consciousness of the commission of political and scientific leaders was
body, an ego, and the formation of a self. He formed in 1784 by King Louis XVI to investigate
describes the syncretic state of the infant with the phenomenon of mesmerism. Led by Benjamin
the mother that begins in fetal development as Franklin, the commission concluded that mes-
an anonymous, undifferentiated state of col- merism was not a scientifically sound treatment
lectivity. In this description of intercorporeality and described its observed effects as having been
and the genesis of consciousness, the child’s first the result of patients’ imaginations. This largely
and original relations are located and embed- destroyed the public’s confidence in and admira-
ded in the maternal relation. It is the very loss tion of Mesmer, who died in relative obscurity.
of this original maternal relation upon birth and Mesmerism was revisited decades later, at which
in development, and the concomitant rupture and point certain aspects of the phenomenon became
discontinuity of being thrown into a world with influential precursors to modern hypnosis.
others, which constitutes the origin of human suf- Mesmer believed that he could treat various
fering and human existence and the genesis of all psychological and physical problems by realign-
human meaning-making activity. These are the ing the magnetic forces in patients’ bodies. The
experiences that Merleau-Ponty probes deeply in development of Mesmer’s treatment, later termed
understanding mental health and mental illness mesmerism, began in 1773, when he treated a
and mental health practice in a social world. patient by touching various parts of her body
with magnets. After some time, the patient report-
Mary Beth Morrissey edly experienced an intense physiological reac-
Fordham Graduate School of Social Science tion to the treatment and later reported a sense of
improvement. Mesmer continued to treat her in
See Also: Ethical Issues; Patient Accounts of Illness; this manner until she was deemed cured.
World Health Organization. Following this success, Mesmer used the treat-
ment with more of his patients. He added to
Further Readings this treatment the direct suggestion that patients
Merleau-Ponty, Maurice. “The Child’s Relations would experience reactions similar to that of
With Others.” In The Primacy of Perception, and other cases (e.g., physiological reaction followed
Other Essays on Phenomenological Psychology, by a sense of relief). As the popularity of Mesmer’s
532 Mesmerism

treatment grew, he adapted it so that he could

treat many patients at once. He eventually came
to believe himself able to transmit the necessary
magnetic forces from his body to his patients by
touching them, without the use of magnets, which
further facilitated his ability to easily treat numer-
ous patients at one time. Mesmer also incorpo-
rated various methods that he believed would
further facilitate the process, such as playing
light music nearby and having a separate room
in which patients could collect themselves should
they become overly uncomfortable. The rising
popularity of Mesmer and his treatment attracted
the attention of influential figures, including King
Louis XVI, George Washington, and Benjamin
Franklin. Franklin, in particular, is known to have
written about his observations of the improve-
ment of Mesmer’s patients, though he doubted
Mesmer’s description of how this occurred.
As mesmerism grew in popularity, so did Mes-
mer’s critics, many of whom believed him to
be an outright fraud. In 1784, King Louis XVI
brought together well-known figures in science
and academia for the purpose of investigating the
phenomenon of mesmerism. Whether this was at
the request of Mesmer is unclear, though there is
evidence to suggest that Mesmer truly believed
in his technique and did not knowingly deceive The Marquis de Puysegur, a friend and colleague of Franz
patients or the public. The commission was led Anton Mesmer, practiced and taught animal magnetism. Later,
by Benjamin Franklin and included Antoine de Puysegur’s student and friend, Jean Deleuze, began to use
Lavoisier, Joseph-Ignace Guillotin, and Jean Syl- “post-hypnotic suggestions,” which hypnotherapists use today.
vain Bailly, along with several other academics.
Their investigation of mesmerism is considered
scientifically rigorous by present-day standards
and is often described as one of the first system- on his part to put together a new commission and
atic scientific investigations of its kind. In its to revive interest in mesmerism, Mesmer’s ideas
report, the commission concluded that Mesmer’s remained largely discredited, and he spent the rest
magnetic forces did not exist and that the effects of his life in obscurity.
of mesmerism were from patients’ imaginations. Today, while most researchers and theorists
In a second report meant specifically for King agree with the commission’s conclusions regard-
Louis XVI, the commission also described mes- ing the mechanism through which changes in
merism as an immoral practice, particularly as it Mesmer’s patients occurred (i.e., they did not
related to the perceived danger to patients while occur from the manipulation of magnetic forces),
under treatment because of their vulnerable psy- many also argue that perhaps mesmerism did
chological state. lead to changes among patients. Some believe
These results were quickly circulated among that although magnetism was not the reason
the French population, which had been largely for change, change occurred nonetheless. In the
enamored with mesmerism, as well as to those 1840s, the Scottish physician James Braid con-
with relatively less exposure to the phenomenon ducted several additional studies on mesmerism
(e.g., those in America). Despite initial attempts in an effort to better understand the process, as
 Mexico 533

well as to discover its true mechanism of change. Mexi, translated as “beard of feathers,” and the
Braid concluded that change occurred not suffix co, referring to “the place of the serpent.”
through magnetic forces but through the psycho- Other researchers identify the word Mexico as
logical process of suggestibility. In other words, derivative from the Nahuatl word for “sun,” the
patients benefited from mesmerism because it was name of the leader Mexitli, and a type of weed
suggested to them that they would experience that grows in Lake Texcoco.
some benefit. Braid coined the term hypnosis to Mexico was the center of the ancient Aztec
emphasize the legitimate experience of change, Empire. Pre-Columbian Mexico featured
while deemphasizing the discredited portions of advanced civilizations, such as the Olmec (1000
Mesmer’s treatment. b.c.e.), Toltecs, Mayans, and Aztecs. Today, the
term Aztec is used in the collective to refer to the
Hope Brasfield historical populations that lived in Mexico.
Heather Zucosky A group of Spanish conquistadors led by
Ryan C. Shorey Hernán Cortés arrived in Mexico around 1519.
Gregory L. Stuart Pursuing gold and other treasures, Cortés con-
University of Tennessee, Knoxville quered the Aztec empire by killing its ruler, Moct-
ezuma. The invasion was characterized by domi-
See Also: Competency and Credibility; Ethical Issues; nation and brutality, as well as by unintentional
Hypnosis; Mind–Body Relationship. germ warfare. The transmission of a smallpox
epidemic devastated the Aztec empire, selectively
Further Readings killing up to half of the population of the Aztec
Greenwald, R. “The Power of Suggestion: Comment people while not affecting the Spaniards, who
on EMDR and Mesmerism: A Comparative mostly had immunity to the disease. After battle,
Historical Analysis.” Journal of Anxiety Disorders, the territory became part of the Spanish empire
v.13 (1999). under the name of New Spain (Nueva España).
Hunt, N. The Story of Psychology. New York: The colonization brought Spanish customs,
Random House, 1994. mores, religion, and language to Mexico. On Sep-
McConkey, K. M. and C. Perry. “Benjamin Franklin tember 16, 1810, Mexico obtained independence
and Mesmerism: Revisited.” International Journal from Spain. In 1821, the Declaration of Inde-
of Clinical and Experimental Hypnosis, v.50 pendence of the Mexican empire from Spain was
(2002). signed. In 1823, a revolt was able to overthrow
Schmit, D. “Re-Visioning Antebellum American Agustín Iturbide after he proclaimed himself the
Psychology: The Dissemination of Mesmerism, emperor of the First Mexican Empire. The revolt
1836–1894.” History of Psychology, v.8 (2005). established the United Mexican States. In 1857, a
new constitution was drafted, and Benito Juárez
became the first president, restoring the republic
and an important separation of church and state.

Mexico Culture
Although Mexico’s official language is Spanish,
The United Mexican States (Estados Unidos the National Institute of Indigenous Languages
Mexicanos) is the official name of the country (INALI) has identified 68 indigenous languages
of Mexico. This nation is a federal republic in and 364 specific varieties of indigenous languages
North America and is a member of the 22 coun- spoken throughout the territory. The majority of
tries that comprise Latin America. Mexico is the the population (82.7 percent) profess the Roman
most populous Spanish-speaking country in the Catholic faith. Mexico comprises 31 states and
world. The origin of the word Mexico is uncer- a federal district containing the capital, Mexico
tain, but it is believed to be derived from the City.
word Mexica, representative of the Nahua Aztec The population of Mexico is estimated at
tribe. It is thought to be composed of the root 113,910,608, making it the second most populous
534 Mexico

country in Latin America, after Brazil. Mexico in recent years. Mexicans are the largest group of
City is the most densely populated city in the immigrants entering the United States, driven by
country, with over 8.7 million residents. poverty at home and a promise of employment
The population of Mexico represents a spec- and a better life in the United States. Mexicans
trum of cultures and ethnic groups derived from who migrate to the United States are more likely
native Amerindian tribes, Spanish colonizers, and to experience depression and anxiety, and rates of
to a lesser extent, African slaves. Most people in psychopathology among Mexican immigrants are
Mexico are mestizo, people of mixed European greater in the United States than in Mexico.
and indigenous descent. Ethnic diversity charac- During World Wars I and II, the United States
terizes the population with a symbiosis of these authorized temporary visas for migrant work-
cultures into what has been described as el mes- ers. Migration patterns continued to increase,
tizaje. The concept of mestizaje has forged the with fewer migrants returning, and currently
Mexican identity with a pride in its traditions and more than half of the Mexican immigrants in the
cultural heritage. United States are unauthorized. Remittances from
Mexican cuisine reflects the hybrid of European the United States to Mexico amount to billions of
and indigenous cultures, as well as the diverse dollars each year. More recently, the patterns of
influx from foreign migrations. Basic staple items migration have changed, as fewer Mexicans are
include corn, tomatoes, flour tortillas, quesadil- entering the United States because of fewer eco-
las, and hot peppers that provide a characteris- nomic incentives and tougher immigration laws.
tic flavor. At an early age, Mexicans develop a
taste for hot foods, with variations depending on Mental Health
the region. The country’s national dish is mole The history of treatment of mental disorders in
poblano, a thick, dark sauce made from various Mexico dates back to 1566 with the foundation
ingredients, including chocolate and chili peppers, of Hospital San Hipólito in New Spain, which
which is typically served for special occasions. was the capital city at the time, and Hospital
Mexico has a tradition of art that dates back to del Divino Salvador in 1698. These institutions
its pre-Columbian heritage that is well preserved cared for psychiatric patients who were home-
in numerous museums throughout the country. less or incarcerated. By 1910, the government
Modern artists such as the renowned muralist opened a specialized mental hospital (Manico-
Diego Rivera and Frida Kahlo represent the more mio General de la Castañeda) that handled psy-
recent history of art in the country. chiatric presentations with limited and often
A highly recognizable aspect of Mexico’s folk- inhumane treatment. Other private mental facil-
lore is the mariachis. This strong musical tradi- ities were subsequently created to address the
tion seems to have evolved from the French “mar- limited capacity of the public health system to
riage” common during the reign of Maximilian, manage psychiatric care.
the French emperor of the Mexican empire. Wed- Between 1940 and 1950, private and social
dings and celebrations often featured music fol- security hospitals were created. With the found-
lowing the Spanish tradition, including violins, ing of the Department of Medical Psychology,
guitars, and trumpets. Psychiatry and Mental Health at the Autonomous
Mexico experienced a golden age of films dur- University of Mexico (Universidad Autónoma de
ing the 1940s and 1950s as a cinematographic México, UNAM), the standards of care were ele-
mecca, producing and exporting movies and vated through a clinical program with academic
music. More recently, the Mexican film industry affiliations.
has been producing and broadcasting telenove- Health care in Mexico is subsidized by the pri-
las, or soap operas, to other Spanish-speaking vate sector and the federal government through
countries. such institutions as the Social Security System, or
Mexico is a country of contrasts. While it boasts Seguro Social. Hospitals within the Seguro Social
the 13th-largest gross domestic product in the provide health care in hospitals and clinics. Tradi-
world, poverty ravages 44.2 percent of the coun- tionally, the mental health field had not been con-
try’s population. Mexico’s middle class has grown sidered a relevant part of public health in Mexico
 Migration 535

because of a focus on morbidity and mortality, as See Also: Cross-National Prevalence Estimates;
well as a lack of knowledge of the implications of Cultural Prevalence; Somatization of Distress; Spain;
mental health for general health. Stress.
More recently, the Mexican Health Foundation
(1995) introduced a relevant analysis of the sta- Further Readings
tus of public health for the development of more Alarcon, R. D. and S. A. Aguilar-Gaxiola. “Mental
effective programs and recommendations for Health Policy Developments in Latin America.”
improvement and reform based on World Health Bulletin of the World Health Organization, v.78/4
Organization guidelines. The Mexican Psychiat- (2000).
ric Association and the Mexican Psychological Benjet, C., G. Borges, M. E. Medina-Mora, C. Fleiz,
Association are the entities that regulate, moni- J. Blanco, J. Zambrano, et al. “Prevalence and
tor, and establish ethical standards and guidelines Socio-Demographic Correlates of Drug Use Among
of practice and promote research and publication Adolescents: Results From the Mexican Adolescent
through peer-reviewed journals. Mental Health Survey.” Addiction, v.102 (2007).
As Mexico exhibits a significant wealth dispar- Berenzon, S., H. Senties, and E. Medina-Mora.
ity in the population, and the public health care “Mental Health Services in Mexico.” International
system is burdened by limitations in the treatment Psychiatry, v.6/4 (2009).
of medical ailments and mental health care, there Breslau, J., G. Borges, D. Tancredi, N. Saito, R.
has been an increased awareness of such needs in Kravitz, L. Hinton, W. Vega, M. E. Medina-
the private and public sectors. Mora, and S. Aguilar-Gaxiola. “Migration From
Many Mexicans are afflicted by cultural bound Mexico to the United States and Subsequent Risk
syndromes (CBS). One of the more common for Depressive and Anxiety Disorders: A Cross-
but disruptive CBS is coraje, best translated as a National Study.” Archives of General Psychiatry,
“deep internal anger.” Unlike the Western view v.68/4 (2011).
of anger as a negative reaction to stress, anger
among many in Mexican culture is manifest as
an intimate relationship between mental states
and physical symptoms to include manifest vio-
lence, severe gastrointestinal and neurological Migration
dysfunctions, and life-threatening pulmonary and
cardiac pathology. This view of psychopathology Migration is a form of social mobility where peo-
is treated by a curandera, who is trained to per- ple move from one country (or one part of a coun-
form healing interventions, where eggs are used try) to another and take up residency there for a
to absorb coraje. period of time. Mobility patterns can be analyzed
Western interventions such as psychotherapy from an individual or collective perspective, and
and medications are based on different beliefs migration can be observed within a society and
about the source of physical and psychopathol- between societies. While migration has a very
ogy, as well as mechanisms for healing, and com- long tradition in the history of mankind, recent
pete for space in a venue that often respects more trends of globalization seem to foster trends of
traditional conceptualizations of illness and treat- migration. In contrast, historical data for many
ment. Current conceptualizations of mental ill- countries show that migration, such as in the 19th
ness are very much tied to and consistent with the century, was at a higher level than it is today.
history and culture of Mexico. Migration is usually interpreted as a form of
transnational mobility, but mobility can also
Christopher Edwards present other faces, such as when people move
Duke University regionally within states with different time zones
Miriam Feliu and cultures or within economically heteroge-
Duke University Medical Center neous states where people move from the east to
Georgina Perez the west (such as in Germany after the reunifica-
University of North Carolina at Chapel Hill tion) or from the south to the north (as has been
536 Migration

occurring in Italy for many generations). The reg- specific economic needs, such as labor migrants
ular border crossing of working migrants, where who are at the lowest skills level. Free access to
people go back and forth on a daily, weekly, or foreign countries is almost nonexistent, which is
monthly basis, is an aspect of migration. why Jonathon Moses refers to these practices as a
Migration is a factor that influences the popu- function of “globalization’s last frontier.”
lation, demographic patterns, and internal com- Within migration, there are differences
position of people in target countries in relation between motives, distances, directions, periods,
to ethnic and religious backgrounds. Historically, socioeconomic areas of departure and arrival,
there are clear changes in the nature of immigra- and the economic sectors and related occupa-
tion streams. While in former times the majority tions of departure and arrival. The largest groups
of migrants moved from Europe to other coun- of migrants are asylum seekers trying to escape
tries, especially to the United States, the propor- political or religious persecution, labor migrants,
tion of migrants who left economically developed and refugees who are forced to leave their coun-
countries declined. Simultaneously, the number tries during war.
of those who left developing countries to move Migration has always provoked much discus-
toward more advanced and wealthy countries has sion and argument in the political arena under
significantly increased. Migrants who end up in social, economic, political, and ethical flags.
situations of social inequality are more vulnerable Many societies are highly dependent on immigra-
to identity disorders. tion because they suffer demographic unbalances
through falling fertility curves and longevity, so
Migration Motivations that the welfare systems experience difficulties
People migrate for a variety of reasons, which of alimentation. Also, immigration is often a
overlap practically. Migrants want to (1) escape source of innovation and new opportunities, as
poverty in their country of departure; (2) find migrants may have knowledge regarding proce-
a new job, better professional employment, or a dures, products, or other combinatory elements
career; (3) escape discrimination or harassment for for new markets that others do not. They also
political, religious, ethnic, gendered, or other rea- often have and maintain transnational networks,
sons; or (4) start a new biographical period of life, which differ from network structures of indige-
such as after retirement or divorce. Migration pro- nous inhabitants.
cesses include diverse sequences of decision mak-
ing, which have to acknowledge various factors Migration, Social Conflict and Inequality,
in family life and biographical planning within a and Mental Illness
social context of their neighborhood, friendships Although several hundreds of millions of people
and other social relationships, and material liv- have first- or second-generation migration his-
ing conditions. Migration is always motivated by tories in their own families, social conflicts do
differently balanced compositions of pushing and arise, as sociologist Georg Simmel described in
pulling factors, including perceived opportunity his famous article “The Stranger” in 1908. Inte-
costs and challenges. grative processes of acceptance on the side of
Until the 19th century, migration fluxes were natives and integration on the side of incoming
rarely controlled by governmental agencies, so migrants are not ultimately fully harmonized and
migrating people were not systematically hin- smooth. Max Weber described the irrational for-
dered from crossing borders. However, over the mation and fragility of ethnic “we groups” along
last 150 years, nation-states have established different languages and cultures as a source of
effective systems of control and access. Many cooperative social clashes. Therefore, migration
countries, especially those that lack specific labor is ultimately intertwined with globalization pro-
markets segments, use migration policies proac- cesses and social inequalities, which are a result
tively to attract migrants; for example, high-tech and mirror of each other. With respect to mental
specialists are sought on an international level. illness, the group that suffers from destiny and
At the same time, countries attempt to suppress the individuals who end up in a negative situation
the number of labor migrants who do not match are the first to be vulnerable to identity disorders.
 Milieu Therapy 537

Policy and ethics are encouraged to de-escalate Moses, Jonathon W. International Migration:
conflicts wherever they are visible or expected. Globalization’s Last Frontier. London: Zed
On the surface, what looks to be a normal social Books, 2006.
process in a global world, which can be described Portes, Alejandro, ed. The Economic Sociology of
in terms of new compositions of social structures Immigration: Essays on Networks, Ethnicity,
and socioeconomic inequalities, can have some and Entrepreneurship. New York: Russell Sage
very serious negative implications at the individ- Foundation, 1995.
ual level. Changing from one area of cultural and Simmel, Georg. “The Stranger.” In Georg Simmel: On
individual embeddedness to another is not always Individuality and Social Forms, Donald N. Levine,
easy to master for some people. The process can ed. Chicago: University of Chicago Press, 1971.
be linked to material losses, social deprivation Wallerstein, Immanuell. “After Developmentalism
and isolation, discrimination, and a feeling of and Globalization, What ?” Social Forces, v.83/3
being stranded in the middle of nowhere. There (2005).
are diverse forms of mental illnesses related to Weber, Max. Wirtschaft und Gesellschaft. Tübingen,
migration, including schizophrenia, higher ratios Germany: C. C. B. Mohr, 1972.
of suicide attempts, and other mental disorders.
Research on the effect of migration’s effect on
an individual level includes areas of urban inequal-
ities, gender disparities, and religious and ethnic
diversities as sources of inclusion and exclusion. Milieu Therapy
The topic of migration highlights the idea that
culture and history are important for an under- Milieu therapy is a term primarily used in psy-
standing of the creative processes of civilizations. chiatry and mental health nursing to note the use
of the total environment as a therapeutic agent
Dieter Bögenhold for the purpose of promoting safety, structural
Alpen-Adria-University Klagenfurt security, social problem-solving, engagement,
and self-management. Milieu therapy is an out-
See Also: Cross-National Prevalence Estimates; growth of the moral treatment movement’s resur-
Cultural Prevalence; Diagnosis in Cross-National gence after World War II, but it waned in popu-
Context; Family Support; Global Mental larity in response to deinstitutionalization. While
Health Movement; Globalization; International many psychological orientations have made use
Comparisons; Marginalization; Social Isolation; of milieu therapy, the two primary models of the
Social Support; War. intervention are the humanistic therapeutic com-
munity and behavioral social learning formats.
Further Readings While there is a dearth of experimental data for
Bhugra, Dinesh. “Migration and Mental Health.” evaluation of milieu therapy’s effectiveness, the
Acta Psychiatrica Scandinavia, v.109/4 (2004). available body of evidence suggests that clients of
Bhugra, Dinesh and Peter Jones. “Migration varying severity of illness benefit from the inter-
and Mental Illness.” Advances in Psychiatric vention approach.
Treatment, v.7 (2001). Prior to the 1750s, residential intervention for
Castles, Stephen and Mark J. Miller. The Age of those deemed “insane” were akin to dungeons
Migration: International Population Movements in where those considered abnormal—including
the Modern World. New York: Guilford, 2009. political dissidents and those with developmen-
Fassmann, Heinz, Max Haller, and David Lane, tal disabilities—were housed with little prospect
eds. Migration and Mobility in Europe: Trends, of improvement or release. At the close of the
Patterns, and Control. Cheltenham, UK: Edward 18th century, an emphasis on moral guidance and
Elgar, 2009. humane care for those deemed mentally ill devel-
King, Russell. People on the Move: An Atlas of oped in Europe as the efforts of Philippe Pinel
Migration. Berkeley: University of California Press, and William Tuke attracted attention; in turn,
2010. this “moral treatment movement” was advanced
538 Milieu Therapy

in the United States by a group of early asylum suggested that staff embrace a domestic orienta-
doctors and by Dorothea Dix, who did much tion; thus, they communicate to clients from a
to persuade politicians to establish state mental parental prerogative, and they promote the con-
hospitals. Every aspect of the institution, from its ceptualization of the clinic as home to the clients.
architecture to the use of work as therapy and the This is in direct contrast to the low interaction lev-
instructions given to the asylum staff, was sup- els of the custodial care models prior to the 1950s.
posed to contribute to the creation of a therapeu- Beyond medical and psychological interven-
tic environment. tions, therapeutic communities emphasize group
Though nominally still the approach to the activities as a key to providing a self-actualizing
treatment of patients, under the pressure of num- environment. Sports, creative arts, and voca-
bers and the shortage of funds, moral treatment tional activities are often provided, and cohort
began to degenerate into moral management from groups often democratically choose and complete
the 1850s. Mental hospitals began to revert back tangible projects. Through group activities and
to long-term institutionalization and the provision staff–client interaction, emphasis is placed upon
of distinct custodial and medical care. However, goal-directed communication, promoting a high
belatedly and just as hospital populations began level of engagement by clients, problem-solving,
to shrink, the pendulum swung back to the moral conflict resolution, and group cohesion. In con-
treatment philosophy as media exposés, such as trast, illness and patient role are downplayed.
“Suffer the Little Children” of Pennhurst Men- Group therapy often focuses on peer relations
tal Hospital in Philadelphia, and reactive reform and self-management.
regulation were launched in the second half of the In contrast to the therapeutic community, the
20th century. second popular form of milieu therapy, social
learning, relies on operant and observational
Types of Milieu Therapy learning principles to motivate change in clients
The primary models of milieu therapy are derived in residential settings. Social learning’s form of
from humanistic and behavioral perspectives. milieu therapy was developed by American psy-
Following World War II, Maxwell Jones, a Brit- chologists in the 1960s. In the 1950s, behavioral
ish psychiatrist, introduced the concept of milieu psychologists had little status in mental institu-
therapy through his development of what he tions where therapeutic communities had flour-
called the therapeutic community. Therapeutic ished, and they were primarily only permitted to
communities have their philosophical roots in the work with patients with very severe problems.
humanistic tradition. Through tailoring an envi- Pioneered by the work of Teodoro Ayllon, years
ronment where opportunities for independence, of experimentation demonstrated that the use of
meaningful activity, responsibility, and positive operant conditioning principles could change the
self-regard can be exercised, self-actualization behavior of these residential patients. He advo-
and wellness can be advanced. Jones’s ideas were cated the use of token economies—the vesting
very popular, and most English-speaking facilities of cards, chips, or other objects with value—in
claimed to embrace milieu therapy by the 1960s. which clients could earn, spend, and lose these
While the philosophy of milieu therapy has tokens to motivate learning. Such tokens could be
been well established, defining its specific tech- spent on food, cigarettes, hospital privileges, or
niques remains elusive. The central characteristic other desired items.
of the therapeutic community is that unit-wide In addition to token economies, social learning
procedures are adopted to enlist clients as agents programs adopt a variety of other behavioral con-
of change for themselves and the community. All cepts into their milieu therapy approach. Frequent
aspects of support, including medical therapy, assessment is required to maintain precision for
psychotherapy, activities, and recreation, are shaping. During all activities of the milieu, mod-
integrated into the community. High levels of eling and shaping through successive approxima-
client–staff interaction are central to therapeu- tions are used to increase desired skills. In turn,
tic community. Akin to the familial model of the graduated exposure and response-cost inter-
moral treatment movement, ethnographies have ventions are used to reduce undesired behavior.
 Military Psychiatry 539

Similar to therapeutic communities, illness and See Also: Architecture; Clinical Psychology;
patient role are downplayed; additionally, social Community Mental Health Centers; Group Homes;
learning models often de-emphasize the use of Mental Institutions, History of; Nursing.
psychotropic medication.
Beyond these two models of milieu therapy, Further Readings
other theoretical orientations also have adopted Gunderson, John, O. A. Will, and Loren Mosher, eds.
milieu principles. Psychodynamic clinicians claim Principles and Practice of Milieu Therapy. New
to have been using milieu therapy principles since York: Aronson, 1983.
Ernst Simmel’s work in Berlin in the 1920s. Addi- Jones, Maxwell. The Therapeutic Community. New
tionally, a number of integrative approaches have York: Basic Books, 1953.
developed. In treatment of addictions, integration Kazdin, Alan. “The Token Economy: A Decade
of cognitive behavioral and motivational inter- Later.” Journal of Applied Behavior Analysis, v.15
viewing principles into therapeutic communities (1982).
has been used in halfway houses with success. Paul, Gordon and Robert Lentz. Psychosocial
Treatment of Chronic Mental Patients: Milieu
Efficacy of Milieu Therapy vs. Social-Learning Program. Cambridge, MA:
Various forms of milieu therapy have been demon- Harvard University Press, 1977.
strated to be effective, albeit with some differences
in response across populations. Milieu therapy is
believed to work because each component of the
environment is individually therapeutic, and the
whole is therapeutically greater than the sum of its Military Psychiatry
parts. Furthermore, presence in the milieu makes
clients available to receive more types of interven- Psychiatry has had a presence in the U.S. military
tion and support than they likely would receive since the 19th century. During its history, military
elsewhere. For populations with serious mental psychiatry has repeatedly addressed the issue of
illness, social learning models appear more effec- combat stress on many battlefronts. Despite this
tive and cost efficient. However, for less severely long history, providers in World War I and II did
impaired populations, social learning and thera- not have the necessary resources or information
peutic community approaches work more effec- to address mental health problems related to
tively than traditional custodial programs. combat.
Critics of milieu therapy observe that the thera- Active-duty personnel are treated in the Mili-
peutic community and the behavioral modification tary Health System under the management of the
interventions are intensive, making them difficult Department of Defense (DoD), and veterans have
to replicate upon client discharge. Additionally, the option of receiving treatment in the Veterans
opponents question generalization of behavior to Administration (VA) health care system. In recent
the aftercare environment. Most research on effi- years, the DoD and VA have created guidelines
cacy and effectiveness is descriptive in nature, and for the treatment of psychiatric conditions. These
more experimental investigation is necessary. guidelines emphasize the use of evidence-based
With the deinstitutionalization movement of practices (EBPs) for active-duty military person-
the 1970s, milieu therapy’s employment dimin- nel and veterans with mental health diagnoses.
ished with downsized staffs and diminished hos- Both the DoD and VA provide training in EBPs.
pital funding. However, with managed care’s The military offers training through the Center
emphasis on evidence-based approaches and for Deployment Psychology (CDP).
increasing political trends toward integrated care, DoD and VA providers address areas that
milieu therapy has shown promise for resurgence are salient to active-duty military personnel and
in residential care. veterans. These include, but are not limited to,
post-traumatic stress disorder (PTSD), suicide,
Gerald E. Nissley traumatic brain injury (TBI), sleep disorders,
East Texas Baptist University and substance abuse. While addressing these
540 Military Psychiatry

conditions, mental health providers are often con- Substance Abuse

fronted with the issue of stigma that surrounds PTSD and substance abuse or dependence are
psychiatric treatment in the military. Providers frequently comorbid. Theoretically, this can
in each of these systems balance service to their be understood as a mechanism of avoidance.
organizations and patients. Avoidance symptoms are central to the diagno-
Military providers utilize principles of treat- sis of PTSD and maintain the disorder. Alcohol
ment that are effective in combat. The BICEPS may be used by those with PTSD to escape from
principle, for example, stands for brevity, imme- traumatic memories and improve sleep; however,
diacy, centrality, expectancy, proximity, and sim- substance use can actually intensify flashbacks
plicity. In other words, medical treatment on the and nightmares and worsen problems with sleep,
battlefront needs to be practical and expedient, anger, and concentration.
given available resources. Assessment of fitness Guidelines from the VA indicate that these dis-
occurs at any time when there is a question of orders should be treated concurrently. Both the
competence for work duties. DoD and VA provide treatment for substance
abuse. The commanding officers of active-duty
Post-Traumatic Stress Disorder military personnel are informed when they request
Prior to the Vietnam War, military personnel often or are referred for substance-abuse care.
returned from combat with symptoms that were
labeled “shell shock” or “battle fatigue.” World Suicide
War I veterans with symptoms related to combat Mental health diagnoses such as PTSD, depres-
were termed to have “soldier’s heart” or even hys- sion, and substance dependence increase risk for
teria and often displayed physiological symptoms suicide. Rates of suicide in the military doubled
such as tachycardia and vomiting. The Ameri- between 2001 and 2006. Steps to address this
can Psychiatric Association did not officially growing problem have included increased training
recognized PTSD as a diagnosis until the 1980s, for mental health providers and nonmedical mili-
largely as the result of military providers working tary personnel. In 2012, President Barack Obama
with Vietnam veterans who were struggling with signed an executive order expanding suicide pre-
symptoms that impacted their daily functioning vention programs and treatment for active-duty
and were without effective treatment options. personnel and veterans. This includes the hiring of
Even then, PTSD was thought to be a short-term over 1,600 new mental health providers to address
adjustment reaction. Compensation was not pro- rising suicide concerns. This order also mandates
vided for veterans with PTSD until the chronic that veterans in crisis be seen within 24 hours. In
nature of the disorder was finally acknowledged. September 2012, the DoD and VA announced a
Today, the DoD and VA provide guidelines in joint suicide awareness campaign that targets fam-
the use of evidence-based treatments for PTSD ily, friends, and colleagues of those at risk.
that emphasize the use of prolonged exposure
(PE) or cognitive processing therapy (CPT.) PE Traumatic Brain Injury
and CPT were chosen because they have the most Another growing problem in the military in recent
evidence demonstrating their efficacy with civil- years has been addressing TBI. Due to advances in
ian and veteran populations. The VA guidelines medical technology, military personnel are surviv-
mandate that all veterans with diagnoses of PTSD ing with combat injuries in a way that was previ-
be offered evidence-based treatment. Promising ously unknown. The use of improvised explosive
research is being conducted on the use of these devices (IEDs) is another factor contributing to
treatments with active-duty military personnel. high rates of TBI in returning military personnel.
The war in Iraq and drawdown in Afghani- Mental health and medical providers in the mili-
stan have resulted in a large influx of claims for tary and VA systems are seeing patients who at
compensation. World War II, Korean War, and times have multiple, cumulative head injuries.
Vietnam War veterans also continue to apply for Recent advances in military medical care have
compensation, and wait times for claims process- included assessing for this type of injury on
ing can be lengthy. the battlefront. Ongoing symptoms of TBI can
 Military Psychiatry 541

include headache, dizziness, problems with con- place on a predictable schedule. Military person-
centration, sleep disturbance, changes in mood, nel often sleep while they can during deployment,
and irritability. There is a notable overlap in the catching a few moments of rest at any opportu-
symptoms of PTSD and TBI. Recent research is nity. They may have to sleep in their uniforms,
being conducted in the adaptation of therapies including footgear, so they can be ready to take
for PTSD to accommodate those with comorbid action at a moment’s notice. Military personnel
TBI. Adaptations can include additional repeti- may also become accustomed to sleeping with a
tions of information. The use of electronic devices weapon. These patterns of fragmented and dis-
to aid in scheduling and remembering assign- turbed sleep often become habitual and can last
ments, appointments, and medications may also long after returning from the battle zone.
be useful. The VA provides training in the use of cognitive
behavioral therapy (CBT) for insomnia (CBT-I),
Sleep Problems which has more empirical support than any other
Problems with sleep are the most commonly insomnia treatment. CBT-I provides education
reported symptom of PTSD, but military person- and instruction in sleep hygiene as well as in hab-
nel who are deployed often experience a disrup- its that enhance sleep quality. Myths about sleep
tion in their sleep patterns even in the absence of and unhelpful cognitions are challenged, while
a PTSD diagnosis. During deployment, missions helpful habits—such as planning a schedule for
can go on through the night and do not take decreasing activity before bed—are encouraged.

Participants with the Jimmy Miller Memorial Foundation greet each other at the Del Mar shoreline at Camp Pendleton, California,
before hitting the water for a surf session as part of their ocean therapy, May 5, 2012. Ocean therapy facilitates improved self-esteem
for U.S. military service members dealing with mental and physical illness. The Department of Defense and the Veterans Administration
have created guidelines for the treatment of psychiatric conditions, emphasizing the use of evidence-based practices.
542 Mind–Body Relationship

Stigma and Barriers to Care U.S. Army and Medical Department. “Combat and
Recent attempts to reduce the stigma around Operational Behavioral Health.” http://www.cs
receiving mental health care have included train- .amedd.army.mil/borden/Portlet.aspx?ID=2331c1
ing and education. While these efforts continue, fa-753b-449c-a2aa-dd10ea69b9b9 (Accessed
military personnel may be reluctant to seek help, November 2012).
fearing that doing so could negatively impact their
career. Military personnel seeking treatment may
also have the false perception that discussing prob-
lems or seeking help means that they are weak.
Early in treatment, it is important for providers Mind–Body Relationship
to address stigma, confidentiality, and self-percep-
tions about having a mental health diagnosis. Spanning the scholarly works of philosophers,
VA and DoD mental health providers are in theologians, neuroscientists, and psychologists,
the unique position of not only providing care for few lines of inquiry intersect with as many aca-
patients but also assessing for disability and com- demic disciplines as does the subject of the mind–
pensation. The outcomes of these exams have the body connection. The topic of the mind–body
potential to greatly impact the lives of those being connection figures prominently in the investiga-
assessed in terms of career and future monetary tion of mental illness and mental health, particu-
and medical benefits. Providers respond to both larly as it relates to the manner in which profes-
the demands of their organization and the needs sionals classify and treat mental disorders.
of their patients. Active-duty service members The dualistic manner in which the mind and
seeking help may wish to remain in the military body have conventionally been conceptualized
and continue their careers. Mental health provid- find roots in the work of classical Greek philoso-
ers treating these service members do so with the phers such as Plato and Aristotle, who shared the
knowledge that their patients may be given orders belief in multiple immortal souls that existed in
to deploy following treatment. a specialized hierarchical arrangement in living
organisms. These souls possessed distinct connec-
Charity Wilkinson tions with the physical body, but were understood
University of Texas Health Science Center as composed of qualitatively different substances.
at San Antonio In the Greek worldview, the mind–body connec-
tion represented an inconvenient relationship
See Also: Cognitive Behavioral Therapy; Drug between two qualitatively different substances.
Abuse; Policy: Military; Post-Traumatic Stress To these Greek philosophers, separating the
Disorder; Shell Shock; Stigma; Suicide; Veterans; ephemeral, spiritual substance (the psyche) from
Veterans’ Hospitals; Violence; War. the body facilities the highest achievement of wis-
dom and rationality because the spirit is unen-
Further Readings cumbered from the shackles of finite corporeality.
Department of Defense, Department of Veterans The mind–body dichotomy was later reinforced
Affairs. “VA/DoD Clinical Practice Guidelines, by, and most closely linked to, the seminal work
Management of Post-Traumatic Stress.” http:// of 17th-century philosopher René Descartes,
www.healthquality.va.gov/ptsd/CPG_Summary whose now iconic observation “cogito ergo sum”
_FINAL_MgmtofPTSDfinal.pdf (Accessed (“I think, therefore I am”) best captures his dual-
November 2012). istic attitude. Descartes argued that the mind
Friedman, M. J. “Post-Traumatic Stress Disorder exists as an indivisible, immaterial entity and is
Among Military Returnees From Afghanistan and synonymous with consciousness and self-aware-
Iraq.” American Journal of Psychiatry, v.163/4 ness. While acknowledging that the mind inter-
(2006). acted with the brain (and the rest of the body),
Stanton, Dennis G. and Lawrence R. Castaneda. he emphasized the material nature of the human
Military Psychiatry: New Developments. New body, viewing it as merely a mechanical medium
York: Nova Science, 2010. by which the mind/soul finds expressions.
 Mind–Body Relationship 543

Although perhaps serving some utility for increase the likelihood of developing a range of
didactic purposes, many contemporary philoso- medical conditions, such as heart disease. For
phers and psychological theorists have eschewed instance, in an especially illustrative 2009 study
the traditional Cartesian dualism (Cartesian conducted at Columbia University, researchers
deriving from the Latin form of the name Des- concluded that clinical depression actually func-
cartes), understanding the mind–body distinc- tions as an independent risk factor for heart dis-
tion as an artificial dichotomy propagated by ease, apart from commonly known medical mark-
atavistic theories of the mind. Rather, research- ers such as diabetes and high blood pressure.
ers and theorists alike have offered compelling To increase awareness of the connection between
evidence that the mind and the body are more psychological and physical health, in 1996, the
than simply connected, but actually interpen- American Psychological Association (APA) estab-
etrate each other in a holistic way that opposes lished the Mind/Body Health Public Education
efforts of reductionism. Campaign. As an extension to this campaign, in
The seminal work of the neurologist Antonio 2007, the APA commissioned an annual nation-
Damasio has been widely acknowledged as spark- wide survey to investigate how stress impacts
ing the contemporary neuropsychological focus general psychological wellness and mental health.
on researching the foundational interpenetration Findings from these series of surveys suggest that
of mind/body processes. Using the famous exam- stress is linked to a variety of physical and psy-
ple of Phineas Gage and other brain damage cases, chological disorders such as obesity and depres-
Damasio presented his “somatic marker hypoth- sion, is particularly acute among caregivers, and
esis,” which argues that rationality stems from plagues children and adolescents, with 43 percent
emotion, with emotions deriving from bodily sen- of teens reporting that they feel worried, and 47
sations. In this paradigm, rationality and decision percent of tweens indicating that they experience
making, which had conventionally been aligned general sadness. To relieve stress responses, many
purely with cognitive processes (in the mind), are individuals tend to engage in sedentary activities
intractably shaped and guided by emotional input such as listening to music or watching television,
(from the body). which tends to contribute to rampant obesity and
begets more stress. This downward spiral connec-
Mind–Body Connection in Mental Disorders tion between stress and physical wellness has led
The primary nosological reference undergirding the APA to advocate grassroots programming to
contemporary Western psychiatry, the Diagnostic educate the nation about the critical role of the
and Statistical Manual of Mental Disorders (DSM- mind–body connection.
IV-TR), has likewise recognized the interactional The psychiatric use of drugs to positively
nature of the mind–body connection concerning impact mood, sensations, cognition, and behavior
the role it plays in mediating many mental disor- has become, in contemporary times, an increas-
ders, especially those linked with general medical ingly attractive option in the treatment of numer-
conditions such as endocrine disorders, neurolog- ous psychological symptoms and syndromes
ical disorders, infectious diseases, brain tumors, and further underscores the elemental relation-
metabolic disorders, vitamin deficiency states, and ship between mind and body. Although the evi-
substance abuse. Conversion disorder (formally dence base for psychopharmacological treatment
known as hysteria) perhaps represents the most remains uneven across symptoms, and is gener-
prominent pathological intersection between the ally weaker in the real-world community versus
mind and body and is characterized by symptoms in controlled clinical experiments (what has been
or deficits that affect voluntary motor or sensory referred to as the “efficacy-effectiveness para-
functions (e.g., numbness, blindness, and paraly- dox”), there nevertheless exists a growing knowl-
sis) that cannot fully be explained by neurological edge base pointing to the benefit of drug therapy
or other general medical conditions. in acute symptomatic improvement.
Research has likewise indicated that untreated The mind–body connection has also been uti-
or undertreated mental disorders substantially lized by the mental health establishment as a way
shorten an individual’s life span and significantly to destigmatize the condition of mental illness by
544 Minor Tranquilizers

emphasizing the physicochemical processes of the Further Readings

brain as the primary determinant of behavior and Damasio, A. Descartes’ Error: Emotion, Reason, and
psychological well-being. This strategy has been the Human Brain. London: Putnam Publishing,
shown to destigmatize mental disorders, particu- 1994.
larly among certain minority groups such as Afri- Szasz, T. S. “Debunking Antipsychiatry: Laing, Law,
can Americans and Latin Americans, although and Largactil.” Existential Analysis, v.19 (2008).
with other minority groups, such as Orthodox Szasz, T. S. “The Myth of Mental Illness.” American
Jews, promoting the biological underpinnings of Psychologist, v.15 (1960).
psychological disorders has recently been shown
to increase stigmatization.

Mental or Physical Illness

The sometimes controversial and renowned psy- Minor Tranquilizers
chiatrist Thomas Szasz, however, has long argued
that the use of the term mental illness is con- The first of the modern antipsychotic drugs, chlor-
ceptually obsolete and semantically confused. promazine (trade name Thorazine, or in Europe,
According to Szasz, relying on a disease model of Largactil) was introduced in the United States in
understanding psychological distress by labeling 1954 and was rapidly adopted by a psychiatric
what he describes as “problems of living” as “ill- profession desperate for effective treatments for
nesses” carries several critical hazards. The medi- psychosis and impressed by its effects in the treat-
cal model of psychopathology, says Szasz, acts to ment of the florid symptoms of schizophrenia.
obscure the fact that living is a difficult task, if The following year, meprobamate, a drug first
not an outright struggle, as well as serves to mask synthesized in 1950, was introduced by Wal-
moral and interpersonal conflicts within a bio- lace Laboratories under the trade name Miltown
logical paradigm, again creating the illusion that and by Wyeth as Equanil. To distinguish the two
if one were medically better, problems in living classes of drugs, they became known as the major
would accordingly be corrected. and the minor tranquilizers, respectively, though
The shift in the way that the mind–body split those labels oversimplified both their pharmaco-
is understood by mental health professionals logical and clinical properties.
encourages a move beyond a one-dimensional
approach to management of a disease to an inte- Phenothiazines
grated style that more fully appreciates the role Phenothiazines like Thorazine became massive
and effect of the mind–body connection when best sellers within a year of their introduction.
diagnosing, treating, and promoting wellness in The minor tranquilizers enjoyed an even greater
individuals with psychiatric disorders. Recent success in the marketplace. By 1957, Ameri-
developments in philosophy, neurology, and can physicians had prescribed them on 36 mil-
psychology are beginning to promote a multidi- lion occasions, and these drugs accounted for a
mensional mind–body perspective on psychiat- third of all the prescriptions being written in the
ric illness that promises to empower health care United States. They were enormously profitable,
professionals to enhance therapeutic outcomes but drug company claims to the contrary, their
by improving various aspects of patient care with side effect profiles were not noticeably different
the expectation that meaningful, enduring change from the barbiturates, except for being somewhat
will be promoted. less sedating. Patients developed tolerance to both
classes of drugs and were at risk of developing psy-
Paul Cantz chological and physical dependence on them, and
University of Illinois, Chicago College of Medicine cessation of both medications is accompanied by
sometimes life-threatening abstinence syndrome.
See Also: Psychosomatic Illness, Cultural Ultimately, in 1967, their potential for abuse led
Comparisons of; Somatization of Distress; Szasz, to initial attempts to limit their prescription, and
Thomas. by 1970, these drugs were listed as controlled
 Minor Tranquilizers 545

substances. In the United States, meprobamate is the drugs were widely prescribed to treat anxi-
listed as a Schedule IV controlled drug. The Euro- ety, insomnia, and the symptoms of acute alcohol
pean Medicines Agency recommended suspension withdrawal, as well as for sedation before medical
of marketing authorization in early 2012. procedures such as endoscopy, where its amne-
siac effects are welcome. This class of drugs also
Benzodiazepines has useful properties as a muscle relaxant. Hoff-
A second group of minor tranquilizers, the benzo- mann–La Roche threw huge marketing muscle
diazepines, had in the meantime reached the mar- behind the selling of minor tranquilizers, and they
ket. Their introduction was largely serendipitous. became a source of massive profits. Valium was
Originally synthesized in the mid-1950s as part immortalized by the Rolling Stones as “Mother’s
of an effort to develop drugs that relieved anxi- little helper.”
ety without the excessive sedative and addictive The benzodiazepines are drugs that act rela-
properties of earlier generations of drugs (such as tively rapidly, but they have a very long half-life in
opiates and barbiturates), a whole series of chem- the body. Moreover, they tend to suppress rapid
ically related compounds had been tested and dis- eye movement (REM) sleep and impair motor
carded by Hoffmann–La Roche scientists, and the function, particularly among the elderly, and may
whole line of research was on the brink of being produce impaired balance. Such effects are exac-
discontinued when Leo Sternbach (1908–2005) erbated by the concomitant ingestion of alcohol.
came across one of these compounds, known As with Miltown and Equanil, they were initially
internally as Ro 5-0690, that had not yet been marketed as drugs that were free of the problems
tested. Animal research, initially on monkeys and of dependence and withdrawal that had been seri-
then on leopards, tigers, lions, and panthers at the ous drawbacks to the prescription of barbiturates,
Boston and San Diego zoos, seemed to demon- and as with these other minor tranquilizers, these
strate calming effects with minimal loss of alert- claims proved unfounded.
ness, and Hoffmann–La Roche obtained a patent Both tolerance (requiring increased dosage to
on the drug in 1959. Chemically, it and related produce the same clinical effects) and withdrawal
drugs are based upon a fusion of a benzene ring symptoms when the drug is discontinued are very
and a diazepine ring. serious problems. Impairment of short-term mem-
Initial clinical trials involving geriatric patients ory and of the ability to absorb new information
who were administered relatively large doses is common. Confusion, amnesia, and depression
were not promising. Patients were sedated, their also are complications that frequently emerge
speech became slurred, and many experienced with chronic use, and the higher the dosage and
loss of muscle control or ataxia. The drug only the longer the drug is used, the greater the risk
came to be marketed, under the trade name Lib- that these side effects will emerge. Up to 50 per-
rium, after Phase III testing on a larger array of cent of patients experience serious difficulties on
patients, some prisoners and others ambulatory discontinuing these drugs, sometimes including
patients seen by psychiatrists in out patient set- psychoses and seizures and often manifesting as
tings, produced evidence of its usefulness as a rebound anxieties that are more serious than the
means of reducing anxiety with relatively minor anxieties that originally led to their prescription.
effects on cognition and level of consciousness. Paradoxical effects like gross excitement and rage
These effects appear to depend upon reductions are not uncommon. Accordingly, it has become
in the strength of incoming nervous stimuli. standard clinical practice to avoid their use for
Librium was joined in 1963 by the closely extended periods and to attempt to monitor the
related drug Valium, whose usefulness was made health status of those taking these drugs very
manifest to Hoffmann–La Roche executives after carefully. Taken with alcohol or with other cen-
Sternbach administered trial doses to their moth- tral nervous system depressants, diazepam may
ers-in-law, who instantly became, the executives prove fatal. Given the clinical usefulness of these
reported, significantly less annoying. (Presumably, drugs, however, they remain widely prescribed,
Sternbach could have produced the same effect by available in oral, injectable, inhalable, and rectal
giving Valium to the executives.) In rapid fashion, forms and in more than 500 separate brands.
546 Monoamine Oxidase Inhibitor (MAOI) Antidepressants

Potential for Abuse Lader, M. “History of Benzodiazepine Dependence.”

Minor tranquilizers have obvious potential for Journal of Substance Abuse Treatment, v.8 (1991).
abuse, and that potential has been widely realized. Tone, Andrea. The Age of Anxiety: A History of
Celebrities who have owned up to Valium addic- America’s Turbulent Affair With Tranquilizers.
tion include Elizabeth Taylor, Elvis Presley, and New York: Basic Books, 2009.
Tammy Faye Baker. Recreational use, particularly
among high school and college-age students, con-
tinues to be widespread, and so is off-label use by
adults. As many as 35 percent of drug-related visits
to hospital emergency rooms in the United States Monoamine Oxidase
involve benzodiazepines, and they are widely
regarded as the most abused class of prescription Inhibitor (MAOI)
drugs. The prevalence of binge drinking among
college students and the powerful interactions of
Antidepressants
benzodiazepines and alcohol undoubtedly contrib- Monoamine oxidase inhibitors (MAOIs) were
ute to the severity of these problems. Panic attacks, the first recognized antidepressants, though a
insomnia, and crippling anxiety are frequent con- case could be made for amphetamines as the first
comitants, ironic given that these recreational to psychotropic drugs to define our contempo-
users are drawn to the drug by its initially calming rary definition of major depression. In fact, it was
and relaxing effects and the associated feelings of in describing the MAOI effects seen in patients
euphoria. Because dosages in these situations often that psychiatrist Max Lurie, in 1952, first used
greatly exceed recommended levels, complica- the term antidepressant. Although the MAOIs
tions such as blurred vision, disorganized thinking, held primacy in the market for less than a decade,
impaired motor functions and judgment, vomiting, their impact on the field of psychopharmacology
memory loss, and hallucinations are very real risks. cannot be understated. At the time they were
Benzodiazepines are now classed as Schedule discovered, there was, at best, only a glimmer
IV controlled drugs under the International Con- of an antidepressant medicine, other than over-
vention on Psychotropic Substances, like mepro- the-counter energy tonics and mild stimulants;
bamate before them. About 14.7 million prescrip- no one was looking for a new drug specific to
tions were written for Valium in 2011, though it the treatment of depression. The antidepressant
has now been upstaged by Xanax, for which 48.7 properties of MAOIs were a serendipitous dis-
million prescriptions were written in that same covery by researchers working to improve tuber-
year. Still another benzodiazepine first released cular medications.
by Upjohn (now absorbed by Pfizer) in 1981, this
has now become the most prescribed and the most Early Development
misused minor tranquilizer on the U.S. market. In the late 19th century, Emil Fischer discovered
phenylhydrazine, from which Hans Meyer and
Andrew Scull Josef Malley in 1912 developed isonicotinyl-
University of California, San Diego hydrazine at the German Charles-Ferdinand Uni-
versity. The apparently useless compound was all
See Also: Antidepressants; Mood Disorders; Side but forgotten until it was simultaneously resyn-
Effects. thesized in the early 1950s by Herbert Hyman-
Fox at Hoffmann–La Roche and Harry Yale at
Further Readings the Squibb Institute, both of whom were looking
Goddard, A. W., J. D. Coplan, A. Shekhar, J. M. for more effective antitubercular agents. Both
Gorman, and D. S. Charney. “Principles of teams were testing isonicotinyl-aldehyde-thios-
Pharmacotherapy for the Anxiety Disorders.” In emicarbazone and were surprised when isonic-
Neurobiology of Mental Illness, 2nd ed., D. S. otinyl-hydrazine, the intermediary, proved more
Charney and E. J. Nestler, eds. New York: Oxford effective in animal models. They published their
University Press, 2004. results within a fortnight of each other. Clinical
 Monoamine Oxidase Inhibitor (MAOI) Antidepressants 547

trials found the new drug, given the name isonia- House Hospital in Baltimore, both presented
zid, to be highly successful in reducing tuberculo- evidence of the euphoric effects of iproniazid in
sis (TB) symptoms in humans. Following this suc- tubercular patients, yet neither discussed the com-
cess, the team at Hoffmann–LaRoche synthesized pound as a psychiatric medication. It was psychi-
a derivative, iproniazid (trade names: Marsilid, atrist Nathan Kline and his team from Rockland
Iprozid, Ipronid, Rivivol, Propilniazida), which State Hospital in New York who first purposively
showed similar effectiveness in animal models. tested iproniazid as a potential antidepressant.
In 1952, during the clinical trials of ipronia- During the 1957 APA meeting, they presented the
zid at Sea View Hospital in Staten Island, doc- results of their study of the efficacy of iproniazid,
tors Irving Selikoff and Edward Robitzek noted which had produced significant improvement in
that one of the side effects was a stimulation of 70 percent of nontubercular depressed patients.
the central nervous system. They cited symptoms These positive results encouraged Hoffmann–La
such as hyper-reflexia, headache, involuntary Roche (HLR) to hold a symposium looking at
muscle twitching, peripheral neuropathy, consti- all its possible uses. Despite iproniazid’s promis-
pation, vertigo, difficulty in initiating micturition, ing antidepressant properties, the HLR medical
mouth dryness, minor difficulty in visual accom- leadership could not see a big-enough market in
modation, variations in sexual stimulation and depression to warrant a major sales effort. Kline
activity, mood enhancement, mild euphoria, and and his team arranged to meet the head of the
excitability. Iproniazid was almost abandoned company in secret and convinced him of the
because of these numerous side effects. However, utility of continuing to study the compound’s
researchers also observed that patients who had antidepressant effects. Although iproniazid was
previously been bedridden and morose displayed approved in 1958 only for tuberculosis, 400,000
increased vigor and sociability. Jackson Smith, patients received the drug for depression during
who tested the drug in a few depressed patients this year, thus confirming the market potential of
at Baylor University, and Gordon Kamman, who this new treatment.
observed its mood-boosting effects in tubercu-
lar subjects at the University of Minnesota, both Development of Related Compounds
thought that the new compound had potential Following the success of iproniazid, HLR and
solely as a mood enhancer. its competitors worked on finding related com-
The explanation of the action pathway of pounds. HLR developed isocarboxazid (trade
MAOIs had started prior to their discovery as name: Mardal), which never had much success,
antitubercular agents. In the 1920s, Mary Hare Warner–Lambert synthesized phenelzine (trade
at Cambridge University first demonstrated the name: Nardil), and Smith, Kline, and French pro-
ability of an enzyme to cause oxidative disami- duced tranylcypromine (trade name: Parnate),
nation of biogenic amines. A decade later, Her- which differed from iproniazid in that it was not
man Blaschko and Derek Richter, also working at a hydrazine derivative but rather an amphetamine
Cambridge, and Caecilia Pugh and Juda Quastel analogue. It attracted great clinical interest due to
at Cardiff City Mental Hospital identified and hopes that the alternate formulation would have
named this enzyme, monoamine oxidase (MAO). lower toxicity. By the end of the 1950s, MAOIs
In 1952, Ernst Zeller and his team at Northwest- were the most prescribed treatment for depression.
ern Medical School were the first to note that MAOIs began to decline in usage in the early
iproniazid inhibited MAO. They suggested that 1960s because of worries about their safety and
this could result in a rise in the levels of multiple the development of tricyclic antidepressants,
monoamines in the brain. Zeller posited that this which appeared to have a much better safety
change in levels could be the cause of the positive profile. Iproniazid was withdrawn from the U.S.
mood effects that were being seen. market in 1961. There were reports of jaundice,
At the annual meeting of the American Psycho- nephrotoxicity, and hepatotoxic effects across
logical Association (APA) in 1957, two research- all the MAOIs, leading to their diminished use
ers, George Crane from Montefiore Hospital in internationally. Tranylcypromine was withdrawn
New York and Frank Ayd from the Taylor Manor from the U.S. market in 1964 after a number of
548 Mood Disorders

patients experienced hypertensive events accom- Mood Disorders

panied by severe headaches and sometimes sub-
arachnoid intracranial hemorrhages. The cause of Mood disorders, or affective disorders, are a type
the hypertensive events was eventually discovered. of mental health problem that includes depressive
MAOIs interfere with the metabolism of tyramine, disorders, bipolar disorders, substance-induced
a compound found in certain cheeses. By inhibit- mood disorders, and mood disorders caused by
ing the breakdown of tyramine, MAOIs can lead general medical conditions. Most general depres-
to increased blood pressure after the ingestion of sive disorders, while prevalent, often go unde-
food laden with tyramine. Eventually, multiple tected. These disorders vary across cultures and
foods were found to have negative interactions over time.
with MAOIs. In addition, reports emerged that
MAOIs could have fatal interactions with tricy- Classifications
clic antidepressants (TCAs) and over-the-counter There are many different types of mood disor-
pain medication. Though a number of MAOIs ders. One common type is depression, or depres-
have remained on the market, patients must exer- sive disorder, which is experienced by approxi-
cise caution in regard to their diets (avoiding foods mately 8.5 percent of the world’s population. An
rich in tyramine), and they are currently consid- important type of depressive disorder is major
ered second- (or third-) line antidepressants. depressive disorder (MDD), also known as
The future of MAOIs (and RIMAs) is uncer- major depression, unipolar depression, or clini-
tain. Even if they are found to be effective for dif- cal depression. MDD can be diagnosed during a
ferent disorders, the lingering unease elicited in single episode or as a recurrence of symptoms.
clients and providers alike by the mere mention of These include diminished interest in the plea-
these compounds is a major hurdle to their wide- sure of daily activities, changes in weight and
spread use. Yet the discovery of MAOIs, which appetite, insomnia or hypersomnia, psychomo-
changed the field of depression and its treatment, tor agitation or retardation, fatigue, feelings of
was a historic event. The advent of MAOIs trans- worthlessness, diminished ability to concentrate
formed depression into a treatable, biomedical or think, recurrent thoughts of death (not just
disease, introduced a new type of medication the fear of dying), and/or suicidal ideation. MDD is a
antidepressant, and started a story that would be unipolar depression because it is characterized by
continued by TCAs, selective serotonin re-uptake these symptoms without accompanying mania.
inhibitors (SSRIs), and the antidepressant medica- The depressed mood remains in a fixed state as
tions yet to come. opposed to bipolar disorder, in which cycles of
mania and depression are common. Those with
Rebecca Wilkinson MDD are at risk of suicide unless treated by a
University of California, Los Angeles mental health professional.
In addition to MDD there are a number of
See Also: Amphetamines; Antidepressants; Biological equally serious depression disorders. These
Psychiatry. include atypical depression (AD), melancholic
depression, psychotic major depression (PMD),
Further Readings catatonic depression, postpartum depression
Healy, D. The Antidepressant Era. Cambridge, MA: (PPD), seasonal affective disorder (SAD), dysthy-
Harvard University Press, 1997. mia, double depression, depressive disorder not
Lopez-Munoz, F. and C. Alamo. “Monoaminergic otherwise specified (DD-NOS), depressive per-
Neurotransmission: The History of the Discovery sonality disorder (DPD), recurrent brief depres-
of Antidepressants From 1950s Until Today.” sion (RBD), and minor depressive disorder.
Current Pharmaceutical Design, v.15 (2009). AD is a mood reactivity that causes weight
Selikoff, I., E. Robitzek, and G. Ornstein. “Treatment gain, excessive sleep, heaviness in limbs, and
of Pulmonary Tuberculosis With Hydrazine social impairment. Melancholic depression is the
Derivatives of Isonicotinic Acid.” Journal of the loss of pleasure in activities and insensitivity to
American Medical Association, v.150 (1952). pleasurable stimuli. PMD or psychotic depression
 Mood Disorders 549

is when an individual experiences a major depres- effects of a psychoactive drug or other chemical
sive episode that includes a delusion or halluci- substance. It can occur simultaneously with sub-
nation. Catatonic depression is a rare but severe stance intoxication or withdrawal. A person can
form of major depression that impairs an indi- have a substance-induced mood disorder along
vidual’s motor behavior by immobilizing them with another major mood disorder. For instance,
or causing them to show abnormal movements. stimulants such as amphetamine, methamphet-
This is commonly associated with schizophrenia amine, and cocaine can cause manic, hypomanic,
or mania. and depressive episodes.
PPD is an intense, sustained, and occasion- Two common substance-induced mood dis-
ally disabling form of depression that occurs in orders are alcohol-induced mood disorders and
women after they give birth. SAD, also known benzodiazepine-induced mood disorders. Alco-
as winter depression or winter blues, is when an hol-induced mood disorders occur in alcoholics
individual has depressive episodes during the win- or heavy drinkers. Alcohol-induced mood dis-
ter months. Dysthymia is a condition similar to orders are frequently associated with increased
unipolar depression, while individuals with dou- alcohol use as a consequence of stressful events,
ble depression have occasional periods of major deviant peers, unemployment, and partners who
depression. DD-NOS is a depressive disorder abuse substances. Benzodiazepine-induced mood
that is harmful but does not fit the specification disorders occur when benzodiazepines, recom-
of the other depressive disorders. DPD is a per- mended for treatment of insomnia, anxiety,
sonality disorder that has depressive characteris- and muscular spasms, are used long term, with
tics and remains controversial. RBD is diagnosed adverse affects on the brain. It is believed that
when individuals have depressive episodes once decrease in levels of serotonin and norepineph-
a month that typically last less than three days. rine is responsible for the subsequent onset of
Minor depressive disorder is a depressive condi- depression.
tion that does not meet the full criteria of major Finally, some mood disorders are triggered by a
depression but consists of at least two symptoms secondary medical condition such as autoimmune
that impair an individual for two weeks. diseases (such as rheumatoid arthritis or can-
Bipolar disorders (BD) are another type of cer), cardiovascular diseases (such as myocardial
mood disorder. BD manifests when there are infarction), endocrine diseases (such as thyroid
abnormal cycles of persistent high mood (mania) abnormalities), gastrointestinal diseases (such as
and low mood (depression). Subtypes of bipolar cirrhosis), metabolic disorders (such as electro-
disorder include bipolar I, bipolar II, cyclothy- lyte disturbances), neurological disorders (such
mia, and bipolar disorder not otherwise specified as dementias), and pulmonary diseases (such as
(BD-NOS). Bipolar I is diagnosed when an indi- chronic obstructive pulmonary disease).
vidual has one or more manic episodes. Bipolar
II is when an individual has recurrent hypomanic Origins and History
and depressive episodes. Cyclothymia is a type Some theoretical circles use an evolutionary adap-
of bipolar disorder that is diagnosed when an tation framework to explain the prevalence of
individual has recurrent hypomanic and dysthy- depression. It is argued that individuals increase
mic episodes but not manic or major depressive their ability to cope with threatening situations
episodes. BD-NOS is when an individual suffers by a reduction in function and motivation consis-
from some symptoms of bipolar disorder but not tent with a depressed state of health. A depressed
enough to qualify the condition as one of the mood limits an individual’s motivation to pursue
three subtypes of bipolar disorders. Inheritability nonadaptive and often high-risk actions. As evolu-
of bipolar disorder is 15 to 30 percent when one tionary adaptations, mood disorders serve to limit
parent is diagnosed with it and 50 to 75 percent extraneous physical activity. For instance, sea-
when both parents have it. sonal affective disorder is diagnosed when individ-
Substance-induced mood disorders are another uals display symptoms associated with low-level
type of mood disorder that are characterized by depression during the winter months. In this case,
symptoms directly resulting from the physiological a depressed mood helps reduce physical activity
550 Mood Disorders

when there is a limited amount of food available.

A counterargument to this theory points out that
people still experience depression during the win-
ter months even when food is abundant.
Depressed mood can also be viewed as an
adaptive response to reproductive capacity. Life
occurrences such as loss of status, divorce, aging,
or death of a child or spouse foster depression for
reasons of adaptive functioning. Status changes
and death signal loss of reproductive ability or
potential, which is paralleled by reduced func-
tioning. These events are frequently triggers for
a depressive episode. Adaptation arguments tend
to have a strong gender component to them. An
adaptation perspective suggests that mood disor-
ders will be more prevalent for women than men
and more prevalent for women who have aged
out of their reproductive cycle. Research bears
out these expectations.

Prevalence and Treatment

In the late 1980s, a study involving U.S. adults
between the ages of 17 and 39 examined life-
time prevalence of six mood criteria: (1) major
depressive episode (MDE), (2) major depressive
disorder with severity (MDE-s), (3) dysthymia,
(4) MDE-s with dysthymia, (5) any bipolar dis-
order, and (6) any mood disorder. It was con-
cluded that 8.6 percent of the population have
major depressive episode (MDE), 7.7 percent
have major depressive disorder with severity
(MDE-s), 6.2 percent have dysthymia, 3.4 per- Some symptoms of major depressive disorder symptoms include
cent have MDE-s with dysthymia, 1.6 percent diminished interest in daily activities, insomnia or hypersomnia,
have any bipolar disorder, and 11.5 percent have psychomotor agitation or retardation, fatigue, feelings of
any mood disorder. worthlessness, lack of concentration, and/or suicidal ideation.
Treatment of mood disorders includes thera-
peutic and medicinal methods. The therapeutic
treatment for depression is cognitive behavior
therapy. For major depressive disorders, antide- disorders. As such, depression reflects complex
pressants are frequently used, while antipsychot- interactions between individuals and the broader
ics, mood stabilizers, and/or lithium can be used culture. Depression is not simply the result of
as treatment for bipolar disorders. unfortunate situational problems or hormonal
imbalances, although such causes can be central.
Sociocultural Aspects and Depression is an expression of a sociocultural
Cultural Comparisons complaint that involves a core set of symptoms
Sociocultural differences are readily apparent that vary between sociocultural groups, depend-
in the experience, communication, and diagno- ing on how groups report the experience of their
sis of health problems, especially in the area of conditions, how group structures shape treatment
mental health, where specific norms promote or decisions, and how groups access health care
inhibit the manifestation and treatment of mental resources.
 Mood Disorders 551

Depression varies along these dimensions Evidence shows that depression in some cul-
among various social groups. In Western cul- tures is expressed in somatic terms rather than
tures, studies have shown that whites have the as a purely psychological complaint. Among
highest prevalence of major depressive disorder. Latino and Mediterranean groups, presentation
Whites and Mexican Americans are more sus- may take the form of complaints about nerves
ceptible to early onset of major depressive dis- and headaches; among Asian groups, it may
order compared to African Americans. Studies be described in terms of imbalance or weak-
have also shown that people who live in poverty ness; and among Middle Eastern groups, it may
are 1.5 times more likely to have major depres- be described as problems with the heart. The
sive disorder. However, this higher likelihood is seriousness of symptoms of depression may be
only associated with whites. Mexican Ameri- determined by cultural metrics such that certain
can individuals have a higher chance of getting forms of behavior such as irritability may cre-
major depressive disorder if they have less than ate greater concern among family, friends, and
eight years of school. employers than sadness or withdrawal. Halluci-
The prevalence of dysthymic disorder is cor- natory or delusional experiences may be clearly
related with race/ethnicity, gender, and educa- understood as such in one culture while less
tion. Poor education is a major risk factor for obviously so in another, where being hexed or
dysthymic disorder. In both white males and visited by the dead represents a shared experi-
females, the prevalence of dysthymic disorder ence of well-socialized members of the group.
declines as education increases. Education does In short, the experience and manifestation of
not have much of an effect on rates of prevalence depression, while perhaps of somatic origins, is
for Mexican Americans and African Americans. a sociocultural phenomenon.
African American and Mexican American indi-
viduals have a significantly higher chance of hav- Matthew Archibald
ing dysthymic disorder than white individuals. Lloyd L. Liang
However, effects of dysthymic disorder tend to Colby College
be more gender-related than racial and ethnic
related. Women are twice as likely to have a See Also: Antidepressants; Bipolar Disorder; Cultural
mood disorder such as major depression. Women Prevalence; Depression; Drug Abuse; Schizoaffective
also have a slightly higher chance of having bipo- Disorder; Suicide.
lar II disorder than men.
International studies show that low socioeco- Further Readings
nomic status and efficacy, or perceived lack of Abell, S. and J. L. Ey. “Bipolar Disorder.” Clinical
control, are two preeminent forces influencing Pediatrics, v.48/6 (June 4, 2009).
depression. The odds of reporting depression are American Psychiatric Association (APA). Diagnostic
almost twice as high for those from lower rather and Statistical Manual of Mental Disorders.
than higher social positions, while lower lev- 4th ed. Washington, DC: APA, 2000.
els of efficacy are reflected in greater depressive Lam, Raymond W. and Robert D. Levitan.
symptomatology. “Pathophysiology of Seasonal Affective
However, efficacy is both culturally specific as Disorder: A Review.” Journal of Psychiatry and
well as socially determined, which suggests that Neuroscience, v.25/5 (2000).
its relationship with depression will be multidi- Parker, Gordon, Dusan Hadzi-Pavlovic, and Kerrie
mensional and complex rather than one-dimen- Eyers. Melancholia: A Disorder of Movement and
sional and simple. For example, one perspective Mood: A Phenomenological and Neurobiological
considers the relationship between an individual’s Review. Cambridge: Cambridge University Press,
subjective experiences of depression as a cultur- 1996.
ally mediated psychological experience, while Semple, David, Roger Smyth, Jonathan Burns, Rajan
another perspective emphasizes that experience as Darjee, and Andrew McIntosh. Oxford Handbook
it is manifest in physical symptomatology. A more of Psychiatry. Oxford: Oxford University Press,
complete analysis would seek to integrate both. 2007.
552 Moral Insanity

Moral Insanity observation of patients in Parisian asylums led

him to proffer a nonintellectualist insanity: manie
Although the term moral insanity is most directly sans délire (mania without delerium). Without
associated with James Cowles Pritchard, whose delusion or any other cognitive defect, a subset of
1835 text Treatise on Insanity and Other Disor- his patients were said to be under the dominion
ders Affecting the Mind provided the first com- of an abstract force propelling them into inex-
prehensive treatment of a mental derangement plicable violence they were powerless to inhibit.
that left intellectual and reasoning faculties intact, Pinel’s focus on a separate and exclusively emo-
medical references beginning in the late 1700s tional insanity resonated with the romanticism of
mentioned a type of insanity characterized by the Enlightenment, in which heightened sensation
emotional chaos with no accompanying error in and an appeal to emotional sensibility occupied
reasoning. In effect, this was a “clear-thinking” theorists of the human condition.
insanity. Significant for medical, psychological, Pinel’s work also revealed an emerging fissure
philosophical, and theological debate, the conten- between clinically based, empirical observations
tion that individuals could be carried away by an of the mentally distracted and the armchair/the-
exclusively affective madness directly challenged oretical tradition dating at least to Locke. Phy-
the Victorian belief that the inculcation of proper sicians in daily contact with the mad tended to
habits of self-control and self-discipline would affirm the existence of a madness circumscribed
necessarily arm the individual against unruly by the passions in which the reasoning powers
impulses and emotional excess. were left intact. Theoreticians who began with
But it was the impact of this expansive view the premise that the mind was a unified whole
of mental illness for the determination of crimi- could not countenance the existence of separate
nal responsibility that placed moral insanity on a reasoning and volitional powers, specifically that
collision course with the common law and those one faculty could be healthy while the other was
who jealously guarded their role as protectors pathologically deranged. When Pritchard gave
of the community and the integrity of the legal this restrictively emotional madness a compre-
process. For the first time, the battle over moral hensive description and the name moral insanity,
insanity pitted the emerging field of forensic psy- he was therefore not springing a new conception
chiatry against the established profession of the onto the medico-legal community—the term had
judiciary as well as juridical theorists. been mentioned by Thomas Arnold in 1782—but
he did manage to give it a firm home in the diag-
Conceptual Background nostic world of 19th-century mental medicine.
Since antiquity, medical practitioners and philos- Moral insanity was formally defined as a
ophers had conceived of mental derangement as derangement of feelings, of affections, of the tra-
a question of delirium, some intellectual error or ditional sentiments associated with human emo-
state of manic mental excitement that had derailed tion. This was a disturbance in one’s moral archi-
the madman’s reasoning capacities. “Delirium tecture: how one was supposed to feel toward
without fever” remained the most historically one’s children, a spouse, or even the sovereign.
enduring depiction of madness, so closely did the The morally insane were in a full cognizance of
ravings of the mad resemble the frenzied utter- their actions; there just was no reason for the
ance of persons in the throes of febrile delirium. behavior. When Edward Oxford entered the Old
The exclusive frame of insanity as a reasoning Bailey in 1840 to answer the charge of assault-
failure continued into the 16th century in John ing Queen Victoria when he fired two pistols
Locke’s depiction of the madman as one who at her carriage, the defendant’s complete want
argues rationally from false concepts: having of motive prompted five medical men to testify
joined together errors in thinking, the distracted regarding his suffering a variant of moral insanity
could not be disabused of their bedrock beliefs. known as “lesion of the will.” That the defendant
The restrictive focus on madness as a derange- harbored no ill will against the queen, that the
ment of the intellect was challenged in early 19th- crime was committed in broad daylight with no
century France by Philippe Pinel, whose clinical steps taken to elude detection, and that he freely
 Moral Insanity 553

acknowledged his actions upon apprehension of what he was doing, midcentury jurors faced
only underscored a morbid propensity to (sense- with a defense of moral insanity had to contem-
less) violence to which the unfortunate man was plate how autonomously disordered emotion or a
subject. It was a vivid demonstration affirming diseased will had left the defendant powerless to
the existence of moral insanity: that a person’s intrude upon the depraved nature of his feelings.
will could separate from his reason while he was Later in the century, the likelihood that the mor-
swept away into destructive violence (often self- ally insane were “out of the pale of self control”
destructive, as in this case). The want of motive, would receive further support in Bénédict-Augus-
not the want of intellectual coherence, sat at the tin Morel’s theory of anthropological degeneracy
root of this species of insanity. as well as conceptions of atavism fueled by the
ideas of Charles Darwin and Cesare Lombroso.
Moral Insanity and Physicalism
One can see in the term lesion of the will (moral Opposition to Moral Insanity
insanity’s fellow traveler) what was at stake with Moral insanity engendered strong reactions
the introduction of a materialist grounding for within a host of professions and intellectual cir-
aberrant behavior. The retention of free will— cles. To many in the legal community, it threat-
and with it, moral choice—had already been chal- ened to remove all responsibility from criminal-
lenged earlier in the century by phrenology. Tak- ity, rendering any act the lamentable result of
ing the notion of cerebral localization to perhaps diseased will, whether or not infected by a lesion.
its most prescriptive end, the followers of Josef In the decades before moral insanity was intro-
Gall and J. G. Spurzheim proffered a model of the duced into the courtroom, medical testimony met
brain as constitutive of 27 organs, each with its with little hostility because of the asylum doctor’s
own function and vulnerable to its own derange- proclivity to confine his testimony to questions
ment. One did not choose to steal; one suffered an of intellectual incoherence. Delusion, delirium,
enlarged organ of cunning. Mothers who killed and confusion clearly spoke to a madness that
their own children did not intend to murder; the had left the defendant bereft of a modicum of
tragic death had resulted from an under- or over- intention. Without a sufficiently integrated intel-
developed organ of philoprogenitiveness (the love lect, one could hardly be said to have understood
of one’s children). This mechanistic rendering the nature and consequence of his behavior. With
of human action grounded criminal behavior in the introduction of moral insanity into the court-
disordered matter. One could uncover the errant room, however, the easy relationship between the
organ by passing one’s fingers over the afflicted’s two professions would end. Moral insanity struck
skull to discern the bulge or depression in the cra- at the heart of intentional behavior: without the
nial surface that housed the implicated faculty. purposeful resolve to choose an action, the law
And it was the organ, not the actor, that phre- was left without its moral buttress for ascribing
nologists suggested merited the blame. Phrenol- blameworthiness. Further, law was hardly going
ogy was the first of the materially deterministic to welcome a model of human functioning that
conceptions of behavior that 19th-century society gave medical practitioners carte blanche in plac-
found increasingly fashionable. ing criminal behavior beyond the reach of moral
Although moral insanity in Pritchard’s formu- accountability.
lation was not given an explicit organic ground- In addition to legal resistance, the possibility of
ing, the closely allied diagnosis of lesion of the a nonintellectual insanity was greeted with skep-
will had managed to combine the physical with ticism by psychological and philosophical theo-
the metaphysical; medical theorists had ren- rists who steadfastly adhered to a conception of
dered the law’s fundamental criterion for ascrib- the mind as a unified whole, precluding the pos-
ing criminal responsibility—the will to harm—a sibility of a clear-thinking insanity. No conduct
material concern, subject to infection and decay. existed without motive, and motives suggested at
Just as early-19th-century jurors had to seriously minimum the active work of mental construction.
consider the culpability of a defendant whose Intellectual disturbance, therefore, must be at the
delusion precluded his understanding the nature root of deranged conduct. That such intellectual
554 Morocco

distraction did not make its appearance known to insanity serves to illustrate how deeply psychiat-
the clinical observer was hardly a surprise. The ric diagnosis is embedded in the historical times
defining nature of delusion, after all, had been its that gave it substance and meaning. The fear of a
recondite character—the capacity of the individ- defect in impulse control was a Victorian preoc-
ual to keep it hidden until its florid nature burst cupation. Increasingly freed from constraints of
through once the fatal string had been pulled. The tradition, community, and social hierarchy, the
hidden, circumscribed character of delusion had restless appetites of rootless individuals would
in fact been the point of departure between lay know no necessary force that would restrain their
and medical witnesses. The former did not know instinctual passions. That insanity migrated from
to “persist in the interview,” mistaking surface intellectual to volitional chaos can hardly come
calm for a cessation of the madness. as a surprise. What other medical specialty serves
Philosophical objections to the notion of a to diagnose a cultural malady that arrives in the
depraved moral nature also generated theological form feared most?
opposition. Such a conception violated belief in
God’s most precious gift to man: the innate capac- Joel P. Eigen
ity to know right from wrong and the gift of free- Franklin and Marshall College
dom of the will. Further, man’s choices—informed
by a God-given moral sense—were not confined See Also: Courts; Forensic Psychiatry; Insanity
to this world but reverberated in the afterlife as Defense; Law and Mental Illness; Psychiatry and
well. Even without religious overtones, there was Neurology.
an abiding secular belief that man’s emotions
must be subject to his intellect. Anything else was Further Readings
an invitation to endorse moral and social chaos. Dain, Norman and Eric Carlson. “The Meaning
The medical community was less than uni- of Moral Insanity.” Bulletin of the History of
fied behind the notion of an insanity restricted to Medicine, v.36 (1962).
depraved moral nature or a diseased will. At the Gray, John. “Moral Insanity.” American Journal of
same time that moral insanity reached the trial of Insanity, v.14 (1858).
Queen Victoria’s first of three would-be assassins, Pritchard, James Cowles. A Treatise on Insanity and
editors of leading medical journals took issue with Other Disorders Affecting the Mind. London:
the naming of a madness that did not implicate Sherwood, Gilbert, and Piper, 1835.
the intellectual faculties. To a large extent, the fis- Waldinger, Robert J. “Sleep of Reason: John P. Gray
sure in the medical community followed the lines and the Challenge of Moral Insanity.” Journal of
of clinicians versus theoreticians, the latter hold- the History of Medicine, v.34 (1979).
ing to the unity of the mind. For their part, asylum Wiener, Martin J. Reconstructing the Criminal:
doctors invoked their experience with a universe Culture, Law, and Policy in England, 1830–1914.
of patients who manifested an array of insanity Cambridge: Cambridge University Press,
states, including this variant whose features were 1990.
all too clear. In court, they would refer to the hun-
dreds of patients in their asylum and the experien-
tial base upon which their testimony rested. When
the presiding judge attempted to restrict their tes-
timony to matters of intellectual incoherence and Morocco
confusion, medical men sounded their first signs of
courtroom independence, refusing to answer any There are stories of Moroccan rulers suffering
but their own questions that expressly situated from mental issues: the bloodthirsty actions of
madness in depraved moral sense. King Moulay Ismail (r. 1672–1727) are sometimes
Beyond engaging the era’s most fundamental ascribed to mental problems, but more recent
debates—the existence and nature of free will, historians argue that his actions were similar to
the indivisibility of the mind, the question of an those of some of his contemporaries elsewhere in
innate conception of right and wrong—moral the world.
 Morocco 555

Traditionally, in village society, mental illness Morocco, and Tangier. From the 1960s, there was
was treated by local headmen on advice from also a separate focus on integration, with moves
village religious leaders. This saw many people to have 10 to 30 beds for mental health patients
treated by their extended family, but those with- in wings of general hospitals rather than having
out friends or family were neglected. It was not a totally separate facility. The rights of patients
until 1912, when the French established their and their property were enshrined in the Dahir
protectorate over much of Morocco (the Span- law of April 30, 1959, which saw the creation of
ish taking over the remainder), that modern psy- the Central Mental Health Authority. However,
chiatric practices were introduced. The French there were also allegations that psychiatry was
took over a health care system in which the only used for political purposes, such as the holding of
“hospital” was an asylum, where some inmates a prominent opposition Muslim fundamentalist
were chained together with iron collars, but oth- from Marrakech in an asylum for 3.5 years from
ers “who appear inoffensive” were allowed to 1974. There are also still no safeguards concern-
wander freely, according to a report by Dr. Solo- ing employment and housing for people suffering
mon Lwoff and Dr. Paul Sérieux. They went on a from mental problems.
French investigation of mental illness in Morocco In the 1960s, there were less than 10 psychia-
in 1910, at the instigation of the French Ministry trists in the country, but with improvements in
of the Interior and Ministry of Public Education. health care in the country generally, there are now
The French administration had been involved some 350 psychiatrists. Much of this comes from
in establishing a Westernized approach to psychi- an overhaul of the mental health service with the
atric problems in neighboring Algeria, but French National Mental Health Program, launched in
Morocco was officially a protectorate, making 1974. This has encouraged involvement with for-
some direct actions harder. eign psychiatrists, who have brought wider exper-
In 1920, the French built the Berrechid Hospi- tise. The program was revised in 1994, but many
tal, which was the first modern asylum in French of its aims have not been properly implemented.
Morocco. There was none at that time in Spanish There has been more impetus after the govern-
Morocco, though there were wards in hospitals in ment published its national survey of the preva-
Tangier, then an international city. Located near lence of mental disorders in 2007, four years after
Casablanca, the Berrechid Hospital was largely the data had been collected. This showed that in a
funded by the protectorate government with representative sample of 5,600 people, 48.9 per-
some monies provided by the administration of cent had a mental disorder, with 26.5 percent of
the city of Tangier. It was not long before there respondents reporting that they were depressed.
were 2,200 inmates at Berrechid Hospital, of A World Health Organization report from
whom about 2,000 were described as having been 2006 noted that there were nine mental asylums
“immobilized.” in the country that had a total of 1,147 beds (3.84
As the number of patients grew and the facili- beds per 100,000). They also found that the num-
ties at the Berrechid Hospital became stretched, ber of beds had decreased by 11 percent over the
the Til Mellil Psychiatric Hospital, also near Cas- previous five years, and 9,523 patients had been
ablanca, was built, with smaller asylums with a treated, with less than one-fifth of patients treated
capacity of 80–100 beds each built at Fez, Mar- more than once in a single year.
rakech, and Oujda. There was also by this time a
small facility in Tangier, and two asylums at Tet- Justin Corfield
uan and Meknes in Spanish Morocco. These asy- Independent Scholar
lums followed the European model of the period,
with expansive grounds where some patients were See Also: France; Mental Institutions, History of;
allowed to enjoy quiet walks. Spain.
In 1956, Morocco gained its independence from
France and final independence from Spain two Further Readings
years later. This saw a merger of the health sys- Aouattah, Ali. Interpretations et Traitements
tems operating in the French protectorate, Spanish Traditionnels de la Maladie Mentale au Maroc:
556 Mortality

pour une Psychiatrie “Culturelle” Marociane. might even say the evolutionary function—of
Rabat, Morocco: Editions Okad, 2008. death so that it can be better understood even as
El Khayat-Bennai, Ghita. Une Psychiatrie Moderne we try to forestall it.
pour le Maghreb. Paris: L’Harmattan, 1994. Elephants seem to be among the rare advanced
Keller, Richard C. Colonial Madness: Psychiatry animals with the rudiments of a mourning rit-
in French North Africa. Chicago: University of ual and an understanding of death. However,
Chicago Press, 2007. although they seem to grieve over and visit their
Moussaoui, D. “Psychiatry and Mental Health in dead, there is no evidence that elephants are
Morocco.” Bulletin de l’Académie Nationale de fully cognizant of their own impending death,
Médicine, v.191/4–5 (2007). as are humans. As far as can be ascertained by
Okasha, Ahmed, Elie Karam, and Tarek Okasha. the current state of knowledge, humans are the
“Mental Health Services in the Arab World.” only species that must reckon with the brevity of
World Psychiatry, v.11/1 (2012). their existence and the full brunt of the existential
terror that death imparts. According to Centers
for Disease Control statistics from 2009, even
American females live an average of only 80.9
years, which is an increase from all other previ-
Mortality ous human epochs. Still, while infectious diseases
are now better controlled, chronic degenerative
Globally, the mean age of death is 67 years, illness, such as heart disease, cancer, and stroke,
the mean age of death for modernized Western have consequently become the new leading causes
countries is 78, and the mean age for females in of death. Many feel stalked by these increasingly
such countries is above 80 years. However, lon- common mortal illnesses, causing them to won-
gevity among the severely mentally ill is greatly der not whether but when they will strike.
decreased, directly by suicide and indirectly by an
increased prevalence of chronic physical illness. The Relationship Between Mental Illness
The mentally ill contract chronic physical dis- and Mortality
eases at higher rates and seem to cope less well The mentally ill do not generally enjoy 70-odd
in their wake, failing, for instance, to seek appro- years of life. According to a 2006 report by the
priate treatment and follow medication regimens. National Alliance on Mental Illness, Americans
The increased prevalence of suicide and chronic living with serious mental illness die, on average,
physical disease combine to reduce the average 25 years earlier. The severely mentally ill die pre-
life expectancy of the severely mentally ill by 25 maturely because they appear to less effectively
years. In addition, the relationship between men- manage the symptoms of chronic physical illness;
tal illness and mortality is not confined to severe for example, those with diabetes less reliably self-
diagnosable disorders, as even subclinical symp- administer insulin injections and those with can-
toms are modestly related to mortality. Alterna- cer less frequently adhere to courses of chemo-
tively, there are many protective factors—signs therapy. Moreover, severe mental illness is also
of optimal mental wellness—that are associated associated with increased risk of chronic medical
with longevity, such as coping mechanisms and conditions, such as coronary heart disease and
attendance of religious services. stroke. In other words, those with mental illness
Whether mentally ill or mentally well, all disproportionately suffer from physical illnesses
humans die. The consciousness of death imposes a and thereafter less conscientiously manage them.
psychological trial that is most explicitly endured Recent research in England spanning more than
during the last two of psychologist and psycho- a decade and surveying almost 70,000 people
analyst Erik Erikson’s stages: generativity versus suggests that the association between mental ill-
stagnation and ego integrity versus despair. The ness and life expectancy is linear. In other words,
successful resolution of these stages of life allows while serious forms of mental illness greatly
death to be met with equanimity. Meanwhile, reduce longevity, less serious forms of mental ill-
biologists are describing the mechanics—some ness moderately reduce longevity. It appears that
 Mortality 557

even nonclinical elevations in anxiety and depres- the first question most often entails reorient-
sion moderately reduce longevity. ing away from selfish pursuits and beginning to
The relationship between mental illness and invest in the next generation. The seventh stage
mortality can be largely understood via the rela- is most meaningfully resolved when skill, knowl-
tionship between chronic stress and immunity. edge, wisdom, or experience can be transmitted
Recurrent, severe, and uncontrollable stress to a younger person in need. In this way, a legacy
depresses immune system functioning, inhibiting, of sorts is passed on. The eighth stage is most
for instance, the routine suppression of cancerous meaningfully resolved when satisfaction, success,
mutations. The chronic stress that is associated closure, or contentment are the feelings generated
with mental illness also reduces cardiovascular by retrospection. In this latest of stages, the life is
function, resulting in arteriosclerosis and hyper- in review. The past is evaluated and judged; the
tension. Further still, there are more direct means remaining time is spent examining whether all
by which the correlation between mental illness previous time was well spent. Successful resolu-
and mortality has become so alarmingly posi- tion of these stages softens the sting of mortal-
tive. Suicide, the 11th leading cause of death, also ity. Resignation rather than resentment swells the
significantly contributes to premature mortality heart of the dying.
among those who are mentally ill. Though some
are motivated to take their own life by conditions Scientific Perspectives on Mortality
such as chronic pain and terminal illness, 90 per- The aging of a body is often understood as the
cent of persons completing suicide have a diag- wearing out of a machine; cells, tissues, and
nosed mental illness. organs seem to wear out just as bearings, sprock-
Alternatively, just as mental illness curtails life, ets, and wheels. Despite the intuitive analogy,
so mental wellness prolongs life. Factors as various cells need not become exhausted and die. In the
as socialization, marriage, and vocational auton- beginning, all life replicated itself by simple fis-
omy have been positively associated with longev- sion. Each new generation was a clone of the pre-
ity; regular participation in religious services also vious generation. Until this point, death was not
appears to confer protective benefits. Even per- inevitable; these single-celled life forms did not
sonality seems to influence mortality. Most nota- ineluctably die. There was no internal clock wind-
bly, conscientiousness is positively correlated with ing down, ensuring the eventual degradation and
longevity. Much of this research is derived from death of these diminutive animalcules. Rather,
correlational studies using human participants, yet they starved, were eaten, and were destroyed.
many such findings are buttressed by experimental Only with the advent of sexual reproduction, it
research using animal subjects. For example, one appears, did senescence and death become inevi-
such study showed that rats given a mechanism by table. Evolutionary biologists are beginning to
which to cope with stress resisted human cancer question whether senescence and death is vital to
cells more effectively than those similarly treated the perpetuation of multicellular life. In this view,
but deprived of a coping mechanism. it is possible that death is an inevitable part of
life only if life is complex and sexually reproduc-
Eriksonian Reckoning ing. Therefore, death and sexual reproduction
Although fear of mortality peaks around middle appeared together in time; one seems to follow
age, it is the older person that most sincerely reck- the other.
ons with the coming end of life. There are two This relationship between mortality and multi-
questions that confront the aged: (1) Will I per- cellularity is consistent with the disposable soma
sist—in the pages of a book, the annals of his- hypothesis, which essentially states that bodies are
tory, or the heart of another—past the moment of expendable vehicles for the genes that construct
my death? (2) Have I led a worthwhile life? The them. It takes as its predicate that, as the biologist
first is the central question of Erikson’s seventh Richard Dawkins argues, selection acts at the level
stage, generativity versus stagnation; the second is of the gene more than it acts at the level of the
the central question of Erikson’s eighth stage, ego organism. Curiously, it is not the organism and its
integrity versus despair. Satisfactorily answering survival but the genome and its perpetuation that
558 Movies and Madness

is imperative. When sperm and egg merge, a new human condition, and this has also been true in
genome is formed; once formed, a time limit is set. the case of mental illness. People with mental
The clock winds down and all that is left is the illness have been shown in many films, such as
next generation. It is still not clear why the parent Fatal Attraction (1987) and the film series Rambo
organism cannot simply reproduce sexually but go (1982–2008) as being wildly and violently out
on living itself. Some have argued that the death of control. Curiously, movies may also have the
of the parent organism maximizes the reproduc- influence to create or maintain pathology. This
tive rate and therefore must evolve. In other words, seems to be an unintended consequence of many
those that did not evolve senescence and death were of the films about eating disorders. Film can also
outcompeted by faster-reproducing counterparts. promote understanding of mental illness and
No single theory of senescence and mortal- highlight the process of recovery.
ity has emerged dominant. While the mechanics
remain obscure, the process is obvious; salmon, Depiction of and Impact
swimming upriver, spawning, and fading are on Treatment and Providers
nature’s most conspicuous example of one gen- There are many examples of films that represent
eration dying so the next can live. the historically stark treatment of the mentally ill.
These range from the bleak and unnerving docu-
Steven Charles Hertler mentary The Titicut Follies (1967) to the fictional
College of New Rochelle account of a rebellious man who fights against
the oppressive hospital regime in One Flew Over
See Also: Life Course; Life Expectancy Trends; the Cuckoo’s Nest (1975), the film adaptation
Mind–Body Relationship; Religion; Self-Help; Sex; of Ken Kesey’s novel. Common themes include
Stress; Suicide; Women. horrific living conditions in overcrowded mental
institutions, abusive hospital staff, and rampant,
Further Readings indiscriminate use of procedures such as electro-
Ader, Robert. Psychoneuroimmunology. 4th ed. New convulsive therapy (ECT) and lobotomy. These
York: Elsevier Academic Press, 2007. films often reflect the sad history of mental health
Clark, William R. Sex and the Origins of Death. New care and portray mental institutions as terrifying
York: Oxford University Press, 1998. places where patients are literally at the mercy of
Medina, John J. The Clock of Ages: Why We Age, sadistic staff members. The 1948 film The Snake
How We Age, Winding Back the Clock. New Pit, which depicts overcrowding and indiscrimi-
York: Cambridge University Press, 1996. nate use of ECT, is an early example of how film
can impact public perception of mental health
care. The release of The Snake Pit alarmed many
viewers, shedding light on a topic that was largely
unknown and leading to mental health reforms
Movies and Madness aimed at improving hospital conditions.
The Titicut Follies, directed by Frederick Wise-
Cinema and mental illness have had a long and man, was shot in an institution for the criminally
rich relationship. Depictions of mental illness have insane and documents harsh and inhuman condi-
the potential to shape cultural views and at times tions. Patients are shown naked sleeping in com-
create or dispel stigma. A powerful and important pletely empty locked rooms. Guards dressed like
role of film has been to document treatment of police officers amplify the dehumanization, mock-
the mentally ill. Films have also influenced public ing patients who appear to have severe mental ill-
perception of mental health care and the need for ness. A patient named Jim is mocked and bullied
reform. Additionally, research has demonstrated by hospital guards, then shown being force-fed
that movies also have the power to influence how through a tube in his nose. This image is juxta-
medical students view psychiatric treatment. posed with later images of his body being pre-
Hollywood is of course synonymous with pared for burial after his death. The only kindness
creating larger-than-life representations of the comes when a guard accidentally jostles his coffin
 Movies and Madness 559

and says, “Sorry, Jim.” The documentary was Impact on Pathology: Eating Disorders
officially censored, which some sources contend A slew of films about eating disorders were
was because of the potential violation of patients’ released in the 1980s. Many of these were made
rights; others cite the unflattering depiction of a for television and have common themes, including
state facility as the reason. Though some of the a beautiful young woman who is a high achiever
footage is difficult to watch, this documentary is both academically and athletically. Often these
an important account of abuses that occurred in films portray an overcontrolling mother who does
modern history. not allow her child to make decisions. The child
A famous depiction of ECT treatment occurs in these films is portrayed as suppressing her emo-
in One Flew Over the Cuckoo’s Nest, which por- tions for the good of the family and exerting con-
trays mental institution patients who endure ECT trol over dieting as a way to be in charge of one
and lobotomy as punishments when they fail to aspect of her life.
conform. The hero of the ward, played by Jack Movies about eating disorders may be used by
Nicholson, attempts of flout the vice grip of the those suffering from this form of mental illness
emasculating head nurse. His nonconformity as what is termed thinspiration. These movies
results in the ultimate punishment, a lobotomy are often available as “proana,” short for pro-
that robs him of his personality. anorexia material on Web sites created by people
Frances (1982), the film biography of the actress with eating disorders to inspire others to continue
Frances Farmer, provides a similar, though more to starve themselves. Other examples of proana
terrifying, portrayal of mental institutions. Though material are abundant and can include short
the movie is purportedly based on Farmer’s insti- video montages of images of emaciated or air-
tutionalization in the 1940s, many aspects of the brushed models with the inclusion of quotes that
film are controversial and thought to be highly are intended to help people persist in their disor-
inaccurate. While in a state institution, Frances dered eating. Comments on proana sites are often
is subjected to insulin shock treatment to induce written by very young women looking for friends
seizures, gang raped by a group of soldiers who to help collude in their disordered eating.
pay $20 to a guard to have sex with her, and even- Many of the movies about eating disorders
tually lobotomized. The conditions of the hospi- may be triggering for others who are trying to
tal are deplorable. Frances is shown sleeping in control their problem or may even prompt new
an overcrowded room surrounded by loud, wail- cases of eating disorders. These films may teach
ing women. While there is no evidence or record young women and men how to have an eating
that the rape or lobotomy were actually inflicted disorder, including “tricks” for weigh-ins, exer-
on Farmer, it is notable that 300 lobotomies were cising late at night, cutting food into small pieces,
actually performed at the mental intuition depicted and dressing to hide weight. This seems to be
in the film. There are contentions about the accu- an unintended, though not unforeseeable, con-
racy of what happened to Farmer herself, but little sequence of portraying young women with eat-
has discredited the representation of patient care. ing disorders as affluent, attractive, popular, and
Her story was also depicted in the black-and-white academically gifted as exemplified in films such
documentary Committed (1983). as The Best Little Girl in the World and Sharing
In a 2002 study, over one-third of medical stu- the Secret. These films also attempt to represent
dents who watched scenes from popular films that the seriousness of eating disorders and frequently
depicted ECT endorsed a decrease in support for include hospitalization, forced feeding, and the
the procedure. Students in this study also dem- death of minor characters from their disorder.
onstrated differences before and after viewing the Family therapy sessions are often highlighted in
films, indicating that they would be less likely to these films as a key aspect of treatment.
recommend ECT to a family member or friend Mother blame is a frequent theme in movies
after viewing the films. There was also a signifi- about mental illness of all types. In the case of
cant difference in how likely these students were movies about eating disorders, mothers are rep-
to advise against the use of ECT after seeing the resented in a damning way, telling their daugh-
film clips. ters that they should diet or reward them for
560 Movies and Madness

losing weight. Another common theme is denial this film does contain a great deal of mother
of the problem by the mother when confronted by blame, portraying a distant, emotionless woman
neighbors or friends. This portrayal also ignores who does not love or have empathy for her son.
ethnic and gender variation in eating disorders. Martha Marcy May Marlene (2011) offers a
very different picture of PTSD as it is experienced
Impact on Stigma: Post-Traumatic by a young woman who escapes from a cult to
Stress Disorder return to her family. The main character avoids
While film representations of post-traumatic talking about where she’s been, and her sister and
stress disorder (PTSD) were often made with the brother-in-law have little empathy for her unusual
good intention of shedding light on a condition behavior. She displays classic symptoms of PTSD,
that was misunderstood and undertreated, these including hypervigilance. It is at times difficult for
same representations may have actually resulted viewers to distinguish reality from her symptoms.
in increased stigma and fear of those with the con- This film is a haunting representation of what life
dition. Film series such as Rambo depict Vietnam- might be like for a survivor of trauma and former
era war veterans as violent and dangerous. The cult member.
Deer Hunter (1978) provides another disturbing, Don’t Say a Word (2001) also offers a bal-
and at times difficult to watch, interpretation of anced representation of a traumatized adolescent
traumatized Vietnam veterans who seem hope- coping with PTSD Symptoms. Other movies that
lessly and permanently damaged. While these more thoughtfully depict coping with trauma
films may have been created with the intention include Reign Over Me (2007) and Antwone
of bringing needed awareness to a difficult topic, Fisher (2002).
they may have also helped foster the myth that
PTSD is incurable and increased stigma for vet- Impact on Stigma: Personality Disorders
erans who were often confronted with hostility There are many well-known films featuring per-
when they returned home. sonality-disordered characters, including Fatal
Captain Newman, M.D. (1963) is an exam- Attraction, Single White Female (1992), A Clock-
ple of an earlier and less stigmatizing film about work Orange (1971), Taxi Driver (1976), and
PTSD. Gregory Peck plays a U.S. Air Force psy- Compulsion (1959). These films often have vio-
chiatrist treating World War II veterans in a locked lent themes and offer disturbing portrayals of
hospital ward. Interestingly, the patients are given personality disorders. Compulsion, for example,
“flak juice” (sodium pentathol) and asked to is an intriguing representation of the murder and
recall their traumas in what appears to be a very trial of Richard Loeb and Nathan Leopold. In a
crude version of prolonged exposure treatment. display of narcissism and psychopathy, two main
In one scene, Peck also demonstrates a version of characters kill a child because they want to see if
Socratic questioning to help a patient overcome they can commit “the perfect crime.” This film
feelings of trauma-related guilt. Though one ultimately attests to the value of all human beings
patient commits suicide by jumping from a tower, regardless of their actions.
the film offers a more hopeful picture for trauma- Borderline personality disorder (BPD) does not
tized war veterans. fare as well in film. BPD, a treatable condition
Other balanced representations of PTSD that often results from prolonged traumatic expe-
include Ordinary People (1980), about an adoles- riences and invalidating environments, is sadly a
cent who attempts suicide after his brother dies in highly stigmatized condition. Fatal Attraction and
a boating accident. He is a sympathetic character Single White Female are examples of suspenseful,
who displays feelings of self-blame associated with entertaining films that are a scathing indictment
the trauma and has distressing nightmares. He of people with this diagnosis.
becomes avoidant of social situations, loses inter- The classic film Gone With the Wind (1939) is
est in sports, and has a hard time concentrating often cited as a representation of histrionic per-
in school. His therapist helps him to discuss the sonality disorder. The character Scarlett O’Hara
trauma and his unrealistic feelings of guilt, and he has been held up as the quintessential definition
seems to improve by the end of the film. However, of the disorder, which is no longer included in the
 Movies and Madness 561

Diagnostic and Statistical Manual of Mental Dis- demonstrated when Nash asks a student if she
orders (DSM) after meeting with long-standing can also see the person who is speaking to him.
criticisms of gender bias. In real life, Nash suffered from auditory halluci-
nations and possible delusions instead of visual
Recovery-Focused Films hallucinations.
From the classic movie David and Lisa (1962) Another example of a film based on life is Shine
to the more modern film The Soloist (2009), rep- (1996), which portrays the life of David Helfgott,
resentations of severe mental illness (SMI) have the brilliant pianist. Helfgott’s diagnosis is usually
been present in movies for many decades. These listed as schizoaffective disorder and described
portrayals can offer balanced perspectives and as difficult to pin down, although it is predomi-
attempt to represent challenges in living related nantly manic in presentation. Helfgott himself is
to SMI. Some of these representations are more portrayed as a loving and exceptionally friendly,
realistic than others. humble man who demonstrates pressure of speech
An excellent example is A Beautiful Mind and seems to thrive in the presence of others.
(2001), a film about the life of mathematician The film Silver Linings Playbook (2012) relates
John Nash, known for his work in game theory. the story of a man with bipolar disorder as he is
The film deals with the impact that Nash’s para- discharged from a mental institution. His father,
noid schizophrenia diagnosis has on every aspect played by Robert De Niro, has obsessive-compul-
of life. In one scene, reality testing is beautifully sive disorder. This film has a recovery focus and
highlights family support.
Serious mental illness has also been represented
in documentaries, including People Say I’m Crazy
(1989) and The Devil and Daniel Johnston
(2005). People Say I’m Crazy is the only known
movie about schizophrenia made by someone
with the disorder, John Cadigan, a man who says
he experienced his first psychotic break with real-
ity as a 21-year-old art student. This film pow-
erfully portrays problems encountered by people
with SMI, including frightening medication side
effects, stigma, housing and work difficulties, and
family impact. The film follows him through-
out the process of obtaining his own apartment.
There are disappointments and setbacks, but
there is also determination and a strong recovery
focus. The Devil and Daniel Johnston is another
documentary about the visionary musician and
artist Daniel Johnston. As is typical with many
people who have this diagnosis, his bipolar dis-
order was undiagnosed during early adulthood.
The film highlights Johnston’s many achievements
through a combination of home movies and films
of his performances.

Mental Illness as Entertainment

Other forms of mental illness have been depicted
Bo Goldman (left) and Michael Douglas on the set of Milos in film primarily for entertainment. Examples
Forman’s One Flew Over the Cuckoo’s Nest, May 17, 1975. include portrayals of dissociative disorders,
The film depicted the fictional account of a rebellious man who delusions, depression, and obsessive-compulsive
fights against an oppressive mental hospital regime. disorder.
562 Movies and Madness

Dissociative disorders. Early black-and-white with many allusions to her novel, Mrs. Dalloway.
features about mental illness were often based There are three separate but connected stories
on psychodynamic theory and portray amnesiacs about people living with mood disorders who
who have suffered a traumatic event and were have been impacted by suicide. Woolf’s own con-
completely cured once they reached catharsis finement to her home, which was ordered by her
under the guidance of a dedicated psychiatrist. doctors after prior suicide attempts, is portrayed.
The Hitchcock classic Spellbound (1945) is one In addition to illuminating the pain and isolation
example. A similar process occurs in the classic of depression, this film captures a sort of sorrow
movie The Three Faces of Eve (1957), based on that is linked with the slowed speed of life that
the account of a woman with a dissociative iden- can surround depression.
tity disorder diagnosis. This film is an example of
a psychodynamic cure in that Eve is immediately Obsessive-compulsive disorder. Obsessive-com-
“cured” when two of her personalities “die,” pulsive disorder (OCD) is represented in film
with the most intact personality remaining in con- with varying levels of accuracy. One example is
trol upon Eve recalling her childhood trauma of The Aviator (2004), based on the life of Howard
having to kiss the body of her dead grandmother Hughes, who is portrayed grappling with dis-
at her funeral. Sybil (1976), also based on a living abling struggles related to his diagnosis. As Good
person, details a longer process of psychotherapy as It Gets (1997) is often associated with OCD,
and the integration of her alter personalities. The although it might be a more accurate portrayal of
movie documents the severe childhood trauma obsessive-compulsive personality disorder. Mel-
that led to her condition. vin Udall, acted by Jack Nicholson, struggles with
More fictionalized portrayals of dissociation any minor deviation in his schedule.
occur in films such as Nurse Betty (2000), a dra- A significant portrayal of childhood mental ill-
matization of dissociative fugue. Another imagi- ness can be observed in the film Phoebe in Won-
native portrayal of dissociation as the result of derland (2008). The main character has diagnoses
trauma is seen in David Lynch’s psychological hor- of Tourette syndrome and OCD. Phoebe struggles
ror film Twin Peaks: Fire Walk With Me (1992). with lack of acceptance from her peers, difficulty in
everyday situations, and many misunderstandings.
Delusions. He Loves Me . . . He Loves Me Not This film challenges outdated themes that moth-
(2002) skillfully tackles the subject of erotomanic ers are responsible for all mental illness and could
delusions. The first half of the movie is shown be used educationally by providers. Though not a
from the perspective of Audrey Tautou, who plays movie, the HBO series Girls (2012– ) offers one
a woman who believes she is having a relationship of the most realistic portrayals available of OCD.
with a married doctor. The film then starts again Girls depicts OCD as it truly is—a life-disrupting
from the beginning of the story, with the second condition that causes immense anxiety and pain
half shown from the perspective of reality. This for those with the diagnosis.
film provides significant insight about delusional
disorders. Charity Wilkinson
University of Texas Health Science Center,
Depression. The subject of depression also has a San Antonio
frequent presence in cinema. Two examples are
Splendor in the Grass (1961) and The Hours See Also: Fiction; Internet and Social Media; Mass
(2002), which provide sympathetic portrayals of Media; Popular Conceptions; Psychoanalysis and
characters with mood disorders. Splendor in the Popular Culture; Public Education Campaigns;
Grass is a classic film that follows the life of a Television; Unquiet Mind, An.
popular young woman who is heartbroken and
depressed after a breakup. Natalie Wood plays Further Readings
the main character who is hospitalized follow- Abramson, L. “Staff Sgt. Bales Case Shows Stigma,
ing a suicide attempt. The Hours is a dramatiza- Paradox of PTSD.” NPR (March 28, 2012). http://
tion of Virginia Woolf’s depression and suicide m.npr.org/story/149526314 (Accessed June 2003).
 Munchausen Syndrome 563

Biography. “Frances Farmer Biography.” http://www After presenting a fictitious medical history,
.biography.com/people/frances-farmer-9542364 individuals with this syndrome may simulate
(Accessed June 2013). symptoms, aggravate a pre-existing condition,
IMBd. “Synopsis for ‘A Beautiful Mind’ (2001).” or self-induce an illness. Presenting symptoms
http://www.imdb.com/title/tt0268978/synopsis often consist of feigned or self-induced infections,
(Accessed June 2013). wounds, pain, hypoglycemia, anemia, bleeding,
Kehr, Dave. “Film in Review: ‘People Say I’m Crazy.’” skin conditions, neurological issues, respiratory
New York Times (April 30, 2004). http://www. distress, vomiting, diarrhea, fevers of unknown
nytimes.com/2004/04/30/movies/film-in origin, and symptoms associated with autoim-
-review-people-say-i-m-crazy.html (Accessed mune or connective tissue diseases. The economic
June 2013). cost of MS is high because of potential worker
Reaves, J. “Anorexia Goes High Tech.” Time (July 31, absenteeism, loss of employment, forced retire-
2001). http://www.time.com/time/health/article/ ments, need for daily living assistance, and overall
0,8599,169660,00.html (Accessed June 2003). medical costs.
Walter, G., A. McDonald, J. M. Rey, and A. Rosen. While epidemiological studies have focused on
“Medical Student Knowledge and Attitudes the United States and western Europe, there are
Regarding ECT Prior to and After Viewing ECT case reports of factious disorders from eastern
Scenes From Movies.” Journal of ECT, v.18/1 Europe, Mediterranean countries, Asia, Africa,
(2002). and South America. Prevalence rates are difficult
Wedding, D. and M. A. Boyd. Movies and to ascertain because the same individuals likely
Mental Illness: Using Film to Understand visit multiple hospitals. Higher prevalence is seen
Psychopathology. 3rd ed. Cambridge, MA: among men than women, and its onset is typically
Hogrefe, 2010. in adulthood. “Munchausen by Internet” applies
Zimmerman, Jacqueline Noll. People Like Ourselves: to individuals who join social networking sites or
Portrayals of Mental Illness in the Movies. support groups by feigning illness or trauma to
Lanham, MD: Scarecrow Press, 2003. solicit the sympathy and support of others.
The psychological causes of MS remain rela-
tively unknown, though childhood trauma (e.g.,
physical and sexual abuse, or placement in foster
care); poor self-esteem; inadequate coping skills;
Munchausen Syndrome family dysfunction; and personality, mood, and
anxiety disorders appear to be contributing fac-
Dr. Richard Asher coined the term Munchausen tors. From a medical anthropological perspec-
syndrome (MS) in 1951 to describe cases where tive, MS lies at the end of a continuum of (mal-)
individuals intentionally feign physical or psy- adaptive (though not necessarily pathological)
chological symptoms to chronically maintain a parenting behaviors caused by unmet needs (e.g.,
sick role. Named after Baron von Münchhausen, extreme poverty). From a framework of a perfor-
known for his fantastical stories of being a hunter mative illness, individuals with MS have a com-
and soldier, this disorder includes the manipula- pulsive need to perform, wherein they have stud-
tion of one’s body to initiate attention and medi- ied illnesses with a commitment similar to that
cal interventions in the absence of external incen- of a method actor. Models of institutional sado-
tives (e.g., extended work leave). According to masochism suggest that the patient’s role-playing
the International Statistical Classification of Dis- ultimately disrupts the doctor–patient attachment
eases, 10th revision (ICD-10) and the Diagnos- (i.e., breaches trust) and undermines the doc-
tic and Statistical Manual of Mental Disorders, tor’s authority (i.e., by defying diagnosis through
fourth edition (DSM-IV-TR), MS is an extreme deception) within the doctor–patient relationship.
manifestation of a factitious disorder character- The prognosis for individuals with MS is typi-
ized by chronic feigned or simulated illness, visits cally poor. A therapeutic confrontation between
to various medical facilities (peregrination), and physician and patient, with the help of a psy-
pathological lying (pseudologia fantastica). chiatrist, is sometimes recommended; however,
564 Munchausen Syndrome

confrontation is typically met with denial and to years. While induced apnea (respiratory arrest)
defensive behaviors, resulting in the patient leav- is common in MSbP cases throughout the United
ing and presenting his or her symptoms elsewhere. States and UK, it is not frequently noted in other
countries; this discrepancy may reflect individuals’
Munchausen Syndrome by Proxy exposure to respiratory processes and the diligence
In 1977, the term Munchausen syndrome by with which respiration is monitored. Prevalence
proxy (MSbP) was coined to describe a form of rates also vary based on how medical professionals
child abuse in which individuals (usually mothers) discriminate between spontaneous apnea, sudden
induce or fabricate physical ailments in another infant death syndrome (SIDS), and MSbP.
person who is under their care (typically a child) Maternal thinking and practices are embedded
for the purpose of maintaining contact with medi- in social and economic contexts; therefore, par-
cal professionals, indirectly assuming the sick enting expectations (e.g., idealizations of uncon-
role, and receiving psychological benefit from ditional mother-love), death beliefs (e.g., the pag-
their actions. While MSbP is characterized by the eantry associated with death, or the acceptance
DSM-IV-TR as a factitious disorder by proxy, of infanticide), the cultural value of suffering,
there remains disagreement in the psychiatric field and one’s quality of life are considered in medi-
about its diagnostic criteria (e.g., whether the cal anthropological explanations of MSbP. Most
focus should be on the abuser or the abuse) and cross-cultural explanations of MSbP refer to
the degree to which MSbP is a culturally bound parental psychopathology, though some empha-
and socially constructed pathology. size psychodynamic etiology (e.g., doctors seen as
MSbP has been reported in 52 countries, father figures, or children serving as transitional
though most reports come from economically objects of the parent–physician relationship), the
advantaged areas. Most of the approximately influence of family relationships (e.g., personal
700 cases of MSbP are from the United States, history of child abuse, and paternal disengage-
Canada, the United Kingdom, Australia, and ment), the role of depersonalized Western medical
New Zealand, though cases have also been noted practices, or psychiatric comorbidity (e.g., depres-
in Israel, Europe, South and Central America, sion, personality disorders, and lack of empathy).
Africa, Saudi Arabia, and Asia. Targets of decep- Proposed sources of motivation include attention-
tion may be religious or political leaders, phar- seeking as the child’s rescuer, newfound life pur-
macists, or folk healers in regions where medical pose, or social bonding with the hospital staff.
help is not readily available. There is a scarcity of Many MSbP perpetrators have some medical pro-
prevalence estimates because MSbP is difficult to fessional training, a strong interest in health care,
detect and is inconsistently reported in discharge and a history of exhibiting MS.
summaries. Reporting and detection depends on Allegations of MSbP should be examined by
the perceived severity of the case, the degree of multidisciplinary teams. Initial action, through
MSbP awareness, structure of the health system child protection, is typically taken by the legal
(e.g., focus on history taking), societal expecta- system. After the protection of the child is estab-
tions of parenting, legal and justice systems, and lished, long-term psychological therapy is rec-
child protection laws (or lack thereof). Within the ommended. However, few perpetrators persist
United Kingdom and Ireland, prevalence rates in such therapies. Decisions to remove children
are 2.8 per 100,000 children (for children under from parental custody are grounded in legal and
age 1) and 0.5 incidents per 100,000 (for chil- economic systems, which vary across countries.
dren younger than 16 years of age). Conservative Investigators are urged to complete thorough
prevalence rates in the United States are approxi- medical investigations, with the consideration of
mately 136 new cases per year. alternative medical explanations, to avoid misdi-
Male and female children are victimized at equal agnosis, false accusations, and the potential delay
rates. While the average age of abuse discovery of necessary medical care.
is 39.8 months, more preverbal than verbal chil-
dren are victims. The duration of abuse averages Ariane Schratter
14.9 months, though duration ranges from days Maryville College
 Munchausen Syndrome 565

See Also: Children; Eating Disorders; Internet and Day, Deborah O. and Robert L. Moseley.
Social Media; Mind–Body Relationship; Placebo “Munchausen by Proxy Syndrome.” Journal of
Effect; Self-Help; Self-Injury; Somatization of Distress. Forensic Psychology Practice, v.10 (2010).
Feldman, Marc D. and Rachel M. A. Brown.
Further Readings “Munchausen by Proxy in an International
Damasio, A. Descartes’ Error: Emotion, Reason, and Context.” Child Abuse and Neglect, v.26 (2002).
the Human Brain. London: Putnam Publishing, Kannai, Ruth. “Munchausen by Mommy.” Families,
1994. Systems, & Health, v.27/1 (2009).
Cultural Sociology of
M E N TA L
ILLNESS
Cultural Sociology of
M E N TA L
ILLNESS
An A-to-Z Guide

VOLUME 2

ANDREW SCULL
EDITOR
University of California, San Diego
 N
National Alliance illness had been the dominant perspective within
American psychiatry. Many forms of mental ill-
on Mental Illness ness had been portrayed as originating in patho-
logical aspects of family life, and mothers in par-
The National Alliance on Mental Illness (NAMI), ticular had been pictured as playing a primary role
founded in 1979, was originally known as the in the disturbances of their offspring. Autism was
National Alliance for the Mentally Ill. Over time, blamed on “refrigerator mothers” whose emo-
it has been organized at the national, state, and tionally frozen state (or “genuine lack of maternal
local levels and has developed chapters all across warmth,” as Leo Kanner put it in a seminal paper
the United States. It has become a powerful lob- in 1949) irretrievably damaged the psyches of
bying group, often testifying in congressional their infants and small children. Likewise, schizo-
hearings and actively attempting to influence phrenia was often traced back to the impact of
public discourse about mental illness. It claims “schizogenic” parenting patterns. Such theories,
to be the largest grassroots organization con- though resting upon slender evidentiary founda-
cerned with mental health issues in the country, tions, provoked widespread feelings of guilt and
with some 1,200 local affiliates operating in all 50 blame and prompted a search for alternatives.
states, Puerto Rico, and the District of Columbia. The re-emergence of an account of mental ill-
It regularly seeks to influence media coverage of ness that stressed that mental illness was an ill-
mental health issues and stresses biomedical inter- ness like any other, rooted in brain abnormali-
pretations of mental illness. As an example of its ties that were either genetic or the product of
influence, President Bill Clinton appointed its biochemical imbalances and neurotransmitter
executive director, Laurie Flynn, to the National defects, had obvious attractions for families. In
Bioethics Advisory Commission. turn, biological explanations of this sort were
increasingly closely tied to the psychiatric profes-
Rise of the Psychiatric Perspective sion’s growing reliance on psychopharmacology
NAMI emerged just as American psychiatry was as its primary treatment modality, as chemicals
moving decisively away from the psychodynamic could alter the internal physiological environ-
views of the origins of mental illness. Between ment. NAMI thus quickly came to endorse bio-
World War II and the end of the 1970s, psycho- logical explanations of mental disorder. Its mem-
analytical treatments and explanations of mental bership was increasingly vocal about the merits

567
568 National Alliance on Mental Illness

New York political reporter and talk show host Dominic Carter speaks at a National Alliance on Mental Illness (NAMI) “Walk Against
Stigma” in Lower Manhattan, May 10, 2008. Carter’s mother suffered from schizophrenia. NAMI is mostly comprised of parents and
other family members of the mentally ill. It has become a powerful lobby for influencing public discourse about mental illness.

of drug treatments for the whole spectrum of industry and became a powerful voice apparently
mental disorders. The drug industry naturally speaking for the mentally ill, though its real con-
welcomed this powerful and seemingly indepen- stituency was rather different: families attempt-
dent endorsement of its products and has done ing to cope with the impact of mental illness on
much to publicize NAMI’s views. their own functioning. Patient activists who form
part of the consumer-survivor movement have
Controversy been particularly active in criticizing NAMI, and
Its name notwithstanding, NAMI is mostly com- it has been equally critical of them in turn, accus-
prised of parents and other family members of ing them of taking extremist antipsychiatric posi-
the mentally ill, not mental patients themselves. tions, of ignoring medical science, and of contrib-
It has identified strongly with medical models of uting to increased morbidity and mortality among
mental disorder and has lobbied hard and effec- the mentally ill.
tively for additional funding for research on the In 1999, Mother Jones published a lengthy
neuroscientific basis of mental illness. It has long article alleging that a large fraction of the orga-
promoted the value of psychopharmacological nization’s budget was provided by a number of
approaches to the management of mental illness pharmaceutical companies. One of NAMI’s high-
and has actively sought to spread a biologically level administrators, it transpired, was “on loan”
reductionist interpretation of mental illness as from Eli Lilly and Company. These revelations
brain disease. In doing so, it provided an appar- cast serious doubt on the organization’s indepen-
ently disinterested support for the pharmaceutical dence. The fact that it had actively promoted the
 National Institute of Mental Health 569

value of the medications marketed by the very illnesses through basic and clinical research, pav-
organizations that underwrote much of its opera- ing the way for prevention, recovery, and cure.
tions caused it to be viewed with suspicion, and As ways of accomplishing this mission, NIMH
this provided ammunition for patient activists must foster innovative thinking and ensure that a
who had long taken issue with its stance. Sena- full array of novel scientific perspectives are used
tor Charles Grassley (R–Iowa) revisited this issue to further discovery in the evolving science of
in 2009 as part of a broader investigation of the brain, behavior, and experience, hopefully lead-
ties between the academy and the pharmaceuti- ing first to breakthroughs in science that later
cal industry, and established that as much as 60 become breakthroughs for all people with mental
percent of NAMI’s budget was underwritten by illnesses.
these companies. NIMH is one of 27 institutes and centers that
make up the National Institutes of Health (NIH).
Andrew Scull NIMH is the largest research organization in the
University of California, San Diego world specializing in mental illness. The agency
has a budget of $1.5 billion, used for support-
See Also: Antipsychiatry; Consumer-Survivor ing research on mental health through grants to
Movement; Ethical Issues; Legislation; Marketing; investigators at institutions and organizations
Medicalization, History of; Pharmaceutical Industry. throughout the United States and through its own
internal (intramural) research effort. In recent
Further Readings years, the agency has become particularly well
Arieti, Silvano. The Interpretation of Schizophrenia. known for studies of genetics, neuroscience, and
2nd ed. New York: Basic Books, 1974. clinical trials of psychiatric medication.
Harris, Gardiner. “Drug Makers Are Advocacy
Group’s Biggest Donors.” New York Times Creation, Growth, and Organization
(October 21, 2009). Prior to World War II, mental health had tradi-
Kanner, Leo. “Problems of Nosology and tionally been a state responsibility. After the war,
Psychodynamics in Early Childhood Autism.” there was growing interest in a national initiative
American Journal of Orthopsychiatry, v.19 (1949). in mental health. Attempts to create a National
Silverstein, Ken. “Prozac.org.” Mother Jones Neuropsychiatric Institute failed, but the head of
(November–December 1999). http://www the federal Division of Mental Hygiene pushed
.motherjones.com/politics/1999/11/prozacorg for the inclusion of mental health policy as an
(Accessed July 2012). integral part of federal biomedical policy. The
National Mental Health Act was signed into law
in 1946 with the goal of supporting the research,
prevention, and treatment of psychiatric illness.
The establishment of a National Advisory Mental
National Institute Health Council and NIMH were part of this act.
On April 15, 1949, NIMH was formally estab-
of Mental Health lished. Funding for NIMH grew slowly, increas-
ing from the mid-1950s on. In 1955, the Mental
The National Institute of Mental Health (NIMH) Health Study Act called for “an objective, thor-
has a long and interesting history, with shifting ough, nationwide analysis and reevaluation of the
locations within the federal bureaucracy. These human and economic problems of mental health.”
locations have also represented shifts within the This led to the establishment of the Joint Com-
overall mission of NIMH. What has remained mission on Mental Health and Illness. That group
true from the founding of the organization in issued a report, “Action for Mental Health,”
1946 is the research component of the agency, which was the background for President John F.
while the service component is no longer a part Kennedy’s special message to Congress on mental
of NIMH. Today, its stated mission is to trans- health that eventually resulted in the establish-
form the understanding and treatment of mental ment of a cabinet-level interagency committee to
570 National Institute of Mental Health

examine the recommendations and determine an the new structure, important studies such as the
appropriate federal response. Epidemiologic Catchment Area (ECA) study were
In 1963, Congress passed the Mental Retar- established to help provide an accurate picture of
dation Facilities and Community Mental Health rates of mental and addictive disorders and ser-
Centers Construction Act, ushering in a new era vices usage. Social scientists and epidemiologists
in federal support for mental health services. played a very important role in this study, which
NIMH assumed responsibility for monitor- was one of the first to provide accurate pictures
ing the nation’s community mental health cen- of rates of mental and addictive disorders and
ters (CMHC) programs. Training grants in the services usage for those problems.
social sciences were an important activity within As part of the creation of block grants to the
NIMH in these earlier years and were one of the states in 1981 under the Omnibus Budget Rec-
major sources of training funds in the social sci- onciliation Act, the Mental Health Systems Act
ences, as the more physical-disease-oriented NIH was repealed and the federal role in services to
institutes did not generally fund training in the the mentally ill became that of technical assis-
social sciences. tance to state and local providers. ADAMHA was
Later in the mid-1960s, NIMH began a cam- abolished in 1992, separating the services compo-
paign on special mental health problems, par- nents of NIMH from the research components.
tially as a response to President Lyndon John- The service components became part of the Sub-
son’s promise to apply scientific research to social stance Abuse and Mental Health Services Admin-
problems. NIMH established centers for research istration, and the research components on NIMH
on schizophrenia, child and family mental health, were returned to NIH. At that time, new offices
suicide, crime and delinquency, minority group were created for research on Prevention, Special
mental health problems, urban problems, and, Populations, Rural Mental Health, and AIDs.
later, rape, aging, and technical assistance to vic- By 1993, NIMH established the Silvio O.
tims of natural disasters. Alcohol abuse and alco- Conte Centers program, which had a focus on
holism received full recognition as major pub- the pursuit of a unified research framework for
lic health problems in the mid-1960s, when the collaboration that looked mostly at hypotheses
National Center for Prevention and Control of of brain-behavior relationships in mental illness.
Alcoholism was established as part of NIMH. In In the same time frame, NIMH established the
the same time period, a research program on drug Human Brain Project to focus on cutting-edge
abuse was inaugurated within NIMH with the imaging, computer and network technologies,
establishment of the Center for Studies of Nar- and neuroscience databases, a shift away from
cotic and Drug Abuse. By the early 1970s, sepa- more social-science-oriented approaches and to
rate Institutes of Alcohol Abuse and Alcoholism more biological-psychiatry approaches.
and Drug Abuse were established within NIMH.
Again, many of these new centers had important Current Focus
social science components. Some of the important parts of NIMH today
Between 1967 and 1992, many shifts in are the clinical trials and biostatistics unit, dif-
the location of NIMH and its responsibilities ferences between intramural and extramural
occurred. In 1967 and 1968, NIMH was sepa- research, and programs on mood and anxiety
rated from NIH and given bureau status within disorders. Within NIMH there is a clinical trials
the Public Health Service and as a component of operation and biostatistics unit that serves as the
the Health Services and Mental Health Admin- operations focal point for collaborative clinical
istration, although the intramural research pro- trials on mental disorders in adults and children.
gram remained jointly administered by NIH and This group has the responsibility for both opera-
NIMH. When the Health Services and Mental tions and oversight of both contract-supported
Health Administration was abolished in 1973, and cooperative-agreement-supported multi-
NIMH temporarily rejoined NIH, but then site clinical trial protocols. The unit has general
ADAMHA (the Alcohol, Drug Abuse, and Men- leadership responsibility for overarching matters
tal Health Administration) was created. Within related to clinical trials operations such as the
 National Institute of Mental Health 571

coordination of the ancillary protocols across the other than NIMH, mostly in U.S. universities)
large trials, development of long-term strategies is divided into five different divisions. New pro-
for clinical trials research, and improvement of grams on mood and anxiety disorders were cre-
the quality of clinical trials. The group also pro- ated in 1994. In 1997, NIMH realigned its extra-
vides consultation to NIHM staff and grantee/ mural organization into three research divisions:
contractor staff on biostatistical matters related Basic and Clinical Neuroscience Research; Ser-
to appropriateness of study design, determina- vices and Intervention Research; and Mental Dis-
tion of power and sample size, and approaches orders, Behavioral Research, and HIV/AIDS.
to statistical analysis of data from clinical trials Between 1997 and 1999, NIMH refocused
supported by NIMH. career development resources on early careers and
While intramural research has always been a added more focus on clinical research. Additional
focus within NIMH and has often been subject organizational change since 2002 means NIMH
to changes and reorganizations across its his- has expanded from three extramural divisions to
tory such as a major review in the late 1990s, five, with the two new divisions focusing on adult
extramural research has also been an important and child translational research and continuing
responsibility of the agency as well as the subject the increased focus on childhood mental disorders
of various reorganizations. that was also noted in intramural research. The
While all of the different changes in intramu- last decade has focused on new genetic advances
ral research within NIMH are too complex to and bioimaging methodologies to increase under-
trace, today the different intramural research standing of mental disorders.
groups include fundamental neuroscience, neu- Today’s areas of focus are reflected in divisions
roadaptation and protein metabolism, behavioral such as the Neuroscience and Basic Behavioral
endocrinology, experimental therapeutics and Science, Adult Translational Research and Treat-
pathophysiology, neurobiology and treatment of ment Development, Developmental Translational
mood disorders, development and affective neu- Research, AIDS Research, and Services and Inter-
roscience, developmental genetic epidemiology, vention Research.
molecular imaging, radiopharmaceutical sciences, An important recent initiative in collaboration
neuroimaging sciences, lab behavioral neuro- with the U.S. Army is the Study To Assess Risk and
sciences, molecular and cellular neurobiology, Resilience in Servicemembers (STARRS), a Fram-
directed gene transfer, experimental therapeutics ingham-like effort scheduled to continue through
and pathophysiology, pharmacology, neuroendo- 2014. Many challenges to the understanding of
crine immunology and behavior, veterinary medi- sciences linked to mental illness and translation of
cine and resources, child psychology, childhood research to clinical application remain.
neuropsychiatric disorders, clinical brain disor-
ders, developmental brain imaging, clinical stud- Jennie Kronenfeld
ies, neuropathology, integrated neuroimaging, Arizona State University
neuropsychology, neurobiology of learning and
memory, neural coding and computation, cogni- See Also: American Psychiatric Association; American
tive neuroscience, clinical neuropharmacology, Psychological Association; National Alliance on
brain and cognition, functional imaging meth- Mental Illness; Policy: Federal Government; Psychiatry
ods, cellular and molecular regulation, molecular and Neuroscience; Psychopharmacological Research;
neuroscience (neural), gene expression, and other World Health Organization.
even more specialized programs and laboratories.
Most of the intramural research is part of a bio- Further Readings
logical psychiatry and neurosciences approach, National Institute of Mental Health. http://www.nimh
not a social science approach. There has been .nih/gov (Accessed October 2012).
increased priority placed on childhood mental National Institute of Mental Health. “NIH Almanac/
disorders. The Organization” (2012). http//www.nimh.gov/
Currently, the focus of extramural research about/almanac/archive/1999/organization/nimh/
(research conducted by scientists at locations history (Accessed October 2012).
572 Nazi Extermination Policies

Pickren, Wade E. and Stanley F. Schneider, eds. Sterilization Programs

Psychology and the National Institute of The sterilization program was enforced start-
Mental Health: A Historical Analysis of Science, ing in 1933 and was approached from a public
Practice, and Policy. Washington, DC: American health perspective. The program, the “Law for
Psychological Association, 2004. the Prevention of Genetically Defective Progeny,”
received support from geneticists and eugenicists.
Sterilizations were targeted at a range of condi-
tions including schizophrenia, muscular dystro-
phy, epilepsy, alcoholism, deafness, blindness, and
Nazi Extermination physical deformities. In addition to diagnosable
conditions, Germany also targeted the “weak-
Policies minded.” The rationale for this law was based
on the state’s responsibility to ensure that only fit
Adolf Hitler and the Nazi party came to power individuals produced children.
in Germany in 1933. The regime emphasized In addition, the sterilization policies, the Nazi’s
notions of racial purity and racial “hygiene.” Ini- prohibited marriages between individuals who
tially, with respect to the mentally ill, these led were labeled as having negative eugenics, or
to the adoption of laws requiring compulsory undesirable traits for reproduction. Nazi policies
sterilization of mental patients in the name of succeeded with the support of bureaucratic pro-
eugenics. Similar proposals had been made else- fessionals and scientists. Nazis also targeted the
where in the West, and a number of American criminally insane and the chronically hospital-
states, California foremost among them, had ized. Individuals were chosen for the sterilization
implemented programs of involuntary steriliza- program from public health questionnaires and
tion, policies upheld by the U.S. Supreme Court family reports. In 1939, state institutions were
in Buck v. Bell (1927), a judgment where Chief required to report persons who had been ill for
Justice Oliver Wendell Holmes, upholding invol- at least five years and had been unable to work.
untary sterilization as constitutional, declared, When Germany was on the verge of World War II,
“Three generations of idiots are enough.” The the sterilization program of the early 1930s devel-
Nazis cited these American precedents and Cali- oped into euthanasia programs.
fornia’s experience in particular when legitimiz-
ing their sterilization law. Euthanasia Action
Prior to the start of World War II, the Nazi The early euthanasia program that the Nazi
party was making preparations for what would party implemented was called Aktion T4 after
be later known as the Holocaust (the system- Tiergarten 4, which was the physical address that
atic extermination of European Jews and other the officials of the program occupied to carry out
groups, i.e., genocide) through early steriliza- their administrative duties. The targeted popu-
tion and euthanasia programs. However, men- lation for the euthanasia program remained the
tal patients were the first victims of a policy of same as those who had been selected for the ster-
deliberate extermination, and they were the first ilization programs. The rationale for the eutha-
group to be gassed en masse and cremated, a pro- nasia program was based on two primary prin-
gram that was prosecuted with the enthusiastic ciples. First, the infirm and insane were a threat
participation of the great bulk of the German to the nation through their potential to pass
psychiatric profession. The personnel and the on their physical and psychological deformities
equipment used to exterminate the mentally ill through reproduction. Second, those deemed as
were subsequently moved east and redeployed in unworthy of life wasted resources such as food
the mass murder of Jews and others in the death and water. As the outbreak of war loomed closer,
camps. Mental illness was portrayed by the Nazis the officials for the T4 program asked Hitler for
and their psychiatric henchmen as an incurable formal authorization. Hitler responded with a
hereditary condition, and mental patients were letter of approval, backdated to September 1939,
stigmatized as “useless eaters.” the same time that Germany invaded Poland.
 Nazi Extermination Policies 573

This note is significant in that it was backdated Decisions on those selected for euthanasia were
to show a link between the decision to extermi- made without physical examinations or paren-
nate the unworthy (as a humane program) and be tal consent. The child euthanasia program also
able to fulfill the demands of war as hospitalized enlarged its scope to include children who dis-
individuals would be occupying beds needed for played antisocial behaviors. Selected children
wounded soldiers. Despite the backdated note, were transported to killing centers while the par-
the T4 program was not executed to meet the ents were told that their children were taken to
demands of war but was a product of Nazi totali- receive special and effective treatments. Within a
tarian and genocidal ideologies. few weeks, parents received a package of ashes,
The early euthanasia programs, also described presumably their children’s, with a note stating
as mercy killings, allowed the Nazis to experi- that the child had perished from pneumonia or
ment with various killing methods. The results other acceptable illnesses.
of these experiments helped pave the way for
the efficient mass murder of European Jews. In Resistance
the beginning of the euthanasia programs, many The sterilization and euthanasia programs
individuals died by neglect and starvation. These received little resistance from the German popu-
methods proved too slow for the Nazi agenda; lace. The perpetrators were also not obligated by
therefore, individuals with handicaps or mental the Nazi regime to participate; historical records
illnesses were euthanized by lethal injections. For show that those who refused to participate were
example, psychiatrists selected individuals who not punished, nor were they victims of retribution
exhibited “difficult behavior problems” and dis- by the state. Some have argued that the T4 pro-
played homosexual behaviors for the euthanasia gram ended because of a public outcry that had
programs. The T4 program also utilized shoot- support from leading church officials, but it is sus-
ing as a mode of killing. For instance, the selected pected that the official program was terminated
individuals were forced to dig trenches and then because of the increased demands and resources
stand in a line at the edge of the trench. The Ger- needed elsewhere. Additionally, it became exceed-
man soldiers would then shoot the victims so they ingly difficult for the German state to hide or con-
would fall into the trenches. This was repeated, tinue to provide reasonable explanations for all
with the victims falling on top of each other in of the dead.
stacked rows until the trench was full. Not all vic- Hitler responded to the protests by officially
tims died from the gunshot; those who survived ending the T4 program in 1941, which had
died from suffocation of the stacked bodies or resulted in the killing of 70,000 mentally ill and
when the trench was covered with dirt. physically disabled persons in Germany. However,
In addition to these targeted populations, this the euthanasia programs were still utilized on
program was expanded to include slave laborers children and adults throughout the war (includ-
who were ill, individuals in reform schools, the ing Poles suffering from incurable tuberculosis),
elderly, and individuals from institutions for the in addition to the full-scale genocide of European
poor. This selection process was known as “wild Jews from 1939 to 1945. Mass killings of the men-
euthanasia.” tally ill continued, and there is evidence that some
Children were also a target population for psychiatrists continued to kill patients for several
euthanasia; however, the children’s program was weeks following Hitler’s death and the official
largely carried out behind the scenes. In 1939, end of the war. In total, between 200,000 and
the German law on the “Elimination of Life Unfit 275,000 mental patients were slaughtered. The
for Existence” was passed, which required physi- lack of opposition or resistance to the genocide
cians and midwives to report any newborns with by the average German citizen has been described
physical or mental handicaps or other observed by some scholars as a “lethal indifference.”
disabilities to medical experts. Other health care
providers sent information on older children Complications of the Killing Methods
to a specialized children’s department, where The sterilization and euthanasia programs devel-
three medical experts reviewed the information. oped into an organized system of killing efficiency.
574 Neighborhood Quality

The killing methods that were initially utilized Nicholas, L. H. Cruel World: The Children of Europe
had two primary problems. The first problem in the Nazi Web. New York: Alfred A. Knopf,
(and the primary problem) was the amount of 2005.
time that it took to achieve the death of an indi- Strous, R. “Nazi Euthanasia of the Mentally Ill
vidual, and the fact that each killing had to be at Hadamar.” American Journal of Psychiatry,
carried out one at a time. The second problem v.163/1 (2006).
was the effect that it had on the soldiers who
committed the murders. Documents showed that
the ineffectiveness of the early killing methods
resulted in frayed nerves in soldiers, which con-
tributed to insubordination, drunkenness, and Neighborhood Quality
mental breakdowns. In addition, the mass graves
had unintended psychological consequences for Investigations of high-risk ecological settings are
soldiers. Contributing to the horror, the gases central to understanding the impact of neighbor-
released from the high number of corpses caused hood quality on mental health because evidence
several bodies to occasionally pop out of the cov- suggests that disorganized/disadvantaged neigh-
ered grave into the air. The soldiers were unpre- borhoods are detrimental to the mental health of
pared for the by-product of their killings. residents. Impoverished neighborhoods with low
To avoid these problems, the Nazis needed levels of social control and high rates of crime
improved methods of killing that were quicker or disorder increase residents’ risk of depres-
and less personal. The first attempt at a more effi- sion. Concerns about neighborhood quality and
cient, depersonalized way of exterminating was safety can also induce many other mental health
the use of mobile gas units or “gas van stations.” and stress-related disorders, in part through the
At institutions like Hadamar and Brandenburg, lack of economic resources and the challenges of
“shower blocks” were built that permitted the maintaining meaningful social ties. Finally, poor-
introduction of carbon monoxide gas to kill the quality neighborhoods are disproportionately
patients who had been herded inside, and this inhabited by individuals already overwhelmed
more efficient means of killing en masse was sub- by mental illness, making it especially difficult to
sequently transferred to the death camps in the preserve a healthy mental state in the context of
east and was used in the liquidation of the Jews. neighborhood disorder.

Eugenia L. Weiss Contextual and Compositional

Tara DeBraber Effects of Neighborhood
University of Southern California The relationship between neighborhood char-
acteristics and mental health outcomes is firmly
See Also: Architecture; Ethical Issues; Eugenics; established in the ecological literature. One of the
Germany; Poland; Policy: Federal Government; challenges of studying the relationship between
Human Rights; Racial Categorization; Violence; War. neighborhood traits and any outcome of inter-
est, be it crime or mental health, is disentangling
Further Readings contextual from compositional effects. On the
Bergen, D. L. War and Genocide: A Concise History one hand, if living in certain neighborhoods has
of the Holocaust. New York: Rowman & causal effects on the psychological well-being of
Littlefield, 2007. residents, then such effects are “contextual”; that
Hudson, L. “From Small Beginnings: The Euthanasia is, living in certain neighborhood contexts influ-
of Children With Disabilities in Nazi Germany.” ences the mental health of residents, even taking
Journal of Pediatrics and Child Health, v.47 into account the social, demographic, and behav-
(2011). ioral traits of individuals. Therefore, if they lived
Kershaw, I. Hitler, the Germans, and the Final in better neighborhoods, their mental health out-
Solution. New Haven, CT: Yale University Press, comes would be better. If, on the other hand, the
2008. relationship between neighborhood quality and
 Neighborhood Quality 575

mental health outcomes is simply because those disadvantaged neighborhoods are often charac-
with mental health issues are “trapped” in poor terized by multiple observable signs of physical
neighborhoods, such effects are “compositional”; deterioration, which inhibit the maintenance of
that is, the neighborhood traits not the reason social order and social control. As such, socially
for high rates of mental illness, it is merely that disadvantaged neighborhoods increase residents’
people with poor mental health select themselves risk of depression directly or indirectly through
into poorer neighborhoods (because of the socio- their perceptions of neighborhood conditions.
economic consequences of mental health issues). Perceived neighborhood disorder can exacerbate
The existing research on the relationship between residents’ mental health in part because of poor
neighborhood quality and mental health out- social ties and limited economic resources avail-
comes suggests that both contextual and compo- able in the community. Social disorganization the-
sitional effects are at play. Disadvantaged/disor- orists, for example, postulate that neighborhoods
ganized neighborhoods both select for residents that are highly disordered lack the structural
who suffer from mental health issues and create traits and social capital to help combat neighbor-
or exacerbate these problems. hood crimes and preserve common values among
The issue of neighborhood quality and men- the residents.
tal health has significant policy implications. The In poor neighborhoods characterized by high
prevalence of mental distress and illnesses in dis- racial heterogeneity and residential instability, res-
advantaged neighborhoods has created a sense idents are also less likely to exert collective effort
of urgency among policy planners and social and guardianship against disorder and crime. This
researchers to fully comprehend the impact of lack of “collective efficacy” (defined as the ability
neighborhood attributes. The discipline of sociol- of a community to collectively exert social con-
ogy in America began in the early 20th century trol) hinders the formation of consensus on what
with the study of neighborhoods as ecological characterizes appropriate standards of behavior in
settings. Researchers at the University of Chi-
cago established the Chicago school of sociologi-
cal thought. Scholars such as Ernest Burgess and
Robert Park, followed by later studies of social
disorganization conducted by Clifford Shaw and
Henry McKay, focused heavily on the effects
of rapid social change, especially in the highly
impoverished, immigrant urban communities of
Chicago at the turn of the century. The Chicago
school researchers sought to understand how the
traits of neighborhoods affected everything from
crime to mental health and disease. They discov-
ered that neighborhoods with the highest rates
of crime were also neighborhoods experiencing
a wide range of other social ills, including high
rates of infant mortality, tuberculosis, and mental
disorders. This emphasis on the impact of neigh-
borhood disorder on mental health outcomes has
continued into the 21st century.

Characteristics of Disadvantaged
Neighborhoods A drug-addicted woman named April slumps on the sidewalk of
Modern ecological research has revealed a num- a ghetto in the downtown east side area of Vancouver, British
ber of neighborhood characteristics that are cor- Columbia, Canada. Disadvantaged neighborhoods are often
related with poor mental health outcomes. Unlike physically deteriorated, inhibiting social order and control and
neighborhoods of higher socioeconomic status, therefore increasing residents’ risk of depression.
576 Neighborhood Quality

the community and how residents should respond outcomes may be stronger in neighborhoods of
when faced with violations of these standards. poorer quality.
Consequently, residents in socially disorganized Finally, while neighborhoods generally vary
neighborhoods are likely to become socially iso- in their population composition and structural
lated from the wider community. However, social characteristics, disadvantaged neighborhoods are
cohesion alone is not always associated with bet- densely populated by households headed by single
ter outcomes. Some research suggests that strong parents or ethnic minorities who are poorly edu-
informal ties with neighbors in disorganized/dis- cated. A neighborhood may also be of poorer qual-
advantaged neighborhoods may not produce the ity in part because it is disproportionately occupied
same positive outcomes as strong ties in more dis- by low-income individuals who are struggling with
advantaged neighborhoods. economic hardship and personal difficulties and
Residents’ concerns about neighborhood safety who have limited access to quality mental health
can induce other related mental illnesses and treatment. Poor mental health is widely recognized
social difficulties such as anxiety, hypertension, as a salient risk factor for chronic diseases.
and other stress-related disorders. Compared to Research on residential poverty demonstrates
neighborhoods of higher quality, disadvantaged that the contextual effects of poverty are corre-
neighborhoods are likely to be plagued by mul- lated with higher mortality rate, low birth weight,
tiple social problems, including dilapidated hous- and poor social adjustment. In other words, even
ing, illicit drug use, homelessness, violent crime, if residents of economically disadvantaged neigh-
teenage motherhood, vandalism, and loitering. borhoods have access to affordable mental health
Such neighborhoods send a message to the pub- services outside their community, they may con-
lic that they lack the social support required to tinue to lack the means and social resources to
promote healthy social ties and mental health. preserve a healthy state of mind. As empirical evi-
In fact, residents may become so distressed over dence suggests, neighborhoods of lower socioeco-
the breakdown of their neighborhood that their nomic status frequently lack high-quality public
psychological affliction may prevent them from housing, safe water, adequate sanitation, acces-
becoming fully functional in their daily activities. sible retail stores, and reliable transportation
Perceived powerlessness, especially, can engender systems. The absence of infrastructure in such
a sense of fear and mistrust that hinders residents communities can impact the stress level imposed
from becoming integrated in their community. on the residents on a daily basis. Ultimately, the
risk of psychological distress also compromises
Effects of Neighborhood Quality residents’ resistance to physiological illness and
There is a strong reciprocal relationship between increases health disparities later in life.
neighborhood conditions and residents’ mental
health outcomes because residents’ propensity Yok-Fong Paat
and their social environment can interact in var- University of Texas at El Paso
ied ways. Neighborhoods that promote healthy Trina L. Hope
social relationships increase the mental well-being University of Oklahoma
of their residents. Neighborhood social cohesion,
which is distinguished by shared norms, mutual See Also: Community Mental Health Centers;
aid, and reciprocity, can reduce the harmful Community Psychiatry; Depression; Marginalization;
effects of neighborhood poverty. Compelling evi- Psychiatric Social Work; Self-Help; Social Control;
dence also suggests that neighborhoods with high Social Isolation; Social Support; Welfare.
levels of social integration have lower crime rates.
These supportive living environments foster posi- Further Readings
tive social development for youths and children Caughy, Margaret O’Brien, Patricia J. O’Campo, and
because strong neighborhoods strengthen fam- Charles Muntaner. “When Being Alone Might Be
ily functioning and buffer the negative effect of Better: Neighborhood Poverty, Social Capital, and
poor parenting by mitigating parental stress. As Child Mental Health.” Social Science & Medicine,
such, the link between mental health and child v.57 (2003).
 Neo-Kraepelinian Psychiatry 577

Kim, Joongbaeck. “Neighborhood Disadvantage with symptomology and prognosis. His working
and Mental Health: The Role of Neighborhood assumption was that disease entities of the same
Disorder and Social Relationships.” Social Science kind give rise to identical pathological anatomy,
Research, v.39/2 (2010). symptom profile, and etiology, so that if a psy-
Morenoff, Jeffrey D., Robert J. Sampson, and Stephen chiatrist knows one of the three, he or she can
W. Raudenbush. “Neighborhood Inequality, accurately classify the disease. The approach was
Collective Efficacy, and the Spatial Dynamics of based on the conviction that science would even-
Urban Violence.” Criminology, v.39/3 (2001). tually establish causality and unearth pathologi-
Rios, Rebeca, Leona S. Aiken, and Alex J. Zautra. cal signs for these mental illnesses moreover, that
“Neighborhood Contexts and the Mediating Role doing the necessary research was part of modern
of Neighborhood Social Cohesion on Health psychiatry’s mandate. The paradigmal example in
and Psychological Distress Among Hispanic and this respect—and it greatly influenced biological
Non-Hispanic Residents.” Annals of Behavioral psychiatry—was paralytic insanity, which at first
Medicine, v.43/1 (2012). was a mysterious illness with no known cause and
Ross, Catherine. “Neighborhood Disadvantage and which research subsequently established was the
Adult Depression.” Journal of Health and Social final stage of syphilis.
Behavior, v.41/2 (2000). Throughout most of the 20th century, psychiat-
ric practice was dominated not by biological con-
ceptualization, which Kraepelinian psychiatry was,
but the interpretative or hermeneutic, with psycho-
analysis pivotal. Psychoanalysis privileged psychol-
Neo-Kraepelinian ogy over biology, interpretation over observation,
and developmental crises over symptoms. Corre-
Psychiatry spondingly, it depicted everyone as beset by neuro-
sis. It is largely in opposition to this way of think-
Beginning in the 1950s, and gaining ascendancy ing that neo-Kraepelinian psychiatry emerged. It
in the 1970s, the neo-Kraepelinian perspective has was also in response to hard-hitting critiques of
dominated psychiatry since 1980 with the release institutional psychiatry and a society that was rap-
of the third edition of the Diagnostic and Statisti- idly losing faith in diagnostic consistency. What it
cal Manual of Mental Disorders (DSM-III). Neo- signaled was a return to medicine, the biological,
Kraepelinian psychiatry is a way of understanding, and the measurable. It promised conceptually rig-
validating, and classifying the various problems of orous and otherwise reliable diagnoses.
people deemed “mentally ill”—loosely based on
the work of 19th-century German psychiatrist Dr. Tenets of Neo-Kraepelinian Psychiatry
Emil Kraepelin. It is a school, credo, and rallying The basic tenets of neo-Kraepelinian psychiatry
cry. Defining features are the belief in the pivotal are the following:
role of biology and the centrality of classification
and research. The school espouses empiricism • Psychiatry is a branch of medicine and
and science. It represents a huge departure from should be theorized as such
psychoanalysis, which prioritized interpretation • Mental disorders exist
and psychological causality. Proponents maintain • There are many types of mental disor-
that it put psychiatry on a firm foundation. Critics ders, all of which are discrete and have
argue that it medicalizes what is not medical and firm boundaries—there is likewise a clear
that it is reductionist and harmful. boundary between the “mentally ill” and
Emil Kraepelin was a classifier. Using botany as the “normal”
a model and basing his system on direct observa- • Highly delineated classification is essen-
tion, he introduced the first methodical textbook tial to psychiatry and the criteria should
on psychiatric classification. Diseases were bro- be taught in schools, codified, and thor-
ken down into specific classes and disorders. He oughly researched, subject to ongoing
listed etiology where cause was known, together revision
578 Neo-Kraepelinian Psychiatry

• The focus of psychiatrists should be on the According to advocates, there is now a manual
observable—in particular, the biological that can be used by everyone, irrespective of theo-
• Scientific research, including research retic persuasion, and the realignment with medi-
into genetics and heredity, is paramount cine has been fortuitous, resulting in pharmaceu-
• Statistical measurement should play a tical and other scientific advances—moreover,
substantial role, with special emphasis these disorders pass the reliability test.
placed on achieving high inter-rater reli- Critics of neo-Kraepelinian psychiatry assess
ability (when two practitioners diagnos- the situation differently. With respect to the
ing the same client would be highly likely manual, examples of common critiques are that
to arrive at the same diagnosis) the boundaries between the disorders are arbi-
trary; the disorders pathologize conflict between
Following Kraepelin, neo-Kraepelinian psychia- the individual and society; and the disorders are
trists favor and have been instrumental in creating subjective, reductionist, hegemonic, and culture-
a classification system that is agnostic with respect bound. Critics counter that inter-rater reliability
to etiology. However, it is steeped in medical lan- is no substitute for validity; moreover, no study
guage, and they look to the day when the biological has demonstrated high inter-rater reliability. A
underpinnings for all mental diseases are known. commonly articulated position is that there is no
Starting in the mid-1980s, a common claim has credible biological evidence for any mental disor-
been that biological foundations for a number of der. Critics range from antipsychiatry profession-
the mental illnesses have been established. als such as Thomas Szasz, who holds that mental
The first of the self-described neo-Kraepelinian illness is a myth; to labeling and other politically
psychiatrists—and these surfaced in the 1950s— oriented theorists, who locate the problems that
were British (e.g., Eliot Slader, who worked in people face in the actions of professionals and/
genetics). By the mid-1970s, America assumed or in society more generally; to psychiatric survi-
the lead. Early American groupings include the vor activists, who object that the classification of
St. Louis group and the New York group. Pivotal these disorders does not do justice to their experi-
American figures include John Feighner, whose ence, and maintain that harm is being done.
early work on criteria sets served as a model; Ger-
ald Klerman, who theorizes the movement as a Bonnie Burstow
whole; and Robert Spitzer, the first to apply neo- Ontario Institute for Studies in Education
Kraepelinian principles to the DSM.
The DSM is a product of the neo-Kraepelinian See Also: Antipsychiatry; DSM-III; Ethnicity;
revolution. With the advent of DSM-III, control Kraepelin, Emil.
of the influential text shifted from the psycho-
analysts to the neo-Kraepelinians. This shift was Further Readings
largely facilitated by the appointment of Robert Kirk, S. and H. Kutchins. “The Myth of the
Spitzer as chair of the DSM-III task force. Criti- Reliability of the DSM.” Journal of Mind and
cal features of the modern DSM are a large num- Behavior, v.15 (1994).
ber of disorders; the consistent use of a medical Klerman, G. “The Evolution of Scientific Nosology.” In
frame; disorders that are presented as discrete; Schizophrenia: Science and Practice, J. Shershow, ed.
lengthy individual criteria sets for each disorder; Cambridge, MA: Harvard University Press, 1978.
the use of such concepts as “differential diagno- Kraepelin. E. Clinical Psychiatry: A Textbook for
sis”; overarching classes, under which each of Students and Physicians. New York: Macmillan,
the disorders are subsumed; and decision trees 1907.
to guide the practitioner through the process of Spitzer, R., M. Sheehy, and J. Endicott. “DSM-III:
making a diagnosis. Guiding Principles.” In Psychiatric Diagnosis,
The claim of neo-Kraepelinian psychiatry is V. Rakoff, H. Stancer, and H. Kedward, eds.
that it has placed psychiatry back on secure foot- New York: Brunner, 1978.
ing—psychoanalysis is largely seen as a misstep— Szasz, T. Insanity: The Idea and Its Consequences.
and that substantial progress has been made. New York: John Wiley & Sons, 1987.
 Neurasthenia 579

Neurasthenia L. D. Kelly published a series of before-and-

after photographs documenting the effects of a
Neurasthenia is an older term that makes refer- common treatment for neurasthenia in 2012. The
ence to a constellation of neurological and psy- photographs show increases in weight and posi-
chological symptoms, including cognitive defi- tive changes associated with greater health status
cits; memory loss; insomnia; local, regional, and in the physical features of women with anorexia
hemispheric weaknesses; fatigue and lethargy; who were supposedly plagued by neurasthenia.
dizziness; headache; gastrointestinal disturbance; The “after” photographs were ultimately pre-
sensory nervous system disorders (e.g., blindness sented as evidence that these women were now
and deafness); sexual dysfunctions; and broad ready and capable of assuming and discharging
areas of unremitting pain, in the absence of cen- their roles as wives and mothers in their families.
tral or peripheral nervous system lesions, and Although representative of a more historical view
onset by an overwhelmed or underdeveloped sys- of the role of women and their susceptibility to
tem of coping or structural weaknesses in the spi- illness in Western cultures, neurasthenia still pres-
nal cord that predispose fatigue. A word designed ents as a viable conceptual model of the manifes-
to highlight a weakness of the nervous system tation of complex somataform disease for many.
in the West and social dysfunctions in the east, Vasudeo Paralikar and colleagues explored cat-
neurasthenia was most often applied to women egories of 352 narratives of women seen in urban
and grew to reflect a derogatory characterization outpatient psychiatry, dermatology, and medicine
of a weak or neurotic personality, or a person clinics in India in 2001. The common theme of
who was less than capable or easily overwhelmed social distress was found across clinics in the eti-
by common daily stressors and activities. Reflec- ology of symptoms associated with neurasthenia.
tive of a belief in mind–body integration, the The authors of the study concluded that factors
term best characterized somatic manifestations such as social context and cultural meaning were
of psychological stressors. important to understanding symptoms of neur-
Neurasthenia was a term popularized in 1869 asthenia. They further noted that neurasthenia
by American neurologist George M. Beard to was an important consideration in understanding
describe a condition originally thought to derive physical somatoform pathology and psychogenic
from a neuroanatomical and structural weakness disorders.
in the nervous system, but was later adopted to
describe a set of symptoms consistent with neu- Tropical Neurasthenia
rosis. A psychological concept that was presented A lesser-known and almost extinct derivation of
as a widespread reaction to the diminution of the concept of neurasthenia, tropical neurasthenia
middle-class white American and British cultural has fallen into disuse, along with many other his-
norms, secondary to industrialization and urban- torical terms of that time (e.g., sexual inversion)
ization, the term grew into disfavor as a represen- that represent obsolete thinking following a shift
tative of racist and sexist ideals and as a concept in zeitgeist and the reconceptualization of illness.
that was difficult to validate. Tropical neurasthenia was a condition predomi-
The concept of neurasthenia was initially used nantly experienced by white males and mission-
worldwide in Germany, Russia, the United States, aries who had social and physical stressors (e.g.,
and many other countries to describe premature heat, sun, and high humidity), secondary to their
aging, encephalographic changes associated with colonization of tropical areas and their subsequent
sleep, reactions to medications and stress, idio- exposure to and engagement of social rituals and a
pathic onset and maintenance of fatigue, weak- lifestyle different from their middle-class upbring-
ness, and pains that resemble modern disorders ings. Symptoms included bizarre, aggressive, or
like fibromyalgia, chronic fatigue syndrome, and even sexually promiscuous behavior common to
myofascial pains. Although less widely used today white males in isolated tropical outposts—a dis-
as a conceptual framework to understand illness, ease that could only be manifest in whites and
neurasthenia still exists in many areas as a promi- representing a catchall for any and all symp-
nent etiological model for somatoform disorders. toms manifest by Europeans exposed to tropical
580 Neurosyphilis

environments. Individuals who were not white but British East Africa.” Journal of the History of
who manifested similar symptoms were deemed Medicine and Allied Social Sciences, v.64/4 (2009).
to have different disorders, often disorders with Flaskerud, J. H. “Neurasthenia.” Issues in Mental
much more pejorative connotations. Health Nursing, v.28 (2007).
Tropical neurasthenia became one of the most Kelly, L. D. “Selecting a Somatic Type. The Role of
frequent reasons that British soldiers were dis- Anorexia in the Rest Cure.” Journal of Medical
qualified for service while serving overseas—more Humanities, v.33/1 (2012).
frequent than dysentery and malaria. Tropical Paralikar, V., et al. “Cultural Epidemiology of
neurasthenia was conceptualized, existed, and Neurasthenia Spectrum Disorders in Four General
persisted as a diagnosis because it reflected many Hospital Outpatient Clinics of Urban Pune, India.”
of the values of Europeans colonizing east Africa Transcultural Psychiatry, v.48/3 (2011).
at the time; it gave credibility to the experiences of
many who were working in the exhausting heat of
the jungle away from family, friends, and normal
sources of support; and it became a functional tool
in the conceptualization and management of those Neurosyphilis
who deviated from European national expecta-
tions for maintaining racial purity and national Syphilis is a sexually transmitted bacterial infec-
strength. Hence, when a British or European male tion spread through direct contact with an
deviated from social norms and engaged in sexual infected lesion. This lesion, known as a chancre,
relations with an east African, they did so under is typically found on the external sex organs but
the social umbrella of a mental disorder and so can also occur orally. Transmission is also possible
could be treated and ultimately repatriated to their from mother to unborn child as well as through
home countries without ongoing stigma. intravenous drug use, though this route is some-
Neurasthenia is a psychological concept that what less common. The infection typically occurs
exemplifies an intimate relationship between cul- in stages: primary, secondary, latent, and late.
ture, perceived normality, and the definition of psy- The primary manifestation is characterized by
chopathology. According to Jacquelyn Flaskerud, the presence of the often painless chancre, which
the conceptualization and utilization of neuras- usually spontaneously resolves within a six-week
thenia and its derivatives in science and medicine period, giving way to the secondary stage that may
reflects sociocultural stressors that are perceived feature a persistent rash on the soles of the hands
to influence the etiology of disease, acceptable and or feet as well as on other bodily surfaces. The
unacceptable reactions and behaviors to those primary and secondary phases are broadly con-
stressors, and political and social tolerance for sidered “early” stages of the disease. Importantly,
those symptoms when manifest by those homoge- symptom overlap may occur and individuals may
neous with cultural expectations and values. appear asymptomatic as the disease enters tertiary
phases, or latency. If undetected or untreated, indi-
Christopher L. Edwards viduals may harbor the infection for months and
Duke University possibly years. During this potentially extended
Camela S. Barker period, the likelihood of transmission secondary
B and D Behavioral Health to sexual contact decreases, although the disease
remains present within the infected individual.
See Also: Hysteria; Mind–Body Relationship;
Psychosomatic Illness, Cultural Comparisons of; Complications From Untreated Syphilis
Psychosomatic Illness, History and Sociology of; One of the major complications from untreated
Somatization of Distress; Stress. syphilis infection is the potential development of
neurosyphilis. Initial accounts of a link between
Further Readings syphilis and a condition known as general paraly-
Crozier, A. “What Was Tropical Neurasthenia? The sis or general paresis of the insane (GPI), character-
Utility of the Diagnosis in the Management of ized by psychotic and/or dementia-like symptoms,
 Neurosyphilis 581

date back to the late 18th century. This condition the blood of affected patients was also an accepted
results when the bacterium responsible for the pri- treatment modality well into the early decades of
mary disease, Treponema palladium, comes into the 20th century. Importantly, penicillin remains
contact with central nervous system tissue, includ- the preferred treatment and can be effective in the
ing the spinal cord and/or brain. Though com- full restoration of mental health, and may arrest,
monly thought to reflect a predominantly long reverse, or resolve neurologic insults related to
latency of syphilis infection, researchers have sug- infection.
gested that (1) syphilitic infiltration of the central
nervous system (CNS) likely occurs very early in Ethnocultural and Geographical Factors
the disease course, and (2) neurosyphilis may also Presently, there is little to no data directly exam-
progress in stages similar to syphilis in other parts ining the association between ethnocultural fac-
of the body. tors and neurosyphilis. This is particularly alarm-
The four formal stages of neurosyphilis ing with regard to the monumental, historical
include (1) the asymptomatic phase (no symp- impact of the Oslo and Tuskegee studies in illu-
toms), (2) general paresis phase (mild to mod- minating much of our present understanding of
erate problems with brain functioning, person- the underlying disease. Given the relatively early
ality, mood, and speech), (3) meningovascular CNS involvement of syphilis, it is feasible that
phase (apathy and seizures), and (4) Tabes dor- similar geographical, social, and cultural factors
salis (demyelination of sensory neurons). Relat- remain salient considerations in the prevalence of
edly, neurosyphilis is associated with psychiatric neurosyphilis.
sequelae and may manifest in a number of ways, Historically, African American, Hispanic, and
including presentations of dementia, psychosis, other minority populations in the United States
and pathologic fluctuations in mood. A more show higher rates of syphilis than Caucasians.
recent complication linked to neurosyphilis is In 2004, African Americans had rates of syphi-
the occurrence of stroke, especially in young, lis six times higher than non-Hispanic whites.
seemingly healthy individuals. In general, low socioeconomic minority popu-
While confirmation of syphilis is determined lations are more susceptible to the transmission
via serotoligic (blood) examination, confirmation of syphilis because of poverty, scarcity of men,
of neurosyphilis often requires lumbar puncture lower social status for women, and less accessible
and examination of the cerebrospinal fluid (CSF). health care. In addition, the use of crack cocaine
Only a small number of psychiatric hospitals still in the early 1990s has also been identified as a
test for neurosyphilis in patients presenting with factor influencing the spread of syphilis and other
major affective disorders and delusional demen- sexually transmitted diseases among minority
tia, whereas this procedure is relatively common populations.
in individuals with comorbid health concerns With the advent of antibiotics, rates of both
such as HIV. syphilis and neurosyphilis declined in the United
Prior to Hideyo Noguchi’s identification of States as well as in most countries around the
the characteristic spiral-shaped bacterium in the world. Nonetheless, rates of syphilis infection
brain tissues of deceased GPI patients in 1913, have generally impacted certain geographic
and like the conceptualization of many modern locales more so than others. During previous epi-
diseases, there were several dominant but incor- demics, the southern United States held consis-
rect therapies for GPI and neurosyphilis: mercury tently high rates of syphilis in comparison to the
and, later, the arsenic-based compound arsphen- northern regions. In 2011, for example, the Cen-
amine that was marketed as Salvarsan or Com- ters for Disease Control and Prevention recorded
pound 606. However, the former carried a risk of over 46,000 cases of syphilis in the United States,
further health complications due to toxicity, while with the majority occurring in California, New
the latter was generally ineffective in treating late- York, Florida, and Texas. This is consistent with
stage CNS presentations of the disease. prior research suggesting that the highest rates of
Medically induced fever via the introduction of syphilis in the country occur in the coastal regions
active malaria, streptococcus, or tuberculin into and large urban areas.
582 Neurosyphilis

Gender and Sexual Orientation

Men have higher rates of the disease than women,
which is largely attributed to the spread of the dis-
ease among men who have sex with men (MSM).
In addition, HIV-infected groups have dispro-
portionately high rates of neurosyphilis, and
rates of comorbid neurosyphilis and HIV infec-
tion are highest among MSM than in any other
demographic. For example, the well-established
population of MSM in California accounted for
a 700 percent increase in syphilis cases from 1999
to 2005, and approximately 60 percent of these
men had concurrent HIV infection. A number of
behaviors have been purported as contributing
this such epidemic growth, including decreases in
safe-sex practices, the use of the Internet to find
sexual partners, increased illicit and prescription
drug use, and the belief that oral sex attenuates
the chance of contracting HIV.
A human skull damaged by the late stages of neurosyphilis at The predominant mode of transmission has
the Melbourne Museum in Melbourne, Australia. The late stages shown some variation with homosexual inter-
of syphilis may manifest in presentations of dementia, psychosis, course among men as the primary mode in the
and pathologic fluctuations in mood. 1980s. This trend switched to heterosexual inter-
course, predominantly among African Ameri-
cans in the early 1990s and again to homosexual
intercourse among men in the early 2000s. The
Developing countries such as sub-Saharan only major exceptions are the large urban areas
Africa and southeast Asia have higher rates of of New York City and Chicago, which also have
neurosyphilis than most developing countries high rates of the disease.
because syphilis is often left untreated. In these
areas, the predominant mode of transmission Christopher Edwards
is through heterosexual intercourse and from Duke University
mother to unborn child. In addition, many of LaBarron K. Hill
the same factors that influence its spread in the Andrea Hobkirk
United States affect these cultural groups. For Duke University Medical Center
example, Cape Town, South Africa, has a syphilis
epidemic driven by many of the same factors as in See Also: Cultural Prevalence; Ethnicity; Iatrogenic
the United States, including high rates of illiteracy, Illness; Medicalization, History of; Psychiatry and
alcohol, and drug abuse, poor access to health Sexual Orientation; Racial Categorization; Sex;
care, and high rates of comorbid HIV infection. Stigma.
The symptom manifestations of neurosyphilis
vary across developing countries. For example, Further Readings
nine patients identified with neurosyphilis in the Baumgartner, A. and M. E. Swigar. “A Lack of
Philippines presented most often with tabes dor- Justification for Routine Screening Assays for
salis and seizures, while the South African sample Syphilis in General Hospital Psychiatric Patients.”
presented most commonly with psychiatric symp- Comprehensive Psychiatry (1987).
toms. In northeast India, 10 of 13 neurosyphi- Brandt, A. M. “The Syphilis Epidemic and Its
lis patients presented with psychiatric disorders Relation to AIDS.” Science, v.239/4838 (1988).
such as dementia, behavioral abnormalities, and Centers for Disease Control and Prevention.
chronic psychosis. “Symptomatic Early Neurosyphilis Among
 Neurotransmitters and Psychiatry 583

HIV-Positive Men Who Have Sex With Men— class of receptors and have a means of terminat-
Four Cities, United States, January 2002–June ing their effect, often with a reuptake transporter
2004.” Morbidity and Mortality Weekly Report, or an enzyme that breaks down the neurotrans-
v.56 (2007). mitter, both of which decrease neurotransmitter
Chahine, L. M., R. N. Khoriaty, W. J. Tomford, concentration in extracellular space. The chem-
and M. S. Hussain. “The Changing Face of istry of neurotransmitters is an essential compo-
Neurosyphilis.” International Journal of Stroke, nent of the biological principles of neuroscience
v.6 (2011). and forms the basis for psychopharmacology.
Fenton, K.A., R. Breban, R. Vardavas, J. T. Okano, T. The initial concept of chemically based com-
Martin, S. Aral, and S. Blower. “Infectious Syphilis munication between neurons was demonstrated
in High-Income Settings in the 21st Century.” by examining and chemically treating peripheral
Lancet of Infectious Disease, v.8 (2008). neurons. Through the early 20th century, the
Ghanem, K. G. “Neurosyphilis: A Historical prevailing school of thought ruled that neurons
Perspective and Review.” CNS Neuroscience & functioned only via electrical impulses. However,
Therapeutics, v.16/5 (2010). experiments with adrenaline, acetylcholine, and
Hutto, B. “Syphilis in Clinical Psychiatry: A Review.” other drugs began to challenge this notion. John
Psychosomatics, v.42 (2001). Langley (1852–1925) proposed that adrenaline
Jamora, R. D. G., A. A. Dellosa, and E. V. Collantes. acted on receptor substances to contract or relax
“A 24-Year Review of Neurosyphilis in the muscles, even when their innervating nerves were
Philippines.” Philippine Journal of Microbiology severed. However, he did not suggest that neurons
and Infectious Diseases, v.36 (2007). secreted a chemical to activate the receiving neu-
Kayal, A. K., M. Goswami, M. Das, and B. Paul. ron. This concept fell to one of Langley’s students,
“Clinical Spectrum of Neurosyphilis in North East Thomas Elliott (1877–1961), who speculated that
India.” Neurology India, v.59 (2011). adrenalin was stored and secreted in postgangli-
Marra, C. “Update on Neurosyphilis.” Current onic nerves but was reliant on embryological pro-
Infectious Disease Reports, v.11 (2009). duction and accumulation from the adrenal gland.
Nicol, W. D. “General Paralysis of the Insane.”
British Journal of Venereal Diseases, v.32/1 (1956). Early Theories and Discoveries
Timmermans, M. and J. Carr. “Neurosyphilis A series of crucial experiments demonstrating
in the Modern Era.” Journal of Neurology, chemical transmission from neurons soon fol-
Neurosurgery, and Psychiatry, v.75 (2004). lowed. Walter Dixon (1871–1931) slowed the
Zetola, N. M. and J. D. Klausner. “Syphilis and HIV heart rate of a dog by stimulating its vagus nerve
Infection: An Update.” HIV/AIDS, v.44 (2007). for 30 minutes. He then applied fluid obtained
from the dog to the heart of a frog; its heart rate
also slowed, and the effect could be blocked with
treatment of atropine. However, Dixon believed
that the inhibitory substance was stored in that
Neurotransmitters portion of the heart and not released from the
neuron itself. The seminal experiment came
and Psychiatry to Otto Loewi (1871–1961), purportedly in a
dream, in which he stimulated the vagus nerve of
Neurotransmitters (aka chemical messengers) are a winter frog, took fluid from it, and applied it to
molecules synthesized and released into extracel- a denervated heart of another frog, which led to a
lular space that act upon a neuron by binding to decrease in heart rate. He followed this with stim-
a proteinaceous receptor. Receptor binding typi- ulation of the first frog’s accelerator nerve and
cally triggers a series of events that changes the reapplication of the fluid to the second frog, lead-
receiving neuron’s function. Neurotransmitters ing to an increase of heart rate. He concluded that
can be produced by one neuron and released to the stimulation of the nerves caused the release
a different neuron or released and received by the of substances he called vagusstoff and accelerans-
same neuron. They are typically associated with a stoff. The studies and their conclusion remained
584 Neurotransmitters and Psychiatry

controversial for many years in part because the physostigmine and the marketing and use of psy-
findings could not initially be replicated in other chotropic drugs (e.g., chlorpromazine).
species, including mammals. The recognition that chemicals were involved in
Additional support for this theory came from neuronal transmission led to the further discovery
Henry Dale, who isolated several compounds of their biochemical pathways and the identifica-
from ergot and synthesized many others, includ- tion of drugs that affect them. In 1946, norepi-
ing acetylcholine and histamine. He anticipated nephrine was discovered by Ulf von Euler (1905–
the presence of cholinesterase, which likely 83), who later showed it was made and stored in
caused the failure for those replicating Loewi’s synaptic vesicles. Julius Axelrod (1912–2004) con-
experiments (the winter frogs that Loewi used ducted a series of experiments demonstrating that
have less cholinesterase) and rapidly broke down epinephrine was metabolized by a methylation pro-
acetylcholine into acetic acid and choline. Fur- cess, leading him to discover catechol-O-methyl-
thermore, Dale noted that, at certain sites, acetyl- transferase (COMT). Moreover, when monoamine
choline and muscarine had similar effects, and at oxidase (which was already known to metabolize
those sites, nicotine had no effect. Conversely, at epinephrine) and COMT were both inhibited, nor-
other sites, acetylcholine and nicotine had similar epinephrine was found to be sequestered in sym-
effects, while muscarine had no effect. This led pathetic (presynaptic) nerves, demonstrating the
to the characterization of muscarinic and nico- presence of reuptake transporters. Axelrod went
tinic sites for acetylcholine activation. Similarly, on to show that cocaine and effective tricyclic anti-
Dale later founded the terminology by adding the depressants blocked the reuptake of norepineph-
suffix “ergic” to the neuron that produces a neu- rine. Until this time, catecholamines were thought
rotransmitter (e.g., cholinergic and adrenergic). to be deactivated by rapid metabolism, as acetyl-
Dale eventually discovered acetylcholine in ani- choline is done by cholinesterase. Together with
mal tissue in 1929, and the following year, he and Bernard Katz (1911–2003), who showed release of
Loewi independently reported the discovery of acetylcholine was quantal and led to the discovery
cholinesterase. These discoveries were only per- of synaptic vesicles, von Euler and Axelrod shared
mitted after Wilhelm Feldberg (1900–93) devel- the Nobel Prize in 1970 for their discoveries.
oped a sensitive assay for acetylcholine with the These discoveries led to the identification of
use of eserine (aka physostigmine) as a cholines- additional neurotransmitters. In 1957, Arvid
terase inhibitor. Loewi and Dale shared the Nobel Carlsson (1923– ) examined the intermediate
Prize in 1936 for their discovery of neurotrans- product between L-dopa and norepinephrine and
mission and acetylcholine. discovered dopamine and its role in the brain. By
Nevertheless, the role of neurotransmitters lowering dopamine concentration with reserpine,
remained controversial into the 1950s. Neu- he induced Parkinsonism and demonstrated that
rophysiologists, led by John Eccles (1903–97) treatment with dopamine’s precursor, L-dopa,
remained critical of the pharmacological experi- was an effective treatment. Carlsson’s work also
ments and contended that neurotransmission was laid the foundation for the dopamine hypothesis
solely electrical in nature. The controversy over of schizophrenia. For his discovery of dopamine,
chemical versus electrical neurotransmission in the Carlsson received the Nobel Prize in 2000 with
peripheral nervous system ended in August 1951 Paul Greengard (1925– ), who discovered second
when Eccles himself produced an experiment in messenger signaling, and Eric Kandel (1929– ),
which a state of hyperpolarization, as detected who described the biochemical basis of memory.
by microelectrodes placed inside and outside the Early on the amino acids, such as glutamate and
neuronal membrane, could not be induced elec- gamma-aminobutyric acid (GABA), were shown
trically and, therefore, must have been facili- to change neuronal field potentials; however,
tated chemically. Opposition to neurotransmitter their acceptance as neurotransmitters came later.
theory remained for the central nervous system, As antagonists and mechanisms for transmission
but this resistance waned during the mid-1950s termination were discovered, GABA and glycine
and 1960s following additional experiments with were readily accepted as inhibitory neurotrans-
intraventricular injection of acetylcholine and mitters. However, these elements of evidence
 Nigeria 585

were slower to be delivered for glutamate and initial experiments involving acetylcholine and
excitatory neurotransmitters and were developed adrenaline on sympathetic neurons and at the neu-
from the 1950s to 1970s. Serotonin, on the other romuscular junction, we now realize the brain has
hand, was initially discovered as a vasoconstric- a rich and complex milieu of neurotransmitters,
tor in 1948 by Maurice Rapport (1919–2011), receptors, and associated enzymes and proteins.
initially regarded as a biological contaminant. It
was found in a mammalian brain by Betty Twarog Garth Terry
(1927–2013), and Dilworth Woolley (1914–66) University of California, Los Angeles
demonstrated that lysergic acid diethylamide
(LSD) acted as a serotonin antimetabolite, lead- See Also: Dopamine; Psychopharmacology; Tricyclic
ing him to hypothesize that serotonin played an Antidepressants.
important role in mental illness.
Further Readings
Modern Developments Axelrod, J. “Journey of a Late Blooming Biochemical
The development of several molecular biological Neuroscientist.” Journal of Biological Chemistry,
techniques in the second half of the 20th century v.278 (2003).
permitted discovery of several other neurotrans- Deutch, A. Y. and R. H. Roth. “Neurochemical
mitters that did not fit the catecholamine or amino Systems in the Central Nervous System.” In
acid model. Use of radioisotopes in receptor bind- Neurobiology of Mental Illness, 2nd ed., D. S.
ing studies allowed Candice Pert (1946– ) and Sol Charney and E. J. Nestler, eds. New York: Oxford
Snyder (1938– ) to discover opiate receptors in University Press, 2004.
1973, followed by endogenous peptide ligands, Felder, C. C. and M. Glass. “Cannabinoid Receptors
which were named endorphins. Interestingly, von and Their Endogenous Agonists.” Annual Review
Euler had discovered the peptide neurotransmit- of Pharmacology and Toxicology, v.38 (1998).
ter substance P; however, its connection to neuro- Nobel Media AB. http://www.nobelprize.org
kinin receptors and as a neurotransmitter was not (Accessed July 2013).
clarified for another half century. Following the Todman, D. “Henry Dale and the Discovery of
discovery of nitric oxide as a signaling molecule Chemical Synaptic Transmission.” European
in the body (for which Robert Furchgott [1916– ], Neurology, v.60 (2008).
Louis Ignarro [1941– ], and Ferid Murad [1936– ] Valenstein, E. S. “The Discovery of Chemical
were awarded the Nobel Prize in 1998 and which Neurotransmitters.” Brain and Cognition, v.49
described the mechanism of action of nitroglyc- (2002).
erin), Sol Snyder discovered that the gases nitric Watkins, J. C. and D. E. Jane. “The Glutamate Story.”
oxide, carbon monoxide, and hydrogen sulfide British Journal of Pharmacology, v.147 (2006).
acted as neurotransmitters, or gasotransmitters. Whitaker-Azmitia, P. M. “The Discovery of
Radioligand binding studies in the 1980s also Serotonin and Its Role in Neuroscience.”
confirmed the presence of cannabinoid receptors, Neuropsychopharmacology, v.21 (1999).
and cloning in the 1990s led to further charac- Yeragani, V. K., M. Tancer, P. Chokka, and
terization of these receptors. The endogenous G. B. Baker. “Arvid Carlsson and the Story
cannabinoid ligands, or endocannabinoids, were of Dopamine.” Indian Journal of Psychiatry,
discovered shortly thereafter as fatty acid deriva- v.52 (2010).
tives. Genetic studies have also been used to reveal
that several neurotransmitter receptors have func-
tional splice variants and also led to the discovery
of neurotrophic factors as neurotransmitters.
The discoveries related to neurotransmitters Nigeria
over the last century have revolutionized neurosci-
ence and psychiatry, have launched an industry in Historically, there has been a strong belief in Nige-
psychopharmacology, and continue to affect the ria that mental illness is caused by such factors as
way we conceptualize brain function. From the a spiritual attack or witchcraft, frequently in the
586 Nigeria

form of a curse brought on by an enemy through someone with mental illness. The stigma of men-
the services of a traditional healer. In such cases, tal illness has an impact on access to adequate
a curse might be believed to have been performed health care, and low percentages of those who
by poison or incantations, and avenues of heal- have mental illness actually receive any form of
ing include the use of a traditional healer and/or mental health care.
prayer houses. Treatments may also involve exor- Mental health services in Nigeria are less than
cism of spirits, beatings, cutting of skin, fasting, adequate to meet the needs of those with men-
acid burning, herbal treatments, and chaining. tal illness. For example, there are 0.4 psychiatric
These beliefs have contributed to negative atti- inpatient beds for every 10,000 people in Nige-
tudes and stigmatization of those with mental ill- ria, which has a population of approximately 140
ness in Nigeria, which also has an effect on access million. Furthermore, there are approximately
to appropriate mental health care. 100 psychiatrists in the entire country. Barriers
Though beliefs about appropriate treatment for to mental health treatment include costs of medi-
those with mental illness still include traditional cines, lack of mental health professionals, prob-
healing rather than institutionalization, asylums lems with transportation, and a dearth of acces-
were built after the establishment of colonialism sible clinics. Lack of knowledge regarding the
based on the belief that many people were not value of medical treatment for mental illness also
being best treated by traditional methods. Thus, impedes many people from getting mental health
asylums that could house many people were built treatment.
in 1906 but were still seen as a last resort because In Nigeria, there is also no social welfare or
many felt the mentally ill were better cared for in medical insurance available for those who have
the community. The development of these early severe mental disorders; therefore, the respon-
asylums generated queries regarding the social sibility to care for these individuals frequently
construction of mental illness and how mental ill- falls on family members. However, caring for a
ness is really defined, as many of these institutions family member may positively affect attitudes
served to enforce social order, creating socially toward mental illness. In a study completed in
constructed definitions of “madness” by local or 2001, over two-thirds of family members who
cultural standards. provided care for individuals with mental illness
People identified as insane in one culture or era in Nigeria reported they did not want their family
may not be in another. Such social constructions member institutionalized, even though there may
of mental illness highlight the direct influence of be an experience of social embarrassment due to
the politics and priorities of colonialism. Initially, stigma, and over 80 percent of families reported
the asylums were used as purely custodial insti- they felt that caring for the individual made their
tutions, but calls for reform began in the 1920s family ties stronger.
and the creation of more therapeutic facilities In urban areas there is also some shift toward a
occurred in the 1950s as indigenous psychiatrists biopsychosocial model for mental health, though
began to help run facilities. there are still many negative attitudes toward the
mentally ill. Individuals who report more edu-
Attitudes, Stigma, and cation also report a greater belief in a genetic
Mental Health Access etiology and endorsement of a biopsychosocial
In 2007, research regarding community attitudes model for mental health rather than a reflection
on mental illness in Nigeria indicated as many as of beliefs that are connected to witchcraft or spiri-
96.5 percent of people had negative attitudes and tual attack.
beliefs toward those with mental illness, includ-
ing the belief of dangerousness. This study also Community-Based Services
found that many people reported they would not Because of the widespread problems with access
engage in social interaction with someone that to mental health care, the advantages of commu-
has a mental illness (82.7 percent of people who nity-based services are well recognized and have
fear having a conversation) and only 16.9 per- strong empirical efficacy. Recommendations from
cent of individuals reported they would marry the World Health Organization have included the
 “Normal”: Definitions and Controversies 587

integration of mental health care into primary care Further Readings

settings to increase access. The National Mental Abiodun, O. B. “Pathways to Mental Health Care in
Health Program and Action Plan was developed Nigeria.” Psychiatric Services, v.46 (1995).
to integrate services and was published as official Eaton, Julian and Ahamefula O. Agomoh.
policy in 1991. This policy envisages an increase “Developing Mental Health Services in Nigeria:
in mental health services so that treatment con- The Impact of a Community-Based Mental Health
sidered imperative for severe mental illness is Awareness Program.” Social Psychiatry and
available in the community, including medica- Psychiatry Epidemiology, v.43 (2008).
tion. From this model, services are to be provided Gureje, Oye, Victor O. Lasebikan, Olusola Ephraim-
by primary health workers who are trained, with Oluwanuga, Benjamin O. Olley, and Lola Kola.
supervision from specialist mental health work- “Community Study of Knowledge of and Attitude
ers. Since 1991, the program has not made as to Mental Illness in Nigeria.” British Journal of
much of an impact as was first envisioned. Ser- Psychiatry, v.186 (2005).
vices still reach only a minority of people, and Ohaeri, U. Jude and Abdullahi A. Fido. “The Opinion
approximately only 20 percent of those with of Caregivers on Aspects of Schizophrenia and
mental illness receive any mental health services. Major Affective Disorders in a Nigerian Setting.”
Most primary care settings still do not have basic Social Psychiatry and Psychiatry Epidemiology,
psychotropic medications. Additionally, of those v.36 (2001).
who do get treatment, it is still not adequate, and Sadowsky, Jonathon. Imperial Bedlam: Institutions of
the goal to reduce stigma of mental illness the Madness in Colonial Southwest Nigeria. Berkeley:
community and among health care workers has University of California Press, 1999.
not been fully realized. Saraceno, Benedetto, Makr van Ommeren, Rajaie
Some of the reasons for the lack of the pro- Batniji, Alex Cohen, Oye Guereje, John Mahoney,
gram’s advancement include poor training and Devi Sridar, and Chris Underhill. “Barriers to
supervision of primary care workers, extremely Improvement of Mental Health Services in
low financial backing, and poor political sup- Low-Income and Middle-Income Countries.”
port. Although the program has been developed The Lancet, v.370 (2007).
and there are intentions for its advancement,
crucial support at the government level impedes
progress. Additionally, there is no nongovern-
mental advocacy organization or program in
Nigeria that might provide increased advocacy “Normal”: Definitions
and a call to reform on the practices of mental
health services. and Controversies
There is some scientific evidence that grass-
roots-level mental health awareness programs The distinction between “normal” and “abnor-
may have an effect on increasing awareness of mal” is at the heart of the study of psychological
community-based mental health services and links problems or mental illness. Despite its importance,
to access, though results appear to be significant this distinction continues to be a topic of debate.
at program initiation and have a need for rein- This debate has centered on a single overriding
forcement at regular intervals to create sustained question: Are normality and abnormality and
attitude change with the greatest impact. related terms such as psychopathology, mental
disorder, and mental illness scientific terms that
Erika Carr can be defined objectively and by scientific criteria,
Memphis VA Medical Center or are they social constructions that are defined
largely or entirely by societal and cultural values?
See Also: Congo, Democratic Republic of the; Understanding various conceptions of psychopa-
Family Support; International Comparisons; Kenya; thology is important for a number of reasons.
Religiously Based Therapies; Self-Help; South Africa; As medical philosopher Lawrie Reznek (1987)
Spiritual Healing; Stigma; Sudan; Tanzania; Uganda. said, “Concepts carry consequences—classifying
588 “Normal”: Definitions and Controversies

things one way rather than another has impor- from statistical normality. This is often done by
tant implications for the way we behave toward developing a measure (e.g., a psychological test)
such things.” In speaking of the importance of that attempts to quantify the phenomenon and
the conception of disease, Reznek wrote: “The then assigns numbers or scores to people’s experi-
classification of a condition as a disease carries ences or manifestations of the phenomenon. Once
many important consequences. We inform medi- the measure is developed, norms are typically
cal scientists that they should try to discover a established so that an individual’s score can be
cure for the condition. We inform benefactors compared to the mean or average score of some
that they should support such research. We direct group of people. Scores that are sufficiently far
medical care toward the condition, making it from average are considered “abnormal.” This
appropriate to treat the condition by medical process describes the most frequently used tests of
means such as drug therapy, surgery, and so on. intelligence, cognitive ability, academic achieve-
We inform our courts that it is inappropriate to ment, personality, and emotions.
hold people responsible for the manifestations of Despite its scientific merits, this definition pres-
the condition. We set up early warning detection ents problems because it leaves considerable room
services aimed at detecting the condition in its for subjective judgments. The big question is this:
early stages when it is still amenable to success- How statistically deviant from the norm does
ful treatment. We serve notice to health insurance something have to be to be considered abnormal?
companies and national health services that they Objective, scientific methods can be used to con-
are liable to pay for the treatment of such a con- struct a measure such as an intelligence test and
dition. Classifying a condition as a disease is no develop norms for the measure, but one is still left
idle matter.” with the question of how far from normal an indi-
How we define psychological normality and vidual’s score must be to be considered abnormal.
abnormality has wide-ranging implications for This question cannot be answered by the science of
individuals, medical and mental health profes- psychometrics because the distance from the aver-
sionals, government agencies and programs, age that a person’s score must be to be considered
and society at-large. Normality and abnormality “abnormal” is a matter of debate, not a matter of
cannot be defined independently of one another fact. Is being in the top or bottom 10 percent suf-
because they are two sides of the same coin. A ficiently deviant to be considered abnormal? What
variety of conceptions of normality and abnor- about the top or bottom 5 percent?
mality have been offered over the years. Each has The lines between normal and abnormal can be
its merits and its deficiencies, but none suffices as drawn at many different points using many dif-
a truly scientific definition. ferent strategies. Each line may be more or less
useful for certain purposes, such as determining
Statistical Normality and Abnormality the criteria for eligibility for limited services and
A common and commonsense conception of nor- resources in a school. Where the line is set also
mality and abnormality is that “normal” is what is determines the prevalence of abnormality or men-
statistically average or frequent, and “abnormal” tal disorder among the general population, so it
is what is statistically deviant or infrequent. The has great practical significance. But one cannot
statistical view is built into the English language. use the procedures and methods of science to draw
The words norm and normal refers to what is a definitive line of demarcation between normal
typical or average, and the word abnormal means and abnormal psychological functioning, just as
“away from the norm.” one cannot use them to draw definitive lines of
Perhaps the major merit of this definition is that demarcation between short and tall people, or hot
it lends itself to accepted methods of measurement and cold on a thermometer.
that give it some scientific respectability. The first
step in scientifically employing this definition is Normality and Abnormality as
to determine what is statistically normal (typical, Adaptive and Maladaptive
average). The second step is to determine how far Most people view the word normal as meaning
a particular phenomenon or condition deviates healthy and adaptive, and the word abnormal
 “Normal”: Definitions and Controversies 589

as meaning unhealthy and maladaptive. Normal 70 are equally abnormal in the statistical sense,
and abnormal are statistical terms, but adaptive but an IQ of 130 is much more adaptive than
and maladaptive refer not to statistical norms an IQ of 70. Likewise, people who consistently
and deviations, but to the effectiveness or inef- score abnormally low on measures of anxiety
fectiveness of a person’s behavior. If a behavior and depression are probably happier and bet-
works for the person—if the behavior helps the ter adjusted than people who consistently score
person to deal with challenges, cope with stress, equally abnormally high on such measures.
and accomplish his or her goals—then the behav- In addition, not every maladaptive psycho-
ior is more or less effective and adaptive, and logical phenomenon is statistically deviant. For
therefore normal. If the behavior does not work example, shyness is almost always maladaptive
for the person in these ways, or if the behavior because it almost always interferes with a per-
makes the problem or situation worse, it is more son’s ability to accomplish what he or she wants
or less ineffective and maladaptive, and therefore to accomplish in life and relationships. Shyness,
is abnormal. however, is very common, and therefore is sta-
Like the statistical conception, this conception tistically frequent. The same is true of many of
has commonsense appeal and is consistent with the problems with sexual functioning. They are
the way that most laypersons talk about psycho- almost always maladaptive because they create
logical or mental normality and abnormality. distress and problems in relationships, but they
The major problem with this conception is also are also relatively common.
its subjectivity. Like the distinction between sta-
tistical normality and abnormality, the distinc- Normality and Abnormality as
tion between adaptive and maladaptive is fuzzy Socially Acceptable and Unacceptable
and arbitrary. There is no objective, scientific way Normal behaviors are often viewed as socially
of making a clear distinction. Very few human acceptable and in keeping with social and cultural
behaviors are entirely and always adaptive or rules and customs, and abnormal behaviors con-
maladaptive. Instead, their adaptiveness and mal- flict with or deviate from social or cultural norms.
adaptiveness depend on the situations in which This definition is actually a variation of the statis-
they are enacted and on the judgments and values tical definition, but in this case, judgments about
of the actor and the observers. deviations from normality are informally made
The extent to which a behavior or behavior by people using social and cultural rules and con-
pattern is viewed as more or less adaptive or mal- ventions, rather than formally by psychological
adaptive depends on a number of factors, such as tests or measures.
the goals that the person is trying to accomplish This definition is also consistent to some extent
and the social norms and expectations in a given with common sense and common language.
situation. What is adaptive in one situation might Abnormal people think, feel, and do things that
not be adaptive in another. What appears adap- most other people do not do (or do not want
tive to one person might not appear so to another. to do) and that are inconsistent with socially
What is usually adaptive in one culture might accepted and culturally sanctioned ways of think-
not be so in another. Even “normal” personality ing, feeling, and behaving.
involves a good deal of occasionally maladaptive The problem with this conception, once again,
behavior. is its subjectivity. Norms for socially normal or
Another problem with this definition is that acceptable behavior are not scientifically derived
judgments of adaptiveness and maladaptiveness but instead are based on the values, beliefs, and
are logically unrelated to measures of statistical historical practices of the culture, which deter-
deviation. Therefore, this definition of normal- mine who is accepted or rejected by a society or
ity and abnormality conflicts with the statistical culture. Cultural values develop not through the
deviation definition. Not every statistically devi- implementation of scientific methods but through
ant behavior or experience is maladaptive. In fact, numerous informal conversations and negotia-
sometimes deviation from the norm is adaptive tions among the people and institutions of that
and healthy. For example, IQ scores of 130 and culture. Social norms differ from one culture
590 “Normal”: Definitions and Controversies

to another. Therefore, what is psychologically depend primarily on who defines them. The peo-
abnormal in one culture may not be so in another. ple who define them usually have power, so these
Also, the norms of a particular culture change definitions reflect and promote their interests and
over time. Therefore, a society’s view of what values. Because the interests of people and insti-
is normal and abnormal will change over time, tutions are based on their values, debates over
often very dramatically, as shown by American the definition of concepts often become clashes
society’s changes over the past several decades between beliefs about the way the world works
in attitudes toward sex, race, and gender. For or should work and about the difference between
example, homosexuality was an official mental right and wrong.
disorder in the Diagnostic and Statistical Manual The social constructionist perspective can be
of Mental Disorders until 1973, when changes in contrasted with the essentialist perspective that
social, cultural, and political value eventually led assumes that one can place people in naturally
to its removal. occurring categories and that all members of a
In addition, the social norms conception is at given category share important characteristics.
times in conflict with the adaptive-versus-mal- For example, the essentialist perspective views cat-
adaptive definition. Sometimes, violating social egories of race, sexual orientation, and social class
norms is healthy and adaptive for the individual as objective categories that can be scientifically
and beneficial to society. In the 19th century, verified and that are independent of social or cul-
women and African Americans in the United tural values. From the social constructionist point
States who sought the right to vote were trying of view, such categories describe not what people
to change well-established social norms. Their are but instead describe the ways that people think
actions were uncommon and therefore “abnor- about and attempt to make sense of differences
mal,” but these people were far from psychologi- among people. Social and cultural values also
cally unhealthy, at least not by today’s standards. determine which differences among people are
Earlier in the 19th century, slaves who desired to viewed as more important than other differences.
escape from their owners were said to have the Thus, from the essentialist perspective, normal
mental disorder drapetomania. Although still and abnormal are natural categories whose true
practiced in some parts of the world, slavery is nature can be discovered and described. From the
almost universally viewed as socially deviant and social constructionist perspective, however, they
pathological, and the desire to escape enslave- are abstract ideas that are defined by people and
ment is considered as normal and healthy as the thus reflect their values—cultural, professional,
desire to live and breathe. and personal.
From the social constructionist perspective,
Normal and Abnormal sociocultural, political, professional, and eco-
as Social Constructions nomic forces influence professional and lay con-
Many theorists and researchers have concluded ceptions of psychological normality and abnor-
that normal and abnormal (and related terms mality, which are viewed not as facts about
such as mental disorder and psychopathology) are people that are discovered or revealed by science
not the kind of terms that can be defined by sci- but as agreements that are negotiated through
entific methods because they are social construc- the implicit and explicit collaborations of theo-
tions—abstract ideas defined by social, cultural, rists, researchers, professionals, their clients, the
and political values and by people’s attempts to media, lobbyists, policy makers, and the culture
understand, describe, and explain the world in in which all are embedded.
which they live. From this point of view, words This is not to say that the problems of people
and concepts such as normal and abnormal have who become labeled as psychologically abnormal
constantly shifting definitions because social, cul- or disordered are not real. It does mean, how-
tural, and political values and people’s attempts ever, that what is called a problem depends on
to explain and make sense of the world are con- the social, cultural, and political values of a cer-
stantly changing. Universal or “true” definitions tain time and place. Thus, the debates over the
of concepts do not exist because these definitions definitions of normal, abnormal, and related
 “Normal”: Definitions and Controversies 591

terms such as mental disorders, and the struggles control, prevention, or treatment of this problem
over who gets to define them, are debates over is desirable or profitable. The pattern is then given
the definition of socially constructed abstractions a scientific-sounding name, preferably of Greek
and struggles for the personal, political, and eco- or Latin origin. The new scientific name is capital-
nomic power that derives from the authority to ized. Eventually, the new term may be reduced to
define these abstractions, and thus to determine an acronym, such as OCD (obsessive-compulsive
what and whom society views as normal and disorder), ADHD (attention deficit hyperactivity
abnormal. disorder), and BDD (body dysmorphic disorder).
In the social construction of abnormality, some- The new disorder then takes on an existence all its
one observes a pattern of behaving, thinking, feel- own and becomes a disease-like entity.
ing, or desiring that deviates from some social As news about “it” spreads, people begin
norm or ideal or identifies a human weakness or thinking they have “it”; medical and mental
imperfection and that is displayed with greater health professionals begin diagnosing and treat-
frequency or severity by some people than others. ing “it”; and clinicians and clients begin demand-
A group with influence and power decides that ing that health insurance policies cover the treat-
ment of “it.” Once the disorder has been socially
constructed and defined, the methods of science
can be employed to study it, but the construc-
tion is a social process, not a scientific one. In
fact, the more “it” is studied, the more everyone
becomes convinced that “it” really is something.
The social constructionists view is illustrated in
the American Psychiatric Association’s 1952 deci-
sion to include homosexuality in the first edition
of the Diagnostic and Statistical Manual of Men-
tal Disorders, and its 1973 decision to revoke its
disease status. It is also illustrated by the many
other debates over the years about which human
problems should be viewed as mental disorders
and which should not.
The social constructionist perspective does not
deny that human beings experience behavioral
and emotional difficulties—sometimes very seri-
ous ones. It insists, however, that such experiences
are not evidence of the existence of entities called
“mental disorders” that can then be invoked as
causes of those behavioral and emotional diffi-
culties. The belief in the existence of these enti-
ties is the product of the all-too-human tendency
to socially construct categories in an attempt to
make sense of a confusing world. Acknowledg-
ing that the notions of health and illness are
socially constructed does not diminish the science
of medicine. Acknowledging that the notions of
poverty and wealth are socially constructed does
An 1863 print by H. L. Stephens depicts a runaway slave hiding not diminish the field of economics. The recent
in a swamp. In the early 19th century, slaves who desired to controversy in astronomy over how to define
escape from their owners were said to have the mental disorder the term planet does not make astronomy any
drapetomania. In most parts of the world today, the desire to less scientific. Likewise, acknowledging that the
escape enslavement is considered normal and healthy. basic concepts of normal, abnormal, and mental
592 Nursing

disorder are socially constructed, rather than sci- and recovering from illness to the optimal level
entifically constructed, will not diminish psychol- possible. In the realm of mental health and men-
ogy and psychiatry. tal illness, nurses play a significant role in provid-
ing both physical and mental health care, ranging
James E. Maddux from individual to group treatments, individual
George Mason University therapy, medication management, consultation
liaison, and psychiatric evaluations.
See Also: Labeling; Measuring Mental Health;
Medicalization, Sociology of; Mental Illness Defined: The Evolution of the
Sociological Perspectives. Nursing Role in Psychiatry
Over the past 200 years, the role of nursing in the
Further Readings United States has moved from basic custodial care
Horwitz, Allan V. Creating Mental Illness. Chicago: toward scientifically based, advanced-practice
University of Chicago Press, 2002. positions. Through the contributions of numer-
Kutchins, Herb and Stuart A. Kirk. Making Us Crazy: ous professional nurses, academic preparation
DSM: The Psychiatric Bible and the Creation of has progressed toward equipping independent
Mental Disorders. New York: Free Press, 1997. practitioners who bring the art and science of
Maddux, James E. “Stopping the ‘Madness’: Positive nursing into primary care and specialties such as
Psychology and Deconstructing the Illness psychiatry. In 18 states, advanced-practice nurses
Ideology.” In Oxford Handbook of Positive such as psychiatric nurse practitioners and psychi-
Psychology, 2nd ed., Shane J. Lopez and C. R. atric clinical nurse specialists are independently
Snyder, ed. New York: Oxford University Press, providing comprehensive psychiatric evaluations
2011. and combining psychotherapy with psychophar-
Maddux, James E., Jennifer T. Gosselin, and macology, management, and coordinated care to
Barbara A. Winstead. “Conceptions of provide holistic, person-centered service with a
Psychopathology: A Social Constructionist focus on recovery and strengths.
Perspective.” In Psychopathology: Foundations for This movement has been influenced in part by
a Contemporary Understanding, 3rd ed., James E. changes in gender roles and increasingly signifi-
Maddux and Barbara A. Winstead, eds. New York: cant contributions of women in the workforce.
Routledge, 2012. Prior to the influence of psychiatric nursing dur-
Wilson, M. “DSM-III and the Transformation of ing early American history, “mental patients”
American Psychiatry.” American Journal of were ostracized and restricted from mainstream
Psychiatry, v.150 (1993). culture. As psychiatric medicine embraced more
humane and therapeutic treatment, nursing train-
ing began including psychiatric nursing, and a
model of patient care evolved from barbaric treat-
ments toward protective and eventually more
Nursing therapeutic interventions such as symptom man-
agement and integration into the community.
Perhaps the greatest strength as well as the most Psychiatric nursing in Western cultures has
misunderstood aspect of professional nursing is evolved in concert with more generalized social
the emphasis on health promotion, as well as pri- and cultural changes. Initially dominated by
mary, secondary, and tertiary prevention at the female nurses, the specialty was palatable to phy-
individual and community levels. Wellness is easily sicians and society as women were increasingly
taken for granted until it is jeopardized. Recovery respected for their professional as well as rela-
is usually expected, yet the process is often over- tional contributions to the community. During the
looked. Nursing encompasses the broad scope of turn of the 20th century, when psychiatric care
variables that support mind and body wholeness had moved from minimal caregiving to more pro-
while assisting individuals, families, and commu- tective attending, women were deemed morally
nities in maintaining wellness, preventing illness, superior and thereby preferred caregivers. Male
 Nursing 593

nurses were less favorably received and initially toward advanced practice nursing. Her theory of
met resistance and discrimination as psychiatric nurse-patient relations remains foundational to
caregivers. Cultural and societal factors contrib- psychiatric nursing in psychiatric facilities and is
uted to the struggle faced by both patients and integrated into nursing as a whole.
nurses as the field of psychiatry evolved toward Graduate specialization in psychiatric nursing
evidence-based interventions for psychiatric began in the 1950s, with the clinical nurse spe-
illnesses. cialist role solidified in the 1960s. The psychiatric
mental health nurse practitioner (PMHNP) role
Academic Development evolved in the 1970s, and the licensure, accredita-
of Psychiatric Nursing tion, certification, and education (LACE) model
The academic education of psychiatric nurses can includes the recommendation that the PMHNP
be traced back to its beginnings in the late 1800s. role will be the focus for future education of
Linda Richards is credited as the first trained nurse advanced-practice psychiatric nurses, who have
and developed several formal nursing programs in a master’s or doctoral degree. Advanced physiol-
both the United States and Japan after graduating ogy/pathophysiology, pharmacology, and health
from the New England Hospital for Women and assessment, along with relevant clinical experi-
Children in Boston in 1873. Committed to ensur- ences, are required educational components. After
ing that psychiatric patients were “at least as well completing an accredited educational program,
cared for as the physically sick,” she opened Bos- advanced-practice nurses must pass a national
ton City College’s Psychiatric Nursing program in certification examination, which allows them to
1882. By 1913, psychiatric nursing was included apply for state licensure.
in the general nursing curriculum at Johns Hop-
kins University, and the first psychiatric nursing Theory of Nurse-Patient Relations
textbook was published in 1920. Peplau’s theory provides the framework for psy-
As the field of psychiatric nursing became more chodynamic nursing built upon the following four
academically grounded, Hildegard Peplau led the phases of therapeutic process:
way toward integrating therapeutic methodolo-
gies into the practice. After working in nursing for 1. Orientation, during which the patient seeks
several years, Peplau earned a bachelor’s degree assistance, establishes an introductory
in interpersonal psychology in 1943 and went on relationship with the nurse, and the
to study psychology under Erich Fromm, Frieda problem and services needed are identified
Fromm-Reichmann, and Harry Stack Sullivan. 2. Identification, at which time the patient’s
Her work with Sullivan established the founda- personal feelings about the experience are
tion for integrating Sullivan’s interpersonal theory identified and the patient is engaged as
into nursing practice. Influential in both policy an active participant in care to promote
and practice, Peplau contributed to revisions in personal acceptance and satisfaction
mental health practice and the National Mental 3. Exploitation, which involves assisting the
Health Act of 1946 while also working to expand patient to explore, understand, and deal
the role of nursing from custodial to therapeutic with the problem; gain independence; and
nurse-patient interactions. In 1948, she completed achieve the patient’s goal
her book Interpersonal Relations in Nursing, 4. Resolution, during which the nurse and
although its publication in 1952 took four years patient work through the termination of the
of navigating the social roadblock of her lack of a therapeutic relationship to support ongoing
physician coauthor. Peplau eventually succeeded emotional balance for both the nurse and
while teaching the first class of graduate psychi- the patient
atric nursing students at Teachers College. From
1954 to 1974, Peplau taught graduate-level psy- While Peplau’s theory applies to psychiatric
chiatric nursing at Rutgers University, creating nursing, it remains useful for patients facing any
the nation’s first clinical nurse specialist program number of physical, emotional, relational, or
in psychiatric nursing and leading the movement circumstantial challenges, as well as for nurses
594 Nursing

caring for these patients. Whatever the present- that approximately 1 percent of U.S. adults were
ing problem, the nurse’s primary roles are rela- affected by schizophrenia and 9.5 percent experi-
tional and take into account both the nurse’s and enced a mood disorder in the previous 12 months.
the patient’s values, beliefs, cultural background, In the primary care setting, there have been an
race, past experiences, and expectations. While increasing number of patients reporting depres-
the nurse may be responsible for safety, technical, sion and anxiety symptoms as well as behavioral
and environmental factors related to the patient’s and attention difficulties in the pediatric popula-
well-being, the primary nursing role is to establish tion. Patients who report these symptoms often
a therapeutic relationship that provides support, present with physical health conditions as the
information, counseling, and resources to facili- chief complaint and report comorbid psychiatric
tate the patient’s work toward independence and complaints to trusted medical providers. While
resolution. the U.S. surgeon general reports an “epidemiolog-
ical shift because of changes in the definitions and
Dorothea Orem’s Theory diagnosis of mental health and mental illness,”
of Self-Care Requisites numerous social and cultural factors may also
At the core of nursing is a focus on health pro- contribute to this increase in psychopathological
motion, illness prevention, and early interven- diagnoses.
tion aimed at facilitating recovery and wellness.
Whether physical or psychological health prob- Social Stigma and Military,
lems are identified, a primary goal of nursing is Political, and Financial Factors
to promote self-efficacy. Virginia Henderson, Historically, social stigma has restricted individ-
renowned as “the first lady of nursing,” empha- uals from seeking medical or social support for
sized the role of nursing toward a patient being psychiatric symptoms impacting mood, behav-
to “assist the individual, sick or well, in the ior, thought, or cognition. During the past two
performance of those activities contributing to to three decades, stigma has decreased in part
health or its recovery or a peaceful death, that s/ because of numerous public figures who have
he would perform unaided if s/he had the neces- disclosed mental illness, such as John Nash (the
sary strength, will, or knowledge. And to do this Nobel Prize–winning mathematician with schizo-
in such a way as to help him/her gain indepen- phrenia), Ellen Saks (a law professor at the Uni-
dence as rapidly as possible.” Using this patient- versity of Southern California with schizophre-
centered framework, Dorothea Orem developed nia), and Brooke Shields (a model/actress with
the theory of self-care requisites, which provides postpartum mood disorder).
a framework for assessing a patient’s level of The reauthorization of the Americans with Dis-
independence in self-care and informs the level of abilities Act (ADA) in 2008 was another factor
nursing intervention that is needed for recovery in the increased number of patients who were
with the goal of independence. Both Henderson forthcoming about mental disabilities. Based on
and Orem emphasized that patient-centered care the revisions in the ADA laws, the U.S. Equal
is not diagnosis-centered care. Nursing interven- Employment Opportunity Commission (EEOC)
tions are based on the patient’s perceived need and has expanded its enforcement guidance to include
level of autonomy and not the medical diagnosis. psychiatric disabilities, ensuring equal opportu-
nity for individuals with mental illness as well as
The Increasing Number of Psychiatric others with physical disabilities. In addition to
Diagnoses in the United States seeking medical evaluation and treatment, these
The National Institute of Mental Health (NIMH) legal decisions have led increasing numbers of
defines a serious mental illness (SMI) as one that Americans to seek psychiatric evaluation, diagno-
significantly interferes with functioning and the ses, and intervention.
performance of major life activities. In 2013, Ongoing military involvement in Afghanistan,
NIMH estimated that almost 6 percent of adults a shift in political power, and economic factors
in the United States have suffered from an SMI are among the many possible social and cultural
in the past 12 months. In addition, it estimated factors that may play a role in the recent surge
 Nursing 595

of mental illness and are relevant to a nursing identified with a mental illness may be viewed
assessment of both individual patients and pub- favorably—that is, indicating that individuals
lic mental health trends. Economic factors have are receiving assistance versus the escalation of
been correlated with the most significant increase hopelessness and ultimately suicide. The higher
in acute psychiatric illness and are clearly risk rate of psychiatric treatment may mean any
factors for suicidality and psychiatric hospitaliza- number of things, including the potential for a
tion. Almost simultaneous with the expansion of higher rate of recovery versus increasingly severe
ADA and EEOC, the banking crisis of Septem- pathology following the unprecedented world-
ber 2007 was followed by a worldwide economic wide economic crisis.
recession. As the auto industry suffered from the Psychiatric mental health nurse practitioners
economic decline, the December 2008 govern- (PMHNPs) or clinical nurse specialists (CNSs)
ment bailout of auto manufacturers burdened the evaluate individuals for a variety of presenting
U.S. economy further, and the aging U.S. public psychiatric problems. In many cases, individuals
faced decreased home values and retirement sav- may attempt to manage stress or emotions with a
ings. Many businesses responded by downsizing wide range of legal and illegal substances, includ-
and restructuring, and an unprecedented num- ing alcohol, cannabis, methamphetamines, barbi-
ber of college graduates faced unemployment turates, tobacco, caffeine, and prescribed opioids
coupled with large student loans as middle-aged or benzodiazepines. Risk-taking behaviors and
workers held tightly to their jobs in hope of an compromised sleep hygiene compound the harm-
improving economy. The increased unemploy- ful effect of substance use, particularly in the con-
ment in both the United States and Europe has text of other stressors and a diathesis (or predis-
been linked with an increase in suicides between position) toward mental illness.
2008 and 2010. Before a psychiatric diagnosis is considered,
Third-party payment for health care, coupled a complete psychiatric evaluation begins with a
with parity laws requiring access to psychiatric thorough patient interview that is both diagnos-
services, have likely reinforced the movement tic and therapeutic in purpose. Evaluation and
toward increased psychiatric diagnoses. Under testing are often completed to rule out medical
the World Health Organization’s International causes for psychiatric symptoms. For example,
Classification of Diseases (ICD-10) diagnosed a brain lesion or tumor could cause psychotic
conditions, patients are able to receive psychiat- symptoms. The individual’s presenting con-
ric nursing and/or counseling services that were cern as well as a thorough mental status exam
previously only accessible to more affluent mem- is assessed from the commencement of contact.
bers of society. However, most payment requires All of the components of a psychiatric evaluation
a qualified diagnosis, creating a necessity for at are addressed in order to identify the history of
least provisional or “rule out” diagnoses in order the present illness; past psychiatric history; medi-
to provide psychiatric or mental health services cal and substance use history; medications previ-
to an individual. Patients who might benefit from ously and currently taken; complementary alter-
monitoring and brief therapy often receive a pro- native treatments previously and currently used;
visional or “not otherwise specified” diagnosis and the developmental, social, and legal history,
while they are being further evaluated and receiv- including any past abuse or violence as well as
ing any type of psychiatric services. current legal status.
Developing a partnership with the patient is a
Psychiatric Mental Health Nursing key aspect of advanced-practice nursing. This is
and Advanced Practice Nursing used to facilitate a thorough examination, which
From a psychiatric nursing perspective, any one includes an assessment of the person’s strengths,
of these variables and most certainly the com- resources, and goals as well as an understanding
bination has potential to adversely affect indi- of the level of motivation for change with regard
vidual wellness and self-reliance as well as com- to behavioral patterns. Although not limited to
munity resources for buffering and assisting motivational interviewing (MI), psychiatric nurses
with recovery. An increased incidence of persons and PMHNPs often augment person-centered
596 Nursing

interviewing with MI and other therapeutic Recovery-oriented nursing looks toward identify-
communication strategies with the goal of harm ing the individual’s concept of recovery and sup-
reduction versus provider-centered changes. porting the movement toward the person’s defini-
tion of wellness.
The Nursing Response to Increased
Identification of Mental Illness Deborah Johnson
As soon as the fifth edition of the American Psy- University of California, San Francisco
chiatric Association’s Diagnostic and Statistical Elaine Walsh
Manual of Mental Disorders (DSM-5) debuted University of Washington
in the spring of 2013, critics began warning that
the increased access to psychiatric care would See Also: Community Psychiatry; Depression;
expand the number of individuals with entitle- Disability; DSM-5; Economics; Employment; Family
ment to limited health care resources, disabil- Support; Gender; Health Insurance; Suicide; Women.
ity income, and services. While nursing aims
to support the individual toward recovery to Further Readings
their baseline level of optimal functioning, the ADA National Network. “Disability Law
onus lies on lawmakers to address a faulty sys- Handbook.” https://adata.org/lawhandbook
tem of social support. Under current U.S. law, (Accessed June 2013).
the incentive and opportunity for an individual American Association for the History of Nursing.
to fully recover and regain self-efficacy may be “Linda A. J. Richards, 1841–1930.” http://www
stifled by the arduous process of qualifying for .aahn.org/gravesites/richards.html (Accessed June
publicly funded income, and for that reason the 2013).
concern is well founded. Boschma, G. The Rise of Mental Health Nursing:
From a psychiatric mental health nursing per- A History of Psychiatric Care in Dutch Asylums,
spective, increasing access may actually increase 1890–1920. Chicago: University of Chicago Press,
the opportunities for early interventions and 2003.
provide opportunities to support recovery and Hartweg, D. L. “Dorothea Orem Self-Care Deficit
increased use of personal resources. The over- Theory.” In Notes on Nursing Theories, vol. 4.,
whelming evidence of benefit from early inter- C. McQuiston and A. Webb, eds. Thousand Oaks,
vention has led to funding of 0 to 5 (year-old) CA: Sage, 1991.
and Early Diagnosis and Preventative Treatment Keeling, A. W. “A Brief History of Advanced Practice
(EDAPT) and Early Detection and Intervention Nursing in the United States.” In Advanced
to Prevent Psychosis (EDIPP) programs to reduce Practice Nursing: An Integrative Approach, 4th
severity of conditions such as autism and per- ed., A. B. Hamric, J. A. Spross, and C. M. Hanson,
vasive developmental spectrum, schizophrenia, eds. St. Louis, MO: Saunders Elsevier, 2009.
and mood disorders. In addition, it is clear that Mondaq News Alerts. “United States: ‘New’
early interventions that include family members, Mental Disorders to Spark Increased ADA
schools, and communities have increased resil- Accommodation Requests.” http://www.mondaq
ience, positive mental health, and effective social .com/unitedstates/x/244164/employee+rights+
support and improved daily life skills, modeling labour+relations/New+Mental+Disorders+To+
good decision making and strengthening families. Sprk+Increased+ADA+Accommodation+Requests
Nurses play a strategic role in assessing (Accessed June 2013).
patients who present with mental health issues, National Institute of Mental Health. “Statistics”
planning interventions, evaluating outcomes, and (2013). http://www.nimh.nih.gov/statistics/index
coordinating multidisciplinary patient care. In .shtml (Accessed June 2013).
collaboration with physicians, allied health pro- National Organization of Nurse Practitioner Faculty.
fessionals, and community partners, psychiatric “Consensus Model for APRN Regulation” (2008).
nursing is provided within a holistic framework http://www.nonpf.com/associations/10789/files/
that includes a strength-based, patient-centered, APRNConsensusModelFinal09.pdf (Accessed
culturally competent, patient-centered approach. June 2013).
 Nursing Homes 597

Reeves, A., et al. “Increase in State Suicide Rates in illness one of the most vulnerable groups in the
the USA During Economic Recession.” The Lancet, nursing homes.
v.380/9856 (November 24, 2012). Federal and state policies over the past 60
Sills, Grayce, L. Anne Peplau, and Bertha Reppert. years have had a major impact on individu-
“Hildegard Peplau: 1909–1999.” http://publish als with mental illness. Various federal policies
.uwo.ca/~cforchuk/peplau/obituary.html. (Accessed have been geared toward providing fiscal relief to
June 2013). states’ efforts to share public institutions’ medi-
U.C. Davis Medical Center, Imaging Research cal costs through Medicaid; however, funding for
Center. “Translational Cognitive and Affective mental health care has not been explicitly incor-
Neuroscience.” http://carterlab.ucdavis.edu/re porated into the rates. Inadvertently, these man-
search/ep.php (Accessed June 2013). dates steered the course for the living arrange-
U.S. Department of Health and Human Services. ments of individuals with mental illness to what
“SAMHSA: Promoting Recovery and they are today.
Independence for Older Adolescents and Young Amendments to the Social Security Act in
Adults Who Experience Serious Mental Health 1950 marked the beginning of the shift of indi-
Challenges.” HHS Publication No. SMA-13-4756. viduals with mental illness out of state-funded
http://www.samhsa.gov/children/SAMHSA_Short institutions. These amendments asserted federal
_Report_2013.pdf (Accessed June 2013). and state cost sharing for the medical care of
U.S. Equal Employment Opportunity Commission. individuals in state-funded institutions, exclud-
“EEOC Enforcement Guidance on the Americans ing payments for care delivered to individuals
With Disabilities Act and Psychiatric Disabilities.” with mental illness and tuberculosis. In the early
http://www.eeoc.gov/policy/docs/psych.html 1960s, mental health care expenditures in state
(Accessed June 2013). institutions accounted for the largest component
Virginia Henderson International Nursing Library. of mental health care spending. When Medicaid
“Virginia Avenel Henderson, RN, MA.” http:// was implemented in 1965, granting insurance-like
www.nursinglibrary.org/vhl/pages/vhenderson.html coverage for mental health patients previously
(Accessed June 2013). without coverage, federal and state cost sharing
was excluded for individuals between the ages of
22 and 64, leaving states to bear the burden for
this population. Budgetary issues in many states
also prevented Medicaid reimbursement rates to
Nursing Homes be adjusted for mental health care services, which
are generally more costly than medical services.
Of the 1.7 million individuals residing in nearly As a consequence, funding for state-funded insti-
16,000 U.S. nursing homes, estimates indicate tutions dwindled, and with limited residential set-
that 65 to 91 percent have some form of mental tings, individuals with mental illness were admit-
illness, including Alzheimer’s disease or a related ted into nursing homes.
disorder. During the 1960s and 1970s, a lack of In the early 1980s, a lack of adequate fund-
funding and downsizing of many state-funded ing for community-based mental health services
mental hospitals prompted a shift of persons with as well as an increase in incarcerations of per-
mental illnesses from state-funded mental health sons with mental illness precipitated a large num-
facilities into nursing homes and other residen- ber of involuntary commitments to state-funded
tial care settings. The influx of residents with a institutions. New federal regulations designed
need for specialized psychological care intensified to improve nursing home quality of care were
questions about the quality of mental health and enacted with the 1987 Omnibus Budget Recon-
quality of nursing home care. Persistent concern ciliation Act (OBRA-87), known has the Nurs-
over the ability of nursing homes to care for per- ing Home Reform Act (NHRA). Provisions
sons with mental illness, compounded with indi- within the NHRA created both the Preadmission
vidual psychological challenges of these residents, Screening & Resident Review (PASRR) and the
makes nursing home residents with a mental Minimum Data Set (MDS). Jointly, the PASRR
598 Nursing Homes

and MDS sanctioned tighter regulatory power most appropriate place for individuals with mental
over nursing home admissions of persons with illness. Prevalence estimates are difficult to gener-
mental illness. ate because of various methods of documentation,
The PASRR was developed with two specific such as MDS data, Medicaid claims data, and
functions: first, to prescreen applicants for a seri- various surveys reporting nursing home admission
ous mental illness; and second, to ensure place- data. Moreover, research studies often utilize dif-
ment in a treatment facility that could appro- ferent inclusion criteria. For example, dementia
priately accommodate the applicants’ needs if a was once believed to be the most prevalent men-
severe mental illness such as major depression, tal illness in nursing homes. Newer research now
bipolar disorder, or schizophrenia was suspected. indicates that depression, schizophrenia, and other
These guidelines required persons who were psychiatric disorders have superseded dementia
admitted to nursing homes to have a functional diagnoses in prevalence. Similarly, some research
impairment requiring nursing assistance and to count primary, secondary, or both types of diag-
prevent admission based solely upon mental ill- noses when calculating rates.
ness, thus impeding shifts of individuals from Finally, studies may consider all existing resi-
state-funded institutions into nursing homes dents when calculating rates or may limit analysis
in order to obtain federal cost sharing through to newly admitted residents. Moreover, previous
Medicaid. studies have also demonstrated that unintended
The second major component of the NHRA, incentives may result in providers’ under- or over-
the MDS, is a comprehensive standardized assess- reporting the number of cases of mental illness
ment tool administered on a periodic basis in in a facility because of the amount they are reim-
nursing homes that assesses the physical and bursed for their services. Cumulatively, these fac-
mental needs of nursing home residents as well as tors make it extremely difficult to estimate the
the appropriateness of care plans and treatments. actual number of individuals in nursing homes
The MDS data are also utilized in conjunction with mental illnesses. Additionally, the presence
with the Medicare Prospective Payment System to of comorbid conditions such as diabetes, stroke,
establish Medicare reimbursement rates, known Parkinson’s disease, and chronic obstructive pul-
as Resource Utilization Groups (RUGS). These monary disease is common in older adults, which
payments are primarily for rehabilitation services may shift the focus from a mental illness diagnosis
needed after hospitalization and are designed for to pressing medical conditions that appropriately
short-term placements in nursing homes, not to warrant nursing home care.
meet long-term care needs. To date, studies relating to specific mental dis-
More recently, the Americans with Disability orders have primarily focused on depression or
Act and the U.S. Supreme Court ruling in Olm- severe mental illness, such as schizophrenia and
stead v. L.C., in 1999, deemed involuntary nurs- bipolar disorder, and have had varying results.
ing home commitment discriminatory against dis- For example, studies have shown that the preva-
abled individuals. This landmark decision serves lence of depression ranges from 6 to 26 percent
as the foundation for current ideology, which pos- in nursing homes, depressive symptoms 11 to 50
its that individuals should be able to live in the percent, and have shown that individuals living in
“least restrictive setting” possible in order to pro- nursing homes are three to five times more likely
mote independence and quality of life. However, to be depressed than their community-dwelling
insufficient community-based resources and fund- counterparts. Approximately 3 to 7 percent of
ing often obstruct this objective, and individuals nursing home residents have schizophrenia or
are left to receive care in nursing homes. bipolar disorder. Additionally, research has sug-
gested that the number of residents with mental
Prevalence illness is increasing; however, these numbers may
Over 500,000 individuals with mental illness be driven by depression rates. It is also difficult to
reside in nursing homes on any given day, exclud- ascertain whether these numbers have escalated
ing those with dementia diagnoses, despite the because of the actual number of people increasing
ongoing debate that nursing homes may not be the or whether nursing home staff are better equipped
 Nursing Homes 599

to recognize symptoms or ask appropriate ques- RUGs. Currently, through the implementation of
tions that may lead to a depression diagnosis. MDS 3.0 in 2010, 66 RUGs are utilized. Iden-
Mental illness is one of many predictive fac- tified through MDS assessments, each RUG
tors associated with older adults being placed in classification is weighted to reflect the level of
a nursing home and is often the deciding factor. resources that individual nursing home residents
However, recent studies have approximated that require. Theoretically, a higher mix of residents
15 percent of individuals admitted to nursing requiring high levels of care should elicit a higher
homes are between the ages of 22 and 65 and are reimbursement rate; however, individual states
more likely to become long-stay residents. Addi- are afforded discretionary oversight to determine
tionally, there is tremendous variation in mental rates that are typically calculated by the average
health care services in nursing homes among indi- relative risk of a facility’s residents. Moreover,
vidual states, likely because of Medicaid payment reimbursement rates are dependent upon the reli-
policies. States that have had a large decrease in ability and validity of MDS assessments, which
the number of individuals leaving state-funded has in the past been questioned relative to its abil-
institutions typically have a high admission rate ity to accurately convey mental illness and evalu-
in nursing homes for residents with mental illness. ate subsequent treatment.
Irrespective of age, individuals in nursing Poor quality of care for mental health condi-
homes who have a mental illness diagnosis typi- tions is problematic because it can lead to addi-
cally have lower socioeconomic status and less tional hospitalizations and increase the overall
education. In addition to questions of their abil- cost of care an individual receives. Additionally,
ity to make informed decisions, these individuals studies have indicated that hospitalized residents
are likely on Medicaid, making them more likely often suffer negative consequences because of
to reside in a nursing home with lower qual- exposure to other illnesses, relocation stress, and
ity of care. Additionally, research has suggested an increased risk of mortality. Approximately
that many of these individuals may not require half of nursing home residents who receive anti-
the level of physical care provided in nursing psychotic medication such as benzodiazepines
homes and might be candidates to live in alter- often lack appropriate documentation evidencing
native settings. However, many are unable to be the need for such treatment. Often, these antipsy-
discharged, given the dearth of community-based chotic medications are used to chemically restrain
mental health services and the inability to arrange residents with behavioral issues. The use of benzo-
suitable housing alternatives. diazepines on frail older adults can be extremely
harmful, resulting in delirium, sedation, and even
Quality Issues death. Facilities with high usage of antianxiety
The quality of mental health care services in nurs- medications, sedatives, and antipsychotic medica-
ing homes has been a persistent concern for several tions are also more likely to have deficiency cita-
decades. Medicaid, the primary payer for long- tions; thus, the quality in these facilities is often
term care services, has historically reimbursed at substandard.
low rates, often resulting in inadequate resources Training and insufficient staffing levels have
to provide optimal care. Research has demon- also been identified as influential in the quality of
strated an association between the proportion of care delivered to mental health patients. Typically,
Medicaid residents in nursing homes and quality nursing home staff receive medical-based training
of care, with poorer quality delivered in facilities and are often not equipped to deal with individu-
with a higher proportion of Medicaid beneficia- als with mental illness. In many instances, mental
ries. Additionally, facilities with higher Medicaid health treatment is limited to medication therapy
ratios typically have a greater number of residents in order to compensate for untrained staff.
with mental illness. Therefore, lower-income indi-
viduals with mental illness may be placed in facili- Legislative Efforts to Improve Quality
ties with the fewest resources and poorest quality. In conjunction with the NHRA, PASRR was
In principle, state Medicaid reimbursement credited as a tool to improve the quality of care
rates to nursing homes are adjusted through delivered in nursing homes. Required screening
600 Nursing Homes

of written treatment recommendations and one-

third of recommendations for alternative place-
ment are followed. Thus, the PASRR may be
beneficial in the identification of individuals with
mental illness; however, its limitations lie in its
inability to assure the deliverance of quality care
at the appropriate level.
Additionally, the MDS that was created as
part of the NHRA was geared toward quality
improvement. Publicly reported quality measures
are relied upon by consumers, stakeholders, and
policy makers in order to capture and measure the
overall efficacy of care delivered within a facility.
Quality measures assess specific aspects of resi-
dent care (physical and mental) such as excessive
weight loss, falls, restraint use, depressive symp-
toms, antianxiety and hypnotic medication use,
and psychoactive medication use in the absence
of a related condition. The launch of MDS 3.0
included additional mental health quality indica-
tors in conjunction with the use of antipsychotic
medications because of their use as a treatment in
absence of trained staff. Specifically, the new mea-
sures assess the pervasiveness of antipsychotic
medication given to short-stay residents (30 days
or less), as well as the percentage of long-stay resi-
dents (more than 30 days) who are given antipsy-
chotic medications.
U.S. Navy sailor volunteers help move residents of Little Sisters Over the past few decades, nursing homes have
of the Poor nursing home to a dining room in Apia, Samoa, become a substitute for state-funded mental insti-
June 5, 2013. Mental illness is one of many predictive factors tutions. Policies have fostered and incentivized
associated with older adults being placed in a nursing home. this transition as federal and state governments
have attempted to shift the financial burden for
mental health care services back and forth. While
mental illness is often a deciding factor for older
of nursing home applicants promoted placement adults to enter a nursing home because of comor-
in facilities capable of delivering the level of care bid functional limitations, individuals under the
required; however, PASRR has been widely criti- age of 65 are increasingly becoming recipients of
cized because of noncompliance. In a 2001 report, care in this setting. Unfortunately, nursing homes
the Office of the Inspector General maintained often lack experience, commitment, and sufficient
that fewer than half of applicants with severe financial reimbursement to ensure that individu-
mental illness were appropriately screened prior als with mental illness receive appropriate care.
to nursing home admission, suggesting that the
PASRR may not be effective in ensuring proper Kelly M. Smith
placement of applicants with mental illness. Addi- Kathryn Hyer
tionally, this requirement is often thwarted when University of South Florida
short-stay care recipients enter a nursing home
for postacute care following a hospital stay and See Also: Ageism; Asylums; Medicare and
then become long-stay residents. Further, when Medicaid; Policy: Federal Government; Policy: State
screening takes place, approximately one-third Government.
 Nursing Homes 601

Further Readings Admissions to Nursing Homes, 1999–2005.”

Andrews, E., S. Bartels, H. Xie, and W. Peacock. Psychiatric Services, v.60 (2009).
“Increased Risk of Nursing Home Admission Grabowski, D. C., K. A. Aschbrenner, V. F. Rome, and
Among Middle Aged and Older Adults With S. J. Bartels. “Review: Quality of Mental Health
Schizophrenia.” American Journal of Geriatric Care for Nursing Home Residents: A Literature
Psychiatry, v.17/8 (2009). Review.” Medical Care Research, v.67/6 (2010).
Aschbrenner, K. A., C. Shubing, D. C. Grabowski, Stevenson, D. G., S. L. Decker, L. L. Dwyer, H. A.
S. J. Bartels, and V. Mor. “Medical Comorbidity Huskamp, D. C. Grabowski, E. D. Metzger, and
and Functional Status Among Adults With Major S. L. Mitchell. “Antipsychotic and Benzodiazepine
Mental Illness Newly Admitted to Nursing Use Among Nursing Home Residents: Findings
Homes.” Psychiatric Services, v.62/9 (2011). From the 2004 National Nursing Home Survey.”
Fullerton, C. A., T. G. McGuire, Z. Feng, V. Mor, American Journal of Geriatric Psychiatry, v.18/12
and D. C. Grabowski. “Trends in Mental Health (2010).
 O
Obsessive-Compulsive about threatening possibilities (e.g., “What if
I contracted a disease from touching that door-
Disorder knob?”). Compulsions are repetitive and rigidly
performed mental or physical actions that are
Large-scale epidemiological studies have found intended to reduce obsessive distress by creating
that the basic form of obsessive-compulsive dis- a subjective sense that the threat has been coun-
order (OCD) and its associated themes occurs teracted. While compulsions fulfill their purpose
with remarkable consistency throughout differ- by reducing distress, this effect is often temporary
ent countries, languages, and cultures around and thus perpetuates an obsessive cycle through
the world. Lifetime prevalence rates consistently negative reinforcement (anxiety reduction upon
fall in the 1 to 3 percent range, with an estimated engaging in the compulsion) and enhancing the
worldwide rate of approximately 2 percent. perceived legitimacy of the threat. While the spe-
Contamination appears to be the most common cific expression of OCD can be highly idiosyn-
obsession throughout most of the world, with cratic, the content of obsessions and compulsions
some regional/cultural variation. Checking and often fits into one of several distinct themes that
washing are the most commonly reported com- consistently appear. Factor analysis of OCD symp-
pulsions. Historical texts have revealed accounts tomology has identified combinations of obses-
dating back to antiquity that appear consistent sions and associated compulsions that tend to
with obsessive-compulsive concerns and behav- co-occur, including symmetry/ordering/counting/
ior. Taken together, the robust presence of these repeating, forbidden thoughts/checking (forbid-
concerns throughout varied contexts indicates den thoughts that often consist of blasphemous,
that the pattern of thoughts, feelings, and behav- aggressive, or sexual content), contamination/
iors now referred to as OCD may arise from fun- cleaning, and hoarding.
damental, universal elements of the human expe-
rience and is not merely the product of a modern Universal Theories
Western cultural context. Research has identified signs of strong genetic
OCD is a mental disorder that is characterized and neurobiological factors in the etiology of
by obsessions and/or compulsions. Obsessions are OCD. Twin studies have revealed a relatively high
distressing and recurrent ego-dystonic thoughts. concordance rate of OCD in twins, and there is
They often take the form of “what if” concerns increased risk among first-degree relatives of

603
604 Obsessive-Compulsive Disorder

those with the disorder. Neurobiolgocial hypoth- resonance with people across cultures, and there-
eses have focused on the role of the orbitofron- fore makes it particularly likely that obsessive
tal cortex, caudate nucleus, thalamus, and basal concerns will emerge surrounding this type of
ganglia. Disorders with basal ganglia involve- content.
ment such as Tourette syndrome and tic disorder, Both culturally sanctioned rituals and OCD
show a similarity to OCD in their presentation rituals involve attempts at creating a subjective
of compulsive, stereotyped behaviors and have sense of change through performing a scripted
high comorbidity with OCD, suggesting a com- action that at times has little practical or physi-
mon factor underlying these conditions. There cal connection to the desired goal. Rituals tend
have also been recent observations that a strepto- to operate according to superstition and magi-
coccal infection during childhood can lead to the cal thinking, both of which are associated with
sudden onset or increase of OCD symptoms or OCD. The criteria for successful performance of
tics through autoimmune disruption of the basal the ritual are often not verifiable through sen-
ganglia (the “PANDAS” hypothesis). Selective sory data. For example, one cannot empirically
serotonin reuptake inhibitors and the tricyclic test whether one has washed sufficiently to be
medication clomipramine have both been found pure enough to pray. Most individuals are able to
effective in the treatment of OCD. accept the symbolic, imprecise nature of such an
Others have proposed evolutionary perspec- act and decide that it is “good enough” once they
tives on the origins of OCD. One view holds that have gone through the motions. Individuals with
having an individual with obsessive-compulsive OCD, however, characteristically display a rigid
features present provided group survival benefit need for certainty in their domain of obsessive
in premodern times. For example, having a strong concern, which drives them to seek assurance that
motivation to address concerns such as safety or their actions are complete to absolute perfection.
cleanliness may have placed an individual in a This can lead to pathological repetition or rigid-
useful role in certain contexts. These traits could ity in their involvement of otherwise normative,
therefore have persisted through evolutionary culturally sanctioned rituals.
group selection, despite leading to reduced birth The bulk of research into cultural factors in
rates in the individuals who experience them. OCD has focused on the role of religion. Reli-
Another view proposes that OCD represents dys- gious beliefs and practices may provide a partic-
regulation of a basic threat detection system that ularly fertile ground for obsession because they
transcends culture. As with the group selection have profound implications, deal with absolutes
hypothesis, this concept holds that the themes of that are nonetheless abstract or subjective con-
OCD are grounded in implications for survival cepts (e.g., purity and sin), and often require
and procreation. OCD theorists have noted that engagement in rituals of a symbolic nature that
it is natural to use one’s imagination to project do not have clear criteria for successful comple-
future potential threats, but some may become tion. Extreme preoccupation with adherence to
overinvolved in these “what if” possibilities at the religious rules is considered a subtype of OCD,
cost of lowering their recognition of the present termed scrupulosity. Religiosity and superstition
reality available to their senses, which shows no are associated with higher OCD symptomology.
sign of the threat. The prevalence of religious obsessions and com-
pulsions can be substantially higher in cultures
Culturally Sanctioned Rituals in which religion plays an integral role in soci-
There are striking parallels between cultural ritu- ety. Specifically, religious obsessions occur more
als and the compulsive rituals that characterize frequently in the Middle East as compared to
OCD. Comparisons of descriptions of behavior the West and east Asia. Excessive hand washing
in distinct cultures around the world have found before prayer has a specific term in Muslim cul-
that rituals show more elements in common with tures (Waswas) that alludes to influence by the
OCD (such as efforts toward harm prevention) devil. Likewise, the term obsession was previously
than episodes of performing work. This may sug- used to refer to possession by an evil spirit. There
gest that these themes have some kind of special are also cases noted in research of scrupulosity in
 Obsessive-Compulsive Disorder 605

An example of a compulsive hoarding apartment. Interest in hoarding has increased dramatically among research scientists and clinicians
since the 1990s. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) refers to it as “compulsive
hoarding” under the category of obsessive-compulsive disorders (OCD). However, research showing that hoarding does not respond well
to OCD treatments has resulted in hoarding being redefined in the DSM-5 as a discrete disorder called “hoarding disorder.”

Orthodox Judaism, often related to fears of vio- in terms of their specific content but can typically
lating the rules of kosher eating or otherwise fail- be understood as culturally shaped expressions
ing to act as prescribed by Orthodox laws. of these themes. A man in south India developed
an obsessive fear of being bitten by a snake that
Cultural Shaping of Idiosyncratic would become activated when he felt something
Obsessions and Compulsions brush his leg. He took to compulsive eating of
As with normative rituals, the idiosyncratic pre- a plant that, according to local tradition, was
sentation of OCD is embedded in cultural and believed to lose its bitter taste if one has been bit-
material context. These factors naturally shape ten by a snake. While this belief and behavior is
the types of situations that give rise to obsession. tied to the folklore of a specific area, it is consis-
For example, a common obsession in industrial- tent with Western concepts of compulsive reassur-
ized countries is the fear that one has accidentally ance-seeking or checking.
run over a pedestrian while driving with com- Thus, OCD may represent a pathological pre-
pulsive checking to make sure that this did not occupation with themes that are particularly sensi-
occur. This specific type of obsessive-compulsive tive for an individual, which will often be reflected
pairing is only possible in the context of a society more broadly in the values and common experi-
that has developed roads and automobiles. How- ences of his or her culture. This is consistent with
ever, obsessive fear of unintentionally causing the current cognitive behavioral model of OCD,
harm to others is a common theme of OCD that which holds that the kinds of thoughts that form
occurs regardless of level of technological devel- the basis of obsessions occur in nearly everyone
opment. Compulsions may appear culture-bound and only become pathological when they are
606 Obsessive-Compulsive Disorder

interpreted as having distressing personal signifi- in cross-cultural studies, though examples have
cance. Different cultural contexts might increase been found in which no difference or even a pre-
the likelihood of certain kinds of thoughts, or dominance of males with OCD has been found.
increase the likelihood that an individual will There are findings that OCD leads to greater
assign importance to them. For example, in an impairment in social and occupational function-
investigation of OCD in Bali, the most commonly ing in males. The combined average age of onset
observed obsessive theme was the need to know has typically been found to fall between the 20s
information about strangers who pass by, or even and early 30s. As many as half of the cases that
animals or inanimate objects. This theme is not originate in females during adulthood may be
typically found in Western OCD patients and may precipitated by giving birth. Even among those
be reflective of the Balinese emphasis on relation- who do not develop OCD, the majority of new
ships, impression management, and not creat- mothers experience unwanted intrusive thoughts
ing offense to others. Also, somatic obsessions of harm occurring to their newborn. Some have
appeared more commonly in Bali than in Western attributed this increase in obsession to hormonal
studies (e.g., one patient’s idiosyncratic impression changes during that period. Others have sug-
of having snakes coiled in his head). Inappropri- gested that this finding supports the hypothesis
ate aggressive thoughts have been found to be the that OCD themes reflect areas in which being
most common obsession in multiple OCD stud- concerned was once evolutionarily adaptive. Sim-
ies in Brazil, though the most globally prominent ilarly, morbid, obsessive jealousy shows sex dif-
compulsions, washing and checking, are also high- ferences that make sense from evolutionary per-
est there. It has been proposed that this is because spective: males report more concern about sexual
of a comparatively high rate of violent death there, aspects of infidelity (which would create the risk
particularly from crime and automobile accidents. of raising another male’s offspring, rather than
Obsessions can emerge related to particular passing on one’s genes), whereas females report
health risks, such as diseases, as they become more concern about the emotional/relational
salient in a particular culture. This can coincide aspect of infidelity (which would have risked the
with public health scares related to newly discov- loss of a provider/defender).
ered diseases or can be based on local traditional Females are more likely to experience contami-
understanding of illness. For example, the culture- nation obsessions with cleaning/washing compul-
bound condition known as “puppy pregnancy” sions. This sex difference has been observed in
has a similar presentation to OCD. Local to West disparate cultures around the world, including the
Bengal, India, this involves the fear that a man is United States, South Korea, Spain, India, and Tur-
pregnant with one more dog fetuses. It arises after key (Italy provides a rare counterexample). There
incidental contact with a dog. It can include the is evidence that males in different cultures experi-
somatic experience of puppies moving around in ence symptoms related to symmetry and ordering,
the abdomen, or even hearing the puppies bark- as well as sexual obsessions more often. Sex dif-
ing from inside. Men fear that they will die giv- ferences in OCD may reflect the unique interplay
ing birth through their penis and may believe that of gender roles, physiology, religion, and cultural
they have seen tiny pieces of puppy fetus in their standards in different contexts. For instance, Islam
urine if they have taken faith healer potion meant forbids physical contact between the sexes before
to terminate the pregnancy. The concept behind prayer on grounds of contamination/purity, and
this is maintained or reinforced by others, includ- Hinduism includes rules that treat a menstruat-
ing local media. ing woman as unclean and prescribe steps to limit
contact with others during that time. These reli-
Age and Sex Differences gio-sexual taboos resonate strongly with the fun-
OCD tends to emerge earlier in life for males, damental themes that drive OCD.
though females may be more likely to develop the
disorder during adulthood and ultimately dem- Edward C. Wright
onstrate an equal or slightly higher lifetime inci- University of Texas Health
dence. This gender disparity has been replicated Science Center, San Antonio
 Obsessive-Compulsive Disorder 607

See Also: Anxiety, Chronic; Religion; Religiously Review.” Journal of Psychiatric Research,
Based Therapies. v.38 (2004).
Lemelson, Robert. “Obsessive-Compulsive
Further Readings Disorder in Bali: The Cultural Shaping of a
Cluttergone. “DSM-V.” http://www.compulsive Neuropsychiatric Disorder.” Transcultural
-hoarding.org/DSM-V.html (Accessed June 2013). Psychiatry, v.40/3 (2003).
Fontenelle, Leonardo F., Mauro V. Mendlowicz, Carla Okasha, A., A. Saad, A. Khalil, A. Seif El Dawla,
Marques, and Marcio Versiani. “Transcultural and Nabil Yehia. “Phenomenology of Obsessive-
Aspects of Obsessive-Compulsive Disorder: A Compulsive Disorder: A Transcultural Study.”
Description of a Brazilian Sample and a Systematic Comprehensive Psychiatry, v.35/3 (1994).
 P
Pakistan unable to work, or to make other types of con-
tributions to society, in some Western cultures. In
The concept of mental illness in Pakistan and the Pakistan, these conditions may be interpreted as
treatment pathways that people may follow are personality traits, particularly when several fam-
different from those generally followed in West- ily members present with the same attributes. A
ern countries, where a patient may first turn to man with these conditions will probably marry,
a clinician. In Pakistani communities, a clinician have an income, have children, and manage a
may only be approached after all else has failed, household with a comprehensive support struc-
and family systems have evolved to account for ture around him made up of siblings, parents, and
economic, emotional, and personal factors when children. A reason for this may be that because
supporting someone with a mental illness. many people live on the threshold of poverty,
Pakistan is a mosaic of culture and heritage, there is a heavy reliance by individuals to support
where each province has a different identity, each other. For example, if a couple decided not
including language, diet, and dress. However, the to have their son marry because of ill health, this
sense of belonging that people feel to their family would stop a daughter-in-law coming into the
is consistent; this is in the wider sense of tribe or home who would look after them in their old age,
community and not just restricted to blood rela- and prevent children from being born who would
tions. There is a real sense of existing through bring an income into the house, possibly from
the community to the extent that an individual quite a young age, if the family is poor. In this
may be identified by their personal or social role, way, a person with a mild or manageable mental
rather than by their name, in public life, such as illness would be able to contribute to the upkeep
“Doctor,” or “Mother of. . . .” Any success in of the household just by being married.
such a society is shared by the whole clan or tribe, It is not unusual in a number of rural com-
and failure or problems have a similar effect. munities for someone with a physical or mental
Mental illness is viewed by many as not exist- impairment to be sent to live on the site of a Mus-
ing along a continuum, where an individual may lim shrine, a place where renowned Muslims are
experience varying degrees of mental distress, buried, which can also serve as a local attraction,
but as being paagal or “mad.” Conditions such complete with food stalls, bus routes, and memo-
as Asperger’s syndrome and general anxiety and rabilia. The permissibility of shrines in Islam has
depressive disorders may render an individual been a hotly debated topic among Islamic scholars

609
610 Panic Disorder

for many years; nevertheless, shrines continue to See Also: Family Support; India; Marital Status;
thrive in Pakistan, serving as places where people Religiously Based Therapies; Spiritual Healing.
give food as charity to the poor, hoping that the
dead will intercede with God and ask for their Further Readings
prayers to be heard. Families hope that their loved Kanwar, S. and S. Whomsley. “Working With
one’s mental or physical health will improve if they Pakistani Service Users and Their Families.” NHS
are at a holy place. This process performs a respite Foundation Trust (2011). http://www.cpft.nhs.uk/
function because the family receives a break from Downloads/DVD-Documents/Publications/NHS
managing their loved one’s needs and cost of living. %20Working%20With%20Pakistani%20
Considering the significance of a sense of shared Service%20Users%202011%20PP%20
success or failure, a sick person may be taken to Low%20a4.pdf (Accessed April 2013).
one of the numerous spiritual healers who work Sameer, A. and M. Amer. Counselling Muslims. New
with conditions such as spirit, or jinn, possession, York: Routledge, 2012.
the symptoms of which can present similarly to Swota. A. H. Culture, Ethics and Advance Care
psychosis. The healer will usually pray with the Planning (Practicing Bioethics). Lanham, MD:
individual and refer them to text from the Koran to Lexington Books, 2009.
read at home, without a fee or other recompense.
This sector has grown over the years to include
magicians or illusionists who operate under the
guise of being a spiritual healer and can be found
on most street corners, offering to bring back Panic Disorder
loved ones, increase wealth and fortune, and cure
mental distress. In exchange for a fee, the family Panic disorder is a relatively new psychiatric con-
is given talismans, potions, and texts for a num- dition, introduced under the general heading of
ber of ailments, including evil eye and spells. The “Anxiety Disorders” in the 1980 version of the
magician usually tells of an outside party who has Diagnostic and Statistical Manual of Mental Dis-
cast a spell on the individual through jealousy or orders (DSM-III). After some amendments to
to exact revenge. This ranges from a neighboring this original definition, the criteria were revised
shopkeeper who is jealous of the individual’s shop in 1994 in the DSM-IV. To meet the criteria, an
to a distant relative who wanted their daughter to individual must experience recurrent unexpected
be married into the family but was refused. This panic attacks, and at least one attack must be fol-
is often the method of choice for many families lowed by at least one month of at least one of the
because they become passive recipients of some- following:
one’s ill will, which shifts the shame and stigma
away from the individual and their family. • Persistent concern about having addi-
Mental illness is increasingly treated in a clinical tional attacks;
setting. Traditionally, people in extreme psychosis • Worry about the implications of the
would be admitted into asylum-like institutions as attack or its consequences (such as losing
a last resort. The growing skepticism around spiri- control, having a heart attack, or going
tual healers through negative media attention and crazy); and/or
increased awareness of medical models, primarily • Experience of a significant change in
in suburban areas but spreading to rural parts, behavior related to the attack.
means that more people are turning to clinicians.
However, receiving the right medication that An additional criterion is that the panic cannot
has not been tampered with and is administered be attributed to an external or environmental
through qualified practitioners with a comprehen- cue and cannot be linked to a specific incident
sive understanding of mental illness is challenging. or event.
Even while researchers caution employing
Shama Kanwar Western psychiatric criteria to determine rates of
National Health Service incidence across cultures, something very similar
 Panic Disorder 611

to panic disorder has been found in all the cultural of panic usefully consider the role of interpreta-
groups examined, and rates are similar to those tion of bodily emotions within particular cultural
found in Western contexts. This is also true for contexts. Such an approach offers a view of the
various cultural groups in North America. How- fluid and constructed nature of what is otherwise
ever, a significant finding is the role of culture and thought to be a fixed physiological or psychologi-
gender: Women experience panic disorder three cal event.
times more often than men.
Most medically oriented research has proposed Who Has Panic Disorder?
either physiological or psychological reasons for There are 6 million American adults ages 18 and
this difference, while sociological investigations older, or 2.7 percent of people in this age group,
have explored another avenue, having looked who are reported to have panic disorder. Across
more concertedly at the interpretive relationship all age groups in the United States, about 2.2 peo-
between gender, culture, and panic—specifically, ple of every 100 are newly diagnosed with panic
how the experience of panic is shaped by the gen- disorder in any given year, and this rate seems to
dered cultural meanings that people give to their be found across all countries.
fear. This area of research has been spurred on Panic, or at least variants of it as defined in
by evidence indicating that how a person regards the DSM, is a familiar experience across cultures.
their feelings of fear has greater relevance to their For a while, it was thought that China was an
experience of panic disorder than their physi- exception, with relatively low rates of panic dis-
ological symptoms. Thus, as a supplement to the order. Until now, researchers have been unable
dominant medical approach, sociological studies to explain this difference; however, more recent
information suggests that panic disorder may be
more common among Chinese people than previ-
ous epidemiological surveys had suggested.
Several examples of cross-cultural variations
of panic stand out, including ataques de nervios
among Dominicans and Puerto Ricans. Ataques
de nervios could be considered a form of panic
disorder because it is a recurring, rapidly peaking
fear that lacks any sort of environmental provo-
cation. Additionally, an Iranian form of heart
distress has been found to have elements simi-
lar to panic. Also, Koreans experience a panic-
like syndrome called hwabyung, with symptoms
characteristic of panic: Korean patients indicate
that they are afraid that they will die of asphyxi-
ation from a rising abdominal mass. Vietnamese
patients describe panic as a cold wind hitting the
body, along with urination. Also, rare disorders
such as koro and kayak angst have been pro-
posed as possible cross-cultural forms of panic
disorder.
When researchers employ the DSM criteria,
they commonly discover comparable rates of
the disorder in other cultural contexts, suggest-
ing that core features of panic disorder are shared
A girl at a Cambodian village, June 2003. The cultural differences human experiences and not a reflection of spe-
in the interpretation of dizziness (kyol goeu) by Cambodians, who cific cultural conditions. Yet, they also warn that
fear it will lead to death if not treated by targeted pinching, is such studies are limited because panic is not a
more likely to cause panic in a Cambodian than in an American. fixed entity that can be used to draw meaningful
612 Panic Disorder

comparisons across cultures or groups. Research- Treatments focused on undoing the catastrophic
ers are increasingly aware that cross-cultural stud- cognitions, such as a fear of losing control, are as
ies of panic should not assume that panic in other effective as medication. Such findings underscore
contexts is comparable to the North American the significance of interpretation to the experience
psychiatric conception. So, while panic disorder of panic.
is a human condition found across cultures, one Fear about losing control, however, is perhaps
must also note the various ways in which differ- most apparent in the African American popula-
ent cultures shape, organize, and give meaning to tion. Moreover, data show that African Ameri-
the experience of panic. cans are more likely to be diagnosed with psycho-
For instance, dizziness holds special relevance sis when presenting with panic disorder, which
for Cambodian refugees who regard it with trepi- is perhaps attributable to the greater fear felt by
dation. According to local cultural understand- African Americans about going insane during
ing, dizziness may indicate a case of kyol goeu, panic attacks. Additionally, it has been suggested
or “wind overload,” seen as an excess of wind that systematic evaluation bias could play a sig-
in the body, requiring immediate treatment such nificant role. Given the history of misdiagnosis of
as coining or pinching key areas. Without these affective disorder as schizophrenia in the African
interventions, it is thought that death will result. American population, it is also possible that Afri-
Given the cultural differences in the interpreta- can Americans are more likely to be misdiagnosed
tion of dizziness, it is more likely to cause panic in as psychotic than as having panic disorder.
a Cambodian than in an American. From other data, the experience of panic dis-
Moreover, for Americans, palpitations and order is shown to be impacted by cultures of war,
shortness of breath produces greater reaction violence, and displacement. Research on war
because it conjures a fear of heart attack, which veterans as well as with Korean, Iranian, and
culturally is considered a significant health con- Cambodian refugees has found that these groups
cern. In other cultures, different sensations are experience panic disorder at similar rates, dem-
considered more salient. Nigerians, for instance, onstrating a strong relationship between panic
may selectively complain of heat in the head dur- disorder and post-traumatic stress disorder. Still,
ing panic attacks. While flushing is included in sociologists have yet to explore how cultures of
the DSM-IV criteria for panic attacks, a Nigerian violence and war organize and give meaning to
patient might selectively amplify this as an impor- panic experiences.
tant aspect of the experience of panic because of
the particular cultural importance that becoming Culture, Gender, and Panic
flushed holds. In addition, someone who consid- While studies have been conducted on a variety
ers their panic to be an ataque de nervios would of possible cultural variables, the relationship of
likely be more anxious about limb trembling gender to panic disorder has garnered the most
because it provokes concern about having dis- attention from sociologists. Epidemiological data
ordered nerves. Each of these examples demon- show a strong difference in rates of panic among
strates the profound influence of culture on the men and women. In fact, the most significant
experience of panic disorder. feature of panic disorder found in Western popu-
Several studies have indicated that the Western lations is that three times more women are esti-
cultural concern for self-control is meaningful for mated to have it than men. Anxiety is not gender
how Westerners interpret and experience panic specific because studies reveal no appreciable dif-
disorder. In particular, Western patients report ference in its incidence. However, panic disorder
higher rates of fear around cognitive symptoms is distinguished from other anxiety diagnoses by
including depersonalization and derealization— having a significant gender component, particu-
experiences of being out of control, out of the larly when lifetime prevalence is taken into con-
body, or out of reality. These studies suggest a sideration. It is not yet determined if these gender
link between individualistic cultures in which self- differences exist in cross-cultural experiences of
regulation is highly valued and a fear of losing panic disorder. However, sociologists working in
of command of one’s body, mind, and behavior. Western contexts have been concerned with the
 Panic Disorder 613

interpretive dimension of panic disorder, looking More recently, researchers have questioned the
for clues not only about why gender could influ- validity of the data and have begun to interview
ence the incidence of panic but also regarding the men with panic. An important preliminary find-
gendered meanings of panic and whether these ing is that men, compared to women, less com-
influence the experience of panic disorder. monly seek out and report on their panic to medi-
To make sense of the gender differences associ- cal professionals. Instead, men are more likely to
ated with panic disorder, some researchers have self-medicate, especially with alcohol. Accord-
pointed to the powerful influence of historical ingly, the data and the assumption it embodies—
cultural meanings attributed to gender and fear. that panic is a “woman’s disorder”—is now being
In the West, gender has been used to differenti- questioned. Furthermore, evidence is emerging
ate diagnoses pertaining to anxiety since the late that the medical construction of panic as a “wom-
19th and early 20th centuries. Examples include an’s disorder” may influence men’s and women’s
conditions such as hysteria, which was viewed subjective experiences of what panic means for
principally as a female disorder, and hypochon- them and their identities. Men, for instance, have
dria (“of the abdomen”). Also, neurasthenia was reported that they find panic disorder most prob-
used to describe feminine characteristics such as lematic because it feminizes them, making them
weakness, sleeplessness, mental difficulties, and appear to be out of control, helpless, and like a
irrational fear. Women, and particularly those woman.
of the affluent class, were considered especially The interpretive approach taken by many soci-
vulnerable to neurasthenia because they were ologists offers a view of panic as highly subjective
presumed to have more refined, impressionable and significantly shaped by the cultural mean-
constitutions. Such thinking was also reflected in ings that people give to their feelings of fear and
the classic views of the symptoms of hysteria neu- trepidation. This perspective thus concentrates
rosis—a diagnosis that in many ways mimics the on how people understand their panic, an impor-
symptomology of panic disorder. Such categories tant insight into the meanings it holds for them as
have institutionalized a historical association of members of a specific group, culture, and society.
women with nervousness. While questions remain as to if and why China
Statistics showing panic disorder to have a has low rates of panic disorder, whether there is
strong gender component has meant that most of a gender dimension to panic disorder across cul-
the research conducted on panic disorder has been tures, and whether the significance of gender is
with women. These studies suggest that women’s as strong in Western cultures as thought, addi-
experiences of panic often reflect cultural ideals tional inquiries need to be made into the particu-
about normative femininity. Just as Cambodian lar meanings that under-researched groups give to
refugees experienced panic according to meanings their fear. Children, for instance, are increasingly
significant to Cambodian culture, Western women diagnosed with panic disorder. From a sociologi-
likewise understand their feelings of intense fear cal perspective, there are concerns about whether
in terms of dominant cultural notions—in the lat- this reflects an actual increase in fear among young
ter case, of feminine gender identity. It is common people and, if so, why? How do children make
among Western women, for instance, to report sense of their fear? Or, could increasing incidence
difficulties being alone or moving through public rates among children be expressing new attitudes
space, which reflects modern cultural norms that about childhood and risk? Is there evidence of an
women occupy the domestic sphere, whereas men increase in panic disorder across cultures, or is
are more naturalized in public space. Most often, this a Western phenomenon?
agoraphobia accompanies panic disorder, a com-
bination that has been reported to reflect mod- Riley Olstead
ernization, dominant gender identities, and alien- St. Francis Xavier University
ation. In fact, sociologists have discovered such a
strong spatial dimension in women’s descriptions See Also: Agoraphobia; Anxiety, Chronic;
that their panic disorder has been called “geogra- Assessment Issues in Mental Health; Gender; Post-
phy of fear.” Traumatic Stress Disorder.
614 Pathological Gambling

Further Readings 1970s, when numerous states instituted legalized

Davidson, J. “Fear and Trembling in the Mall: gambling, the gambler was viewed as a deviant or
Women, Agoraphobia, and Body Boundaries.” criminal.
In Geographies of Women’s Health, I. Dyck, For the most part, the systematic study of why
N. Lewis, and S. McLafferty, eds. New York: people gamble began in the 1940s when gambling
Routledge, 2001. was still primarily illegal in the United States.
Friedman, S. and C. Paradis. “Panic Disorder Freudian psychiatrists were the first to look at
in African-Americans: Symptomology and what they labeled “compulsive gambling.” Using
Isolated Sleep Paralysis.” Culture, Medicine, and patients as informants, they focused on “problem
Psychiatry, v.26/2 (2002). gambling” or “compulsive gambling,” which they
Hinton, D. and S. Hinton. “Panic Disorder, classified as a neurosis. For the Freudians, the
Somatization, and the New Cross-Cultural root of compulsive gambling was an unresolved
Psychiatry: The Seven Bodies of a Medical Oedipus complex with a resultant unconscious
Anthropology of Panic.” Culture, Medicine, and desire to lose. According to them, compulsive
Psychiatry, v.26 (2002). gambling was caused by an unresolved effort to
Lewis-Fernández, R., P. Guarnaccia, I. Martínez, relieve the male of the guilt feelings that accom-
E. Salmán, A. Schmidt, and M. Liebowitz. panied wishing for one’s father’s death in order to
“Comparative Phenomenology of Ataques de gain sexual access to the mother, a staple of the
Nervios, Panic Attacks, and Panic Disorder. Oedipus complex. When someone gambles, he
Culture, Medicine and Psychiatry, v.26/2 (2002). wishes to influence an external event. If he is suc-
McLean, C. and E. R. Anderson. “Brave Men and cessful, this translates unconsciously to the belief
Timid Women: A Review of the Gender Differences that his wishes are powerful enough to influence
in Fear and Anxiety.” Clinical Psychology Review, the external event, and if they are this powerful,
v.29 (2009). he can also influence his father’s death. Even if his
father is still alive, this is of no consequence to
Freudians because the wish for the father’s death
is still there. Therefore, when the gambler wins,
he loses in psychic coin; and when he loses, he
Pathological Gambling wins in psychic coin.
In 1957, two ex-gamblers founded Gambler’s
Gambling has existed throughout human history, Anonymous (GA) in Los Angeles, California. Bor-
possibly as a reaction to the perceived random- rowing heavily from Alcoholics Anonymous, GA
ness of life and the need to either understand or offered a diagnostic test of 20 questions, of which
control irrational, everyday occurrences. Initially, a “yes” answer to seven of the questions was seen
gambling was tied to religion in that forms of gam- as indicating that one was a compulsive gambler.
bling, such as the casting of stones and lots, were Accepting the Freudian view, GA believed that the
performed as a means of divination to understand compulsive gambler unconsciously desired to lose.
the minds of the gods. In the Middle Ages, the The next step was for the treatment of compul-
Catholic Church regulated gambling because the sive gamblers to move beyond self-help groups to
time spent gambling was time taken away from mental health specialists. Much of the impetus for
worship. this change can be traced to the establishment at
During the Reformation, Protestant clergy the urging of a local GA chapter of an inpatient
opposed gambling and labeled those who gam- psychiatric treatment program in 1972 for what
bled as sinners who embraced idleness, greed, was now referred to as “pathological gamblers”
blasphemy, and superstition. Later Enlightenment (a term more conducive to a medical condition)
leaders stressed reason above all else, and gam- in Brecksville, Ohio. Although by then the hold
blers were seen as epitomizing irrationality. Dur- of Freudianism among the psychiatric community
ing the Protestant Ethic era, gambling was insti- had waned, the treatment models still accepted
tutionalized as a vice on the level of alcoholism the premise that the pathological gambler har-
and prostitution. In the United States, until the bored an unconscious desire to lose.
 Patient Accounts of Illness 615

It was only a short time before an actual psy- As opportunities to engage in legal gambling
chiatric diagnosis was included in the Diagnos- continue to expand, perhaps gambling will be
tic and Statistical Manual of Mental Disorders seen in a different light. However, the possibili-
(DSM-III). First introduced in the 1980 edition, ties of gambling as a form of entertainment, part
pathological gambling was diagnosed as an of competition related to the capitalist system, a
impulse disorder. Subsequent revisions (the 1987 skill used for financial gain, or, in a more radi-
DSM-III-TR and the 1994 DSM-IV) continued cal vein, a form of support for the belief in the
to characterize pathological gamblers as suffer- “everyone can become rich” part of the American
ing from an impulse disorder. The DSM-5 (2013) Dream is being lost by emphasizing gambling as
defines pathological or compulsive gambling as a pathology or addiction. Without a perspective
a behavioral addiction, which signals the near that considers culture and its great variety in form
acceptance of the medical model, raising with it and content, gambling will continue to be defined
implications for responsibility or lack thereof in from a highly narrow and skewed individualistic
the criminal justice system. perspective.
In a parallel development, the movement
toward the medical model brought with it a focus Joseph A. Scimecca
on the biological roots of gambling. Numerous George Mason University
researchers sought to establish a genetic cause for
pathological gambling, ranging from the DRD2 See Also: Alcoholism; Bipolar Disorder; Freud,
gene to low levels of serotonin, and more recently Sigmund; Genetics; Impulse Control Disorder;
to reduced activation of the mesolimbic reward Internet and Social Media; Kleptomania; Suicide.
system.
The prevailing consensus among biological Further Readings
researchers is that the medical model of patholog- Bergler, Edmund. The Psychology of Gambling. New
ical gambling will be completely accepted when York: Hill and Wang, 1957.
the “gambling gene” is found. As with most other Custler, Robert and Harry Milt. When Luck Runs
simplistic views of the relationship between genes Out: Help for Compulsive Gamblers and Their
and behavior, such a move is scientifically prob- Families. New York: Facts on File, 1985.
lematic but ideologically attractive. Rosencrance, John. “Compulsive Gambling and the
Today, estimates of the percentage of Ameri- Medicalization of Deviance.” Social Problems,
cans who can be classified as pathological gam- v.32/3 (1985).
blers range from 0.5 to 3 percent. However,
these percentages are suspect because what has
been classified as pathology can be said to exist
merely from the consequences of the behavior.
Because psychiatrists, psychologists, and biolo- Patient Accounts
gists work within an individualistic framework,
references to cultural and structural factors are of Illness
conspicuous by their absence. Hence, the result
of this predominantly individualistic viewpoint Many sociologists, psychologists, anthropologists,
is a general acceptance of the medical model and social workers, and other scholars have turned to
an overemphasis on gambling as an addiction, qualitative methods of research to deepen under-
or as a possible addiction, if indulged in too fre- standing of patients’ illness experiences and the
quently. Absent from the general discourse about meanings of their experiences for themselves and
gambling are alternative sociological theories the cultural social world in which they live. This
about why people gamble—that those who have research evidence has been extensively used to
been labeled pathological gamblers are simply the inform mental health practice. Many scholars
result of being socialized into a world of changing have enriched the social science literature with
historical, economic, political, and sociological diverse accounts of patient illness from the unique
conditions. perspective of the patient as subject. In contrast to
616 Patient Accounts of Illness

the world studied by natural science, in which the in the presence of such a person intends to cre-
scientist is the arbiter of experience, qualitative ate an account of the illness experience from the
studies of relational meaning focus on the social first-person perspective, the writer will do so by
world and the patient as situated in that social describing exactly what the patient lives through.
world. The qualitative movement challenges the The more detailed and richer the description, the
validity of the third-person perspective of the greater access the readers have to the illness. For
natural sciences and the material physical world example, social work researcher Cynthia Poind-
it presupposes forms the foundation of the domi- exter has used narrative methods to develop very
nant medical model of care, its objective measure- powerful accounts of patients with HIV, including
ment of symptoms, and diagnosis and treatment women, older adults, and partners.
of disease. These accounts are in-depth descriptions of
The field of mental health has long been bur- patients’ experiences living through HIV illness,
dened by the problem of stigma associated with who have encountered both the burden of the
mental illness, a problem heightened by the physical illness and the shame, stigma, and alien-
voicelessness of the patient in depersonalized ation attached to the disease and diagnosis. Health
health care systems. The efficiency of the medi- and mental health are interrelated in the lives of
cal-industrial complex depends on the increasing Poindexter’s HIV patients. Poindexter describes
medicalization of illness, the commodification of the relationship between HIV illness and patients’
the patient and her/his illness experience, and the self-esteem and self-efficacy and the impact on
promotion of polypharmacy as the treatment for their well-being. Poindexter also describes how the
mental disorders. The recovery movement in men- patients’ social worlds are changed by HIV illness,
tal health has abandoned this misaligned focus on with an attunement and sensitivity to cultural and
patient as object and is transforming the delivery social contexts and meanings. The thick descrip-
of mental health services through person-centered tions allow the reader to deepen understanding of
approaches to care, in which the patient as sub- the HIV illness experience in all its dimensions.
ject identifies present and future goals of care for In a phenomenological study of seriously ill
attaining health and well-being and directs deci- older adult patients, social work researcher Mary
sions about his or her care in a shared, informed, Beth Morrissey found that patients who were
decision-making process. experiencing pain and suffering recollected early
Giving the patient voice through accounts of life cultural experiences and entanglements with
patient illness is critical to broadening access to family, in the family home, with work, and in
the patient’s perspective of living through illness, the country of origin. Recollection is a form of
intentionalities, spiritual meanings and hopes for reflection and meaning-making activity in which
recovery, and the recovery experiences in all their persons engage in life review and evaluation.
human dimensions. The depth of these experi- Recollections can be organized into a temporal
ences cannot be measured in the same way that sequence in narrative accounts of patient illness.
body temperature or blood pressure are measured, Qualitative analysis of such accounts helps to
or even cognitive functioning. There are multiple illuminate the origins of patients’ experiences and
ways of understanding illness experience, includ- their social and developmental structures. While
ing phenomenological psychology and social recollection may be viewed as the remembering
work, grounded theory, discourse analysis, narra- of immutable historical facts, phenomenologist
tive research, and intuitive inquiry, as related by Gabriel Marcel adopts the contrary view that
Frederick Wertz and colleagues. Description is one the past is not immutable and that recollection
of many ways of witnessing the illness experience. involves interpretation. In this sense of recollec-
tion as interpretation, recollection can have dif-
Methods of Recounting Illness ferent modes of appearance.
For many who have never experienced illness Re-enactment of experience involves drawing
or have never visited a family member or friend upon past experience. Such re-enactment could
who is ill, the illness experience may be totally be a mode of conscious recollection or could
unfamiliar. If a seriously ill person or one who is occur below the level of conscious thought in the
 Patient Accounts of Illness 617

form of a passive synthesis. In Morrissey’s study Storyteller, Arthur Frank identified three major
of older adults, seriously ill, frail elderly women types of narratives: restitution, chaos, and quest.
sought to re-enact maternal dimensions of exis- In the case of persons suffering from mental ill-
tence in their life-affirming drive for relational ness, the quest narrative reflects the recovery expe-
empathic care at the end of life. Re-enactments of rience of the person negotiating new meanings,
the maternal for dependent, frail elderly persons new identities, and goals of healing. Recovery
nearing the end of life centered around experi- narratives are increasingly used to help patients
ences such as holding and cradling, soothing with mental illness co-construct their personal
touch to relieve detrimental pain, comfort feed- accounts, fulfilling their intentionalities. Cultural
ing, and a welcoming home. differences and practices may be openly and freely
There is no single definition of narrative as a expressed in one’s narrative.
tradition or qualitative research method. Narra-
tive can have multiple meanings, depending on Bearing Witness
context, and is oriented toward meaning making. In each of the above approaches to creating patient
Such meaning making may take form in telling accounts of illness, there is a bearing witness to the
one’s story or creatively expressing and inter- patient’s experience and the patient’s dignity and
preting one’s experiences, typically in a temporal personhood that is memorialized in the account
account. Narrative methods can also be employed and is given a living presence that goes beyond the
to engage in, support, or strengthen dialogical patient’s experience. The account creates an inter-
interpersonal relations, locate or renew personal personal relationship with the ethical other with
agency, or reveal a living presence. For those whom the account is intimately shared and over
struggling with mental health issues, narrative whom the account creates a hold. Through this
may offer an opportunity to foster healing and sharing, the ethical other is held accountable for
recovery. the patient’s experience. In this way, the person
In her book, Good Days Bad Days, sociolo- who is ill is honored and remembered through
gist and qualitative researcher Kathy Charmaz ongoing dialogues of cultural social intercourse
reported data from her grounded theory study of that occur at many different levels of communica-
chronic illness. She provided in-depth accounts tion, both linguistic and nonlinguistic.
of the experiences of persons living through the This bearing witness, meaning-making activ-
struggles of dealing with serious chronic illness ity has particular significance for persons whose
such as kidney disease, the intrusiveness upon the mental health is compromised as the result of
lived body and lived space of being hooked up to living with dementia or other illness experiences
machines for kidney dialysis, and the slow move- in which there is no continuity or stability of the
ment of time. The accounts documented from the self. Over time, as illness progresses, selves change
patients’ first-person perspective their everyday and a person may develop new identities or move
experiences of living through high suffering and between liminal states. A person’s life may also
illness burden. change as a result of the life-limiting conditions
In another example of narrative that draws that illness imposes. In a narrative account of liv-
upon the phenomenological tradition, psycholo- ing with dementia, Mark Freeman described the
gist and researcher Frederick J. Wertz, in a thick process that he lived through with his mother as
description of trauma and resilience, provided a she approached this stage of her illness.
very intimate account of a young woman who According to Gabriel Marcel, however, what
was confronted with cancer and had to cope with does not change is a person’s core human person-
the loss of her voice. Wertz’s 15-page first-person hood, which is immutable. Marcel makes the dis-
narrative presented 11 temporal moments of tinction between “my life” that undergoes many
“Teresa” living through trauma, the meanings of mutations and what “I am” that transcends my
trauma for her, and the role of spirituality in her life. In bearing witness to the patient’s illness
recovery. experiences, the witness attests not only to what
Narrative has significant implications for per- the patient is living through but to the essential
sons in recovery. In his 1995 book Wounded humanity of the patient as human person.
618 Patient Activism

Patient accounts of illness reflect a humanis- and because the experience of treatment contin-
tic approach to understanding the whole person. ues to be less than fully satisfactory, people with
In creating an ethical stance in relation to others mental illness who speak as advocates or activists
through the construction of an account of illness, have difficulty finding or articulating consensus
the seriously ill person who is the subject of the positions or coordinating political or economic
account may transcend the illness and attune one- actions. Nonetheless, the voices of patient-advo-
self to relational meanings and praxes that will cates have succeeded in changing the course of
support recovery and healing. mental health treatment by spurring widespread
acceptance of the concept of recovery as a guiding
Mary Beth Morrissey principle of psychiatric care.
Fordham Graduate School of Social Service Contemporary patient activism involves a wide
range of issues: whether mental illness is a dis-
See Also: Human Rights; Patient Rights; Stigma: ease or not, whether psychotropic medications
Patient’s View; Suicide: Patient’s View. are effective or appropriate; the extent to which
physicians must honor patient choice in treatment
Further Readings decisions, whether treatment systems may include
Charmaz, Kathy. Good Days, Bad Days: The Self in coercive or involuntary practices, and whether (or
Chronic Illness and Time. New Brunswick, NJ: to what extent) people with mental illness should
Rutgers University Press, 1997. participate in delivering care. Beyond these policy
Jennings, Bruce. “Agency and Moral Relationship in issues, advocates in mental health settings across
Dementia.” Metaphilosophy, v.40 (2009). the United States help people exercise individual
Morrissey, Mary Beth. “Surrogate Decision Making: rights related to access to treatment, access to
The Surrogate’s Value.” In End-of-Life Ethics: information, payment for services, and placement
A Case Study Approach, K. J. Doka, A. S. Tucci, within treatment environments.
C. A. Corr, and B. Jennings, eds. Washington, DC: Most mainstream advocacy on behalf of peo-
Hospice Foundation of America, 2012. ple with mental illness continues to be facili-
Poindexter, Cynthia. “Sex, Drugs, and Love in tated by family members, surrogates, or cham-
Middle Age: A Case Study of a Serodiscordant pions drawn from the larger community. Both
Heterosexual Couple Coping With HIV.” Journal the National Alliance on Mental Illness (NAMI)
of Social Work Practice in the Addictions, v.3/2 and Mental Health America, the largest men-
(2003). tal health advocacy organizations in the United
Wertz, Frederick.J., K. Charmaz, L. M. McMullen, States, are largely comprised of family members,
R. Josselson, R. Anderson, and E. McSpadden. professionals, and community members who
Five Ways of Doing Qualitative Analysis: have not experienced mental illness. Marketing
Phenomenological Psychology, Grounded Theory, efforts by pharmaceutical companies also perme-
Discourse Analysis, Narrative Research and ate the policy landscape. Nonetheless, beginning
Intuitive Inquire. New York: Guilford Press, 2011. in the mid-1960s, people with mental illness have
been finding their advocacy voice. These patient-
advocates have significantly influenced the trajec-
tory of mental health services in the United States
and throughout the world.
Patient Activism
Early Initiatives
Throughout history, and in nearly every culture, Kennedy-era deinstitutionalization initiatives cre-
mental illness has created marginalized, oppressed, ated the first large-scale opportunities for men-
coerced, and impoverished populations. Until tal patients to engage in public policy work. The
relatively recently, people with mental illness had Community Mental Health Centers Act of 1963
difficulty finding an authentic activist voice. Even required each state to include “representatives of
today, because issues at the core of mental illness consumers of the services provided by such centers
are so intimate, intrinsically divisive, and difficult, and facilities who are familiar with the need for
 Patient Activism 619

such services” in mental health planning efforts. religious practices were frequently interpreted by
This statutory opportunity, combined with the coercion-oriented institutional psychiatrists as
ease of travel and communications of mid-1960s psychotic symptoms.
America, also generated opportunities for people Chamberlin and her peers worked diligently to
with mental illness throughout the country to col- create nonmedical solutions to help people for-
laborate with each other. merly treated in asylums to regain control and
These early voices in the consumer-survivor make progress in their lives. Consumer-operated
movement focused on the many abuses of the for- services offered hospitality, social opportunities,
mer asylum system, especially the coercive prac- and mutual support, and avoided both the coer-
tices encountered in these facilities. Their written cive daily regimen of the psychiatric hospital and
body of work shows that they understood their the “chemical straitjacket” of Thorazine and other
historical significance as the first among their psychiatric medications. Facilities operated under
people to have an opportunity to speak with a antipsychiatry principles tolerated a larger range
distinctive voice. Judi Chamberlin (1944–2010), of challenging behaviors among service users. If
a key figure in the movement, dedicated her 1978 people had difficulty complying with a facility’s
book, On Our Own, to “my sisters and broth- rules, the facility adjusted its rules. Only criminal
ers in the mental patients’ liberation movement behaviors such as assault or theft, or institutional
and to all those who have suffered at the hands abuses such as sexual contact between staff and
of institutional psychiatry for the past three hun- service recipients, were forbidden in these facili-
dred years.” ties. Chamberlin did not support peer-run services
Chamberlin spent five months as a patient in that were dominated by psychiatric profession-
six mental hospitals in the mid-1960s, an experi- als or organized by treatment organizations. For
ence that left her traumatized and disillusioned. Chamberlin, even pioneering clubhouse-model
According to Chamberlin, “I had never thought programs such as New York’s Fountain House
of myself as a particularly strong person, but constituted an unacceptable compromise.
after hospitalization, I was convinced of my own
worthlessness. I had been told that I could not Consumer Participation
exist outside an institution. I was terrified that Although mental health consumers and nonpro-
people would find out that I was an ex-patient viders from the larger community have had a
and look down on me as much as I looked down role in governance of publicly funded community
on myself . . . It was years before I allowed myself treatment facilities since the mid-1960s, profes-
to feel anger at a system that had locked me up, sional dominance of mainstream treatment orga-
denied me warm and meaningful contact with nizations persisted and continued as a source of
other human beings, drugged me, and so thor- conflict. In early 1981, the authors of the academic
oughly confused me that I thought of this treat- journal Community Mental Health published
ment as helpful.” a special focus issue on citizen participation in
Along with her peers, Chamberlin found intel- community mental health services. The journal’s
lectual support in the work of Thomas Szasz and editors noted that even mandated citizen partici-
others within the antipsychiatry movement. These pation encountered limits when confronting the
authors argued that the term mental illness had no power of professionals to design and deliver ser-
validity. Mental illness was not a medical prob- vices. Mental health professionals writing in the
lem but a social construct. Chamberlin quotes focus issue viewed mental disability as an illness
E. Fuller Torrey, whose mid-1970s writings sup- or disorder requiring treatment from experts. This
ported this view. “The very term [mental disease] left governing board members feeling frustrated
itself is nonsensical, a semantic mistake. The two and disempowered. Even if they were to identify
words cannot go together except metaphorically; abuses by professionals, the board’s only formal
you can no more have a mental ‘disease’ than you remedy was to seek discontinuation of federal
can have a purple idea or a wise space.” Cham- funding, which would result in harm to clients.
berlin also pointed out how even benign lifestyle One board member challenged the requirement
choices such as dietary preferences, clothing, and to self-identify as “consumer” or “nonconsumer,”
620 Patient Activism

considering the mandate both needless and stig-

matizing. She wrote the following:

To arbitrarily divide the nonprovider citizens

into two groups—consumers versus noncon-
sumers—is to continue to perpetuate the stigma
of mental illness. Perhaps I am naive; I thought
one of the goals of Community Mental Health
was to work to eliminate the labels and to edu-
cate the community that to use mental health
services was not the same as to declare in the
public square that I am a syphilis carrier.

The “angry consumer” whose writing was

featured in the focus issue noted that clients are
typically viewed by professionals as adversaries.
She noted that when a client chooses to direct his
life, and in so doing “complains,” therapists often
view the complaint as a symptom of illness rather
than as a legitimate response to an inadequate
(and perhaps threatening) situation. In addition,
she noted that clients are denied the right to be
angry, an emotion that is legitimate for “normal”
persons in society.
Many mental health activists have lived fierce,
independent, even colorful lives. David Hilton
(1953–2003) was the nation’s first director of a
state office of consumer affairs. He started the
New Hampshire Mental Health Consumer Advo-
cacy Council as well as a statewide network of
consumer-run peer support centers. Although he Demi Lovato performs at Good Morning America in New York
promoted the emerging concept of recovery, Hil- City, July 9, 2012. Lovato, who has disclosed both a mood
ton completely rejected the medical treatment disorder and an eating disorder, supports charitable efforts to
model and cycled in and out of psychiatric facili- help young people who face similar challenges.
ties until his death by suicide in 2003. According to
Hilton’s friend and protégé Ken Braiterman, “He
never resolved the conflict of working for incre-
mental change in a system he wanted to destroy them. Waldbillig worked at a state-run psychiat-
and replace with something totally different. The ric hospital. He reported allegations of client-to-
system had harmed him, still harmed people, and client rape and improper use of force by hospi-
would never reform itself, he believed. He criti- tal staff to his superiors, resulting in firings and
cized me for wasting my time talking to them.” criminal convictions.
In Cincinnati, Ohio, Urban Waldbillig (1928– Waldbillig and other Cincinnati activists also
2001), a former accountant and ordained Catho- helped stop “challenge” studies by Cincinnati-
lic deacon, helped found the local Mental Health area hospital researchers who deliberately induced
Consumer Network and the Health Resource psychosis by injecting amphetamines into patients
Center, a free clinic serving people experienc- who may not have had capacity to consent. Wald-
ing poverty or homelessness. When Waldbillig billig persisted in writing passionate newsletter
addressed police recruits, he shocked his audience articles criticizing the local mental health board
by disclosing his impulses toward violence against despite threats to cut off his funding. Waldbillig
 Patient Activism 621

also opposed pay increases for mental health around questions involving medication compli-
board administrators as long as case managers ance, involuntary hospitalization, or forced out-
providing direct service went underpaid. Until his patient treatment of people with mental illness.
death in 2001, at age 63, Waldbillig introduced
himself with these words: “Hi, I’m Urban Wald- Recovery
billig, and I’m an asshole.” Today’s activists appear to have united around
There is an awkward lack of useful nomencla- the concept of recovery, which constitutes the
ture classifying mental patient advocates by ide- major achievement of patient advocates in the
ology. People receiving public funding for their era of deinstitutionalization. The notion of recov-
activities or who are connected with treatment ery offers hope for a meaningful life that tran-
organizations have, since the 1960s, most often scends the experience of symptoms. Recovery
self-identified as mental health consumers. Those is a fluid but optimistic concept that involves a
who oppose a disease model or any coercive prac- person’s creating the best life possible under the
tices have tended to self-identify as survivors or circumstances. It is described as a process, not a
as members of patient liberation or antipsychiatry goal, because people have different strengths and
groups. In the years since deinstitutionalization, capacities and may continue to experience a wide
the activist community has become even more range of symptoms that vary in intensity, even
diverse. Activists from the 1960s and 1970s, who with medication or therapy.
more often than not shared the experience of psy- As vague as this might seem, the recovery con-
chiatric hospitalization, have over the course of cept stands in stark contrast to the disease model
three decades encountered new generations of of psychiatry, a system characterized by stigmatiz-
activists who never received inpatient psychiatric ing disorder labels and a permanent state of sick-
care. Many newer participants in mental health ness. One’s psychiatric diagnosis is said to persist
treatment avoid identifying with either tradition- throughout life, though it may be “in remission.”
ally defined group and seem uncomfortable using The concept of recovery sometimes aligns with
the term consumer to describe themselves, even if symptom remission but is still evolving. In 2011,
they believe that they have benefitted from medi- the U.S. Substance Abuse and Mental Health
cation or other psychiatric service. Some have Services Administration (SAMHSA) published a
simply experienced less severe symptoms or con- working definition of recovery after an extensive
sequences of mental illness, while others find any process of dialogue and consultation, followed
label attached to disclosure of mental illness limit- by an update in 2012. The evolution and further
ing or stigmatizing. refinement of this concept will largely result from
One trend becoming increasingly evident is the work of the very people who face the chal-
the determination of people with mental illness lenges of mental illness, which is also of great his-
to speak for themselves, not through surrogates torical significance.
or representatives. Messages about the need for Today’s debates concerning the nature and
mental health reform were once voiced nearly meaning of recovery, and program-related issues
exclusively by friends and relatives drawn from such as the role of peer-delivered services in men-
the larger community. Today, however, people tal health treatment are largely taking place over
with mental illness frequently express uneasiness the Internet, where issue activism flourishes. There
with friends and relatives who assume a right to are many active online communities organized
advocate on their behalf, particularly when the around criminal justice diversion programming,
message is from a parent or a parent-controlled the use of restraint and seclusion in treatment set-
organization. When young children need help, tings, the organization of peer-delivered services,
parent advocacy is essential; but when people and other mental health related topics. The major
reach adulthood, a parent’s help is less welcome, social networks and video sharing sites all contain
especially with respect to issues that affect a per- relevant material produced by people with mental
son’s rights or autonomy, or if a person’s child- illness. Many of today’s mental health bloggers,
hood was especially difficult or traumatizing. even those published on major media corpora-
Such intergenerational conflict emerges frequently tion Web sites, self-identify as people who have
622 Patient Rights

experienced or continue to experience the effects Clark, Noelene. “Demi Lovato Reveals Her Diagnosis
of mental illness. of Bipolar Disorder.” Los Angeles Times (April
Mental illness activism also takes place on the 20, 2011). http://latimesblogs.latimes.com/
ground. Although many people with mental ill- gossip/2011/04/demi-lovato-bipolar-disorder.html
ness have careers within every type of industry (Accessed May 2013).
and organization, and even help create public Fagone, J. “The Crusader.” Cincinnati, v.35/9 (2002).
policy, most mental health advocacy still involves Focus Issue. Community Mental Health Journal,
political protest. In 2012, dozens of activists v.17/1 (1981).
protested the closing of mental health clinics in Kristof, Nicholas. “Born to Not Get Bullied.” New
Chicago. Also in 2012, some 200 protesters con- York Times (February 29, 2012).
verged around the American Psychiatric Associa- Tomes, Nancy. “The Patient as a Policy Factor: A
tion convention in Philadelphia to demonstrate Historical Case Study of the Consumer/Survivor
against the revision of the Diagnostic and Statisti- Movement in Mental Health.” Health Affairs,
cal Manual of Mental Disorders (DSM-5). v.25/3 (2006).
New generations of activists are emerging from
the ranks of young people in educational settings.
The Web site Flipswitch Teens produces multiple
weekly podcasts for high school students and
young adults. Across the United States, groups of Patient Rights
college students have organized chapters of the
nonprofit group Active Minds, which focuses on Patient rights are rights accorded to people who
advocacy and support work. are receiving medical care. These rights vary by
Finally, there are a number of media celebrities country and jurisdiction, often in congruence
willing to share their experience of mental illness with local social and cultural norms. Modern
and recovery. Patty Duke and Mike Wallace were understandings of what rights are owed to medi-
early members of this group. More recently, Car- cal patients have largely evolved within a human
rie Fisher and Joe Pantoliano have come forward rights framework since the adoption of the United
with disclosures of depression and bipolar disor- Nations Universal Declaration of Human Rights
der. Glenn Close campaigns with her sister Jessie in 1948.
in a series of antistigma commercials. The televi- Local conceptions of the proper relationship
sion show House maintained a fund-raising and between patients and physicians may nonethe-
outreach partnership with NAMI. Lady Gaga has less reflect local understandings of the relation-
disclosed her experiences of bullying and depres- ship between a citizen and his or her state and the
sion and has founded a charity dedicated to elimi- obligations that each has toward the other. Such
nating bullying and preventing suicide. Demi relationships may be paternalistic (the physician’s
Lovato has disclosed both a mood disorder and determinations regarding the patient’s best inter-
an eating disorder and supports charitable efforts ests take priority over the patient’s wishes), infor-
to help young people facing similar challenges. mative (the patient is a consumer who is entitled
to evaluate and determine his or her own best
Paul Komarek interests, and the physician’s role is to offer infor-
Independent Scholar mation and alternatives), interpretive (the physi-
cian’s task is to help the patient understand his or
See Also: Consumer-Survivor Movement; her personal values and priorities and assist the
Deinstitutionalization; Diagnosis in Cross-National patient in making a choice that upholds those val-
Context; Internet and Social Media; Patient Rights. ues and priorities), or deliberative (the physician
should act as a teacher to the patient and help him
Further Readings or her understand what the best course of action
Chamberlin, Judi. On Our Own: Patient-Controlled would be in his or her specific case).
Alternatives to the Mental Health System. New In practice, elements of each of these ideals may
York: Hawthorne Books, 1978. be present in any given clinical encounter. While
 Patient Rights 623

scholars, policy makers, health care providers, family members to file complaints or grievances,
and service users continue to debate what is fun- thereby serving as a first line of defense against
damentally owed to patients by their physicians maltreatment.
and how best to codify these entitlements, the The specific rights of modern psychiatric
World Health Organization (WHO) has affirmed, patients vary by jurisdiction but tend to reflect an
on the basis of a growing international consen- understanding that individuals deemed “irratio-
sus, that all medical patients have four inalienable nal” or “abnormal” by the state are in a position
rights: the right to privacy, the right to refuse or of unique vulnerability and have historically been
consent to treatment, the right to have informa- shortchanged by overly paternalistic approaches
tion about their health care held in confidence, to rehabilitation. For example, Canada’s larg-
and the right to be apprised of risks associated est psychiatric teaching hospital, the Centre for
with medical procedures. Addiction and Mental Health (CAMH), has
Because the freedoms of psychiatric patients developed a Bill of Client Rights specifying that
may be qualified or curtailed in ways that would all patients have, among other rights, the right to
seem to violate the basic rights that all medical be free from physical, sexual, verbal, emotional,
patients ought to enjoy, they face distinctive chal- and financial abuse; the right to regular access to
lenges in health care contexts. Patients who are recreational activities and the outdoors; the right
deemed cognitively incapable and thus legally to seek an additional medical opinion; the right
incompetent to make decisions concerning their to access toilet facilities in private; the right to
health care cannot give or withhold informed con- know the names of staff members; the right to
sent or refuse treatment. In such situations, health wear their own clothing; the right to nourishing
care providers must turn to legally appointed sur- and appetizing food; the right to file a complaint;
rogates or advance directives for guidance about and the right to be notified promptly when his or
a patient’s original or likely wishes and to obtain her detention is no longer involuntary.
consent to proceed with a given procedure. The Inpatients at CAMH who meet clinical criteria
challenge of assuring that patients’ rights are for mental capacity, and thus legal competence,
respected at all times accordingly requires the additionally enjoy the right to consent to or refuse
ongoing education of ordinary citizens about treatment on their own behaf; the right to manage
what obligations their governments and health their own money; and the right to be free of envi-
care providers have toward them, about what ronmental, chemical, or mechanical restraints.
instruments for safeguarding their current wishes Inpatients who are found mentally incapable do
in anticipation of future incapacitation are avail- not enjoy these latter freedoms because they are
able to them, and about what modes of redress deemed potential threats to themselves or others,
are available to those who believe their rights are but retain the right to have surrogate decision
being violated (such as patients’ advocacy offices, makers give or withhold consent to treatment and
ombudsmen, and consent and capacity boards). may appeal their physicians’ finding of mental
incapacity to a review board.
Psychiatric Patients’ Rights in Custodial The WHO has recommended that mental health
Institutions and in the Community legislation be formulated on the basis of the prin-
In most Western nations, major strides have been ciple of the least restrictive alternative, which holds
made toward redressing the many injustices and that a person’s treatment plan should be designed
abuses that psychiatric patients have historically to minimally impair his or her freedom to move,
endured. Today, many psychiatric hospital wards work, and conduct personal affairs in the com-
and custodial facilities acknowledge, at least in munity. Under WHO guidelines, involuntary hos-
principle, the right of patients to a respectful level pitalization should take place only in exceptional,
of care that takes into account the degree to which clearly defined circumstances, and patients should
they can express preferences, appreciate relevant always have the right to appeal their admission. In
facts and information, and make decisions. While practice, the principle of the least restrictive alter-
these principles are not always realized in prac- native has in recent years resulted in, and validated,
tice, they offer a basic framework for patients and two outcomes that many patients’ rights advocates
624 Patient Rights

have found problematic: (1) the closure of inpa- same circumstances, the applicable standard of
tient facilities and substitution of outpatient com- care has not been violated and the doctor would
mittal programs that manage patients by requiring not be found negligent. This criterion can make
them to take drugs and (2) the reallocation of sav- it difficult for patients who feel maltreated to file
ings to disability allowances that cover drugs but successful malpractice complaints, as their clini-
not other resources vital for mental wellness. Invol- cians’ conduct may not have deviated appreciably
untary outpatient commitment programs (IOCs), from the accepted professional standard as deter-
which are also known as community treatment mined by their peers.
orders, require psychiatric outpatients to take
medications while living in the community or be Historical Development of Patients’ Rights
forcibly detained. Modern rights-based movements in mental health
Patients and their advocates have objected to care are generally said to have arisen in the 1960s
such commitment programs on the grounds that and 1970s in response to abusive practices in
they discriminate against people with psychiat- North American and western European psychiat-
ric disabilities and thereby violate their human ric wards. However, the basic notion that people
rights—that is, they assume prima facie that peo- detained in custodial institutions deserve protec-
ple with psychiatric conditions are predisposed to tion from egregious maltreatment predates the
violence, obligate them to ingest chemicals that modern patients’ rights movement by up to two
may incur serious side effects, and dispropor- centuries. For example, in response to two com-
tionately target the poor. Because IOCs ensure mon forms of abuse in 18th-century madhouses—
compliance on the basis of an implied threat the detention of lunatics in appalling conditions
and because a robust complement of treatment and the wrongful confinement of the mentally
alternatives is generally not presented for consid- well—the Parliament of Great Britain passed its
eration, patients’ rights advocates have argued 1774 Act for Regulating Private Madhouses.
that outpatient commitment programs fail to This piece of legislation mandated the licensing
uphold the doctrine of informed consent. In con- and systematic inspection of private madhouses
trast, governments and doctors have argued that and registration of confined individuals. It thus
IOC programs are actually major guarantors of went some way toward safeguarding the dignity
patients’ rights because they safeguard the right of of actual and potential inmates, although its main
the individual to standards of living adequate to beneficiaries tended to be rich and propertied.
the maintenance of health. From this latter point The introduction of such legislative protections
of view, compulsory medication prevents further in the late 18th century may have been facili-
deterioration in recipients who do not or cannot tated by the rise of therapeutic paradigms such as
recognize the severity of their illness. moral treatment, whose chief proponents, Samuel
Like other medical patients, psychiatric Tuke (1784–1857) in England and Philippe Pinel
patients who believe they have experienced mal- (1745–1826) in France, advocated rehabilitative
practice typically have the right to file grievances methods that relied on habituating patients into
with professional regulatory bodies that over- accepted norms and routines rather than on phys-
see the practice of medicine in a given area by ical coercion.
licensing doctors, investigate allegations of mis- The rise of public asylum systems in the 19th
conduct, and administer disciplinary action. In century was accompanied, and in some cases facil-
common law jurisdictions, a decisive criterion in itated, by new forms of patients’ rights activism.
the evaluation of medical liability is the question During a visit to Britain, American schoolteacher
of whether the “standard of care” was upheld Dorothea Dix (1802–87) learned of the British
in any given case. This term refers to the course lunacy reform movement and was sufficiently
of action and level of prudence that can reason- inspired to begin investigating the unregulated
ably be expected of a physician presented with a detention and abuse of indigent lunatics in her own
particular situation. If a doctor’s treatment of a country. The reports that Dix presented on these
patient was consistent with the pattern of action issues to state legislatures eventually led to the
that other doctors would have undertaken in the establishment of several public mental hospitals
 Patient Rights 625

in the United States, where pauper lunatics could Major patients’ rights groups of this era include
receive regulated care. A contemporary of Dix’s, the Insane Liberation Front in Portland, Oregon
Elizabeth Parsons Ware Packard (1816–97), (founded in 1970), the Vancouver Mental Patients
became a prolific advocate for people accused of Association (1970), the Mental Patients Libera-
insanity after her own wrongful confinement from tion Front in Boston (1971), the Mental Patients
1860 to 1883 in a public insane asylum. Unlike Liberation Project in New York City (1971), the
Dix, Packard’s advocacy did not enjoy the sup- Mental Patients Union in the United Kingdom
port of mainstream medical professionals, as she (1971), and the Network Against Psychiatric
criticized rather than promoted the public asylum Assault in San Francisco (1972).
system. Her significance as an early patients’ rights By the 1970s and early 1980s, due in part to
advocate was rediscovered in the 1960s with the the efforts of such groups, mandatory labor on
rise of Western antipsychiatry and civil liberties psychiatric wards was made illegal, sanitary and
movements. Clifford Beers (1876–1943), a psychi- aesthetic conditions were improved, and most
atric patient and founder of the American mental Western jurisdictions had adopted rights-based
hygiene movement, was another early advocate mental health laws that set out concrete criteria
for inpatients’ right to respectful treatment. Beers for involuntary civil commitment. Throughout
published an influential memoir about the abuses the 1980s, patients’ rights activists lobbied for
he endured in psychiatric hospitals in 1908 and hospitals and other public health bodies to include
founded the first outpatient mental health clinic in patients on their advisory boards. While this aim
the United States in 1913. was largely achieved, many activists became criti-
Up until the mid-20th century, mental health cal of the salaries and benefits their peers enjoyed
laws in the West tended to encourage informal while serving as consultants and argued that the
arrangements for admitting people to inpatient professionalization of patients’ rights advocacy
wards because of the social opprobrium associ- had diminished the politically radical character of
ated with formal civil commitment. In practice, the original movement.
informal arrangements often led to serious abuses In the 1990s, Western jurisdictions began to
arising from the broad statutory discretion that formally recognize the value of advance health
medical professionals enjoyed at that time. More- care directives and other instruments for promot-
over, until the late 1960s, legal statutes through- ing the active participation of mental patients in
out the United States continued to deprive men- treatment decisions. As consent may be elicited
tal patients of the right to vote, marry, and hold in the shadow of involuntary commitment laws,
professional licenses while hospitalized; required doctors have an obligation to discuss options for
patients to perform mandatory unpaid work on care in a sensitive manner that takes into account
hospital wards; and authorized police officers psychiatric patients’ unique dilemmas—patients
to detain and commit people essentially at their with valid objections to their treatment plans may
own discretion. be reluctant to open a dialogue with their clini-
In the 1960s and 1970s, the public’s grow- cians for fear of being labeled “noncompliant.” In
ing awareness of abuses in psychiatric wards 2003, the nongovernmental human rights agency
and the rise of civil rights discourses promot- Human Rights Watch pointed out that recovery
ing the right of the individual to freedom from from psychiatric crisis requires a multidisciplinary
state interference helped to bring questions of therapeutic framework that addresses patients as
autonomy and consent to the forefront of debates individuals with unique life histories and does not
about patients’ rights. It was in this climate that rely excessively on the suppression of disturbing
the modern patients’ rights movement emerged. symptoms through psychotropic medications.
Participants in this movement, many of whom The centrality of nonsomatic, dialogical modes
mobilized under names such as “mad liberation,” of therapy to successful rehabilitation is a major
“patient liberation,” and “psychiatric inmate lib- tenet of today’s patients’ rights movements.
eration,” contributed to many important legal
battles throughout the 1970s and set the stage for Eugenia Tsao
today’s psychiatric consumer-survivor movement. University of Toronto
626 Peer Identification

See Also: Case Managers; Competency and benefits of peer identification have been widely
Credibility; Compulsory Treatment; Consumer- accepted in many areas such as cancer, addiction,
Survivor Movement; Courts; Dangerousness; and trauma support (e.g., Alcoholics Anony-
Euthanasia; Human Rights; Informed Consent; mous, the American Cancer Society, and the
Law and Mental Illness; Legislation; Malpractice; Trauma Survivors Network). Historically, peer
Mechanical Restraint; Mental Hygiene; Patient identification has not been as well utilized in the
Activism; Public Education Campaigns; Right to mental health field because of stigma and cultural
Refuse Treatment; Right to Treatment; Service User stereotypes of mental illness; however, this con-
Involvement; Voluntary Commitment. cept has grown in mental health since the early
1990s and has taken off across the nation. In the
Further Readings mental health field, this concept is more com-
Centre for Addiction and Mental Health. “Bill of monly known as peer support, and it is founded
Client Rights.” (2012). http://www.camh.ca/en/hos on the idea that individuals who have lived men-
pital/visiting_camh/rights_and_policies/Documents tal health experiences and are in recovery can use
/billofclientrights.pdf (Accessed June 2013). their experience to offer mutual support, encour-
Chamberlin, Judi. On Our Own: Patient-Controlled agement, hope, and role modeling to others who
Alternatives to the Mental Health System. New are facing mental illness from an authentic and
York: Hawthorn Books, 1978. empathic viewpoint.
Crossley, Nick. Contesting Psychiatry: Social The first evidence of the utilization of peer
Movements in Mental Health. London: Routledge, identification in the mental health field was by
2006. Harry Stack Sullivan, a psychiatrist who ran an
Human Rights Watch. Ill-Equipped: U.S. Prisons and inpatient service for men who experienced schizo-
Offenders With Mental Illness. New York: Human phrenia in Baltimore, Maryland, in the 1920s.
Rights Watch, 2003. Sullivan recruited patients who had recovered
Morrison, Linda J. Talking Back to Psychiatry: from their illness to serve as his aides in the belief
The Psychiatric Consumer/Survivor/Ex-Patient that the personal experiences of men with psycho-
Movement. New York: Routledge, 2005. sis, who were in recovery, made them specifically
Shimrat, Irit. Call Me Crazy: Stories From the Mad qualified to work with peers facing similar chal-
Movement. Vancouver, Canada: Press Gang lenges. Though Sullivan and a few other thera-
Publishers, 1997. peutic communities utilized peer support in the
Weller, Penelope. New Law and Ethics in Mental 1950s and 1970s, these concepts were not well
Health Advance Directives: The Convention on the received until the aftermath of the deinstitution-
Rights of Persons With Disabilities and the Right alization movement, which moved people who
to Choose. New York: Routledge, 2013. experienced mental illness out of hospitals and
World Health Organization (WHO). Mental back into communities.
Health Legislation and Human Rights. Geneva: As a result of this movement, ex-patients pro-
WHO, 2003. tested against the treatment they experienced
World Health Organization. “Patients’ Rights.” while hospitalized, forming the Mental Health
(2013). http://www.who.int/genomics/public/ Consumer Movement, which also gave way to
patientrights/en (Accessed June 2013). the development of mutual peer support groups.
As individuals moved into the community, more
services were needed to aid people with support-
ive networks as they became restored to commu-
nity life, thus creating an avenue for the growth
Peer Identification of peer support.
Peer support in the mental health field takes
Individuals who have endured and overcome on different forms: consumer-run services, con-
adversity can identify with other individuals with sumers employed as peers in mental health set-
similar experiences and benefit from a personal tings, and mutual support groups. Within these
connection and offering of mutual support. The different contexts, peer support may be provided
 Peer Identification 627

in different forms, such as via drop-in centers, Peer support is not based on psychiatric models
social clubs, support groups, inpatient psychiatric and diagnostic criteria but is a network of giv-
stays, outpatient mental health center visits, peer ing and receiving help with principles of mutual
forums, recreation groups, and recovery-oriented agreement, respect, and shared responsibility. Peer
groups. A prevention-based peer center empow- support foundations include ideals of empathi-
ers individuals by offering resources, activities, cally understanding another person’s experience
groups, and opportunities to reconceptualize per- of emotional and psychological pain from one’s
sonal beliefs about mental illness and personal personal experience, which creates a unique con-
identity. Some of those typical resources might nection. Some of the benefits of peer support
include strengthening self-advocacy, building of include a developed trust in one another, which
mutually empowering relationships, recognition allows peers to respectfully challenge each other,
and diminishment of codependency, parenting try out new behaviors, and build mutual empow-
classes to maintain custody of children, trauma erment, moving beyond an identity built on a
support groups, development of wellness recovery diagnosis or disability. Empowerment is essential
action plans (individual plans to empower indi- because of learned, stigmatized roles as a men-
viduals with ways to stay well), psycho-education tal patient as a result of living in a culture that
on coping methods for individuals who deal with defines individuals who experience mental illness
voices, and social activities that help build the in this manner. Therefore, this social interaction
community and break down isolation. of peer support affords people the opportunity to

Lieutenant Gen. John Sattler of the U.S. Joint Chiefs of Staff speaks to the members and staff of the Tragedy Assistance Program for
Survivors (TAPS) as part of their annual Memorial Day gathering in Arlington, Virginia, May 25, 2007. TAPS provides a peer support
network for the surviving families of those who have died in military service. Many studies indicate positive effects of peer support,
including increased empowerment, social support, social functioning, coping and problem-solving skills, and hope and acceptance.
628 Personality Disorder, Borderline

move beyond socially constructed passive roles as Mead, Shery, David Milton, and Laurie Curtis. “Peer
a patient reliant on experts, and a personal ability Support: A Theoretical Perspective.” Psychiatric
to model, provide feedback, and assist others as Rehabilitation Journal, v.25 (2001).
they face their problems. This shift in roles can
have an incredible impact on people’s lives and
helps build an identity based on meaningfulness
and the creation of a life that one desires. Peer
support encourages diversity, recognizes indi- Personality Disorder,
vidual strengths, helps individuals move toward
autonomy, and empowers people to grow in the Borderline
direction of their life choices.
Research on the efficacy of peer support has Borderline personality disorder (BPD) is a major
presented some inconsistent findings, though it is public health concern and is officially defined in
limited because of the nature of the existing data. culturally relative terms. Still, there has been a
However, many studies indicate that peer support dearth of cross-cultural research relating to BPD.
decreases hospitalizations, increases empower- The extant research suggests that although cul-
ment, decreases stigma, increases social support tural factors may play a role, this form of psycho-
and social functioning, increases community inte- pathology appears to manifest with more simi-
gration, increases coping and problem solving larities than differences across cultures. Prevalence
skills, and increases hope and acceptance. Because rates within a few percentage points of each other
many with mental illness have markedly reduced have been reported across a broad array of nations
social networks, community integration is impor- and cultures, and assessment inventories appear
tant because this empowers individuals to engage to function well across cultural groups. However,
in voluntary relationships, valued social roles, and specific (sub-) cultural factors, such as gender,
life-enriching activities. These valued roles in the affluence, and incongruence with one’s cultural
community are crucial and allow individuals to see individualism/collectivism orientation may be
themselves as instrumental and valuable, afford- associated with differing levels of pathology.
ing avenues for the creation of positive self-worth. Even without culture taken into consideration,
The growth of peer support and its movement has BPD manifests in a wide variety of ways. This is
the opportunity to not just mold the mental health true by its very definition in the fourth edition (text
field but also create healing and positive social revision) of the Diagnostic and Statistical Manual
change, as well as a healthier society. of Mental Disorders (DSM-IV-TR), which applies
a polythetic diagnostic algorithm. In that system,
Erika Carr at least five of the nine listed criteria must be pres-
Memphis VA Medical Center ent for a diagnosis. One implication of this system
is that two patients can receive a BPD diagnosis
See Also: Community Mental Health Centers; and share only a single criterion (e.g., “chronic
Community Psychiatry; Family Support; Group feelings of emptiness”). A second implication is
Homes; Identity; Internet and Social Media; Social that multiple constellations of criteria can meet
Support. the diagnostic threshold: There are 256 possible
combinations of the nine diagnostic criteria that
Further Readings can result in a BPD diagnosis. Thus, there is nota-
Davidson, Larry, Matthew Chinman, Bret Kloos, ble heterogeneity of presentation within this diag-
Richard Weingarten, David Stayner, and Jacob nostic class, culture aside.
Tebes. “Peer Support Among Individuals With When culture is taken into account, the defi-
Severe Mental Illness: A Review of the Evidence.” nitional variety of BPD phenomenology is com-
Clinical Psychology: Science and Practice, v.6 plicated even further. Culture-related factors play
(1999). a prominent role in the diagnosis of this, and all
House, J., K. Landis, and D. Umberson. “Social other, personality disorders. The general person-
Relationships and Health.” Science, v.241 (1988). ality disorder criterion set of DSM-IV-TR requires
 Personality Disorder, Borderline 629

that personality disorder manifest as patterns of the pathology well across cultures. Armand Lor-
cognition, affectivity, interpersonal functioning, anger and colleagues reported that clinicians in a
and impulse control that markedly deviate from wide range of countries (e.g., England, Germany,
the expectations of the individual’s culture. In India, Kenya, Norway, and the United States)
other words, possible culture-related heteroge- found such an internationally oriented instru-
neity of BPD manifestation is enshrined in the ment, the International Personality Disorder
diagnostic manual. Not much literature exists on Examination, to be clinically acceptable for char-
cross-cultural aspects of BPD. This is in contrast acterizing personality disorder, suggesting gener-
to other personality disorders, such as antisocial ally similar manifestations. Other personality dis-
personality disorder, which have received more order assessment measures constructed without
cross-cultural attention. explicit cross-cultural consideration—primarily
The research indicates that BPD presents in a geared toward American patients—have also been
variety of world cultures. In general, these cross- translated into a variety of languages. In general,
cultural manifestations appear more similar than studies of these sorts of measures have also shown
different. Naoki Moriya and colleagues, in the similar psychometric properties and latent factor
first report of BPD in Japan, demonstrated that structures across cultures. This also suggests that
largely equivalent BPD entities existed in Japan the particular constellation of signs and symp-
and the United States. While some differences toms classified as BPD occurs cross-culturally.
were reported (e.g., psychotic phenomena such Although the general clinical picture of BPD
as depersonalization and derealization were appears to be similar cross-culturally, some dif-
more commonly seen in Japan than in the United ferences have been noted. For instance, cultural
States), BPD manifestation was generally similar orientation toward individualism versus collec-
across these Eastern and Western cultures. Other tivism, and the incongruence of one’s orientation
studies in this vein from various cultures (e.g., with the broader cultural milieu, appears related
Japan and Scotland) have identified symptom to BPD. In the highly collectivist culture of Turkey,
presentations that are basically identical to those having an incongruent orientation toward indi-
seen in American individuals with BPD. vidualism has been associated with greater levels
Several studies have examined cross-cultural of BPD (and a congruent orientation toward col-
aspects of variables related to BPD, rather than lectivism has been associated with lower levels).
its formal diagnosis. There is evidence that some Subcultural differences relating to socioeco-
of the associated signs and symptoms of BPD, nomic status may also play a key role in the etiol-
such as suicidal behavior, generally show cross- ogy and manifestation of BPD. For instance, one
cultural similarities. In terms of its core features, study of 4,811 university students in China exam-
BPD represents a confluence of latent internaliz- ined a variety of (sub-) cultural factors in relation
ing and externalizing liabilities. These liabilities to BPD. The results of this study indicated that
are invariant across age, ethnicity, gender, and students from poor families scored significantly
nationality, suggesting that BPD reflects similar higher on BPD scales than students from aver-
psychopathological processes across groups. age or wealthy families. This suggests that sub-
In terms of its diagnostic prevalence, BPD culture group membership defined by affluence
tends to show broadly similar rates across various level relates to BPD. However, research has failed
locales. In a review of this literature, Svenn Torg- to support other subcultural factors (e.g., urban
ersen and colleagues found rates of 1.1 percent in versus rural, singletons versus nonsingletons, and
Mainz, Germany; 3.8 percent in Umeå, Sweden; family parental structure) as relating to differences
2 percent in New York; and 0.7 percent in Oslo, in BPD levels.
Norway. Although these studies used various sam-
pling strategies and assessments, the prevalence fell Nicholas R. Eaton
within a relatively restricted range. Women tend to Stony Brook University
report higher rates of BPD symptoms than men.
Studies have suggested that BPD measures See Also: Antisocial Behavior; DSM-IV; Personality
designed with an international focus can capture Disorders; Schizoaffective Disorder; Schizophrenia.
630 Personality Disorders

Further Readings an atypical thought style, along with difficulty

Caldwell-Harris, Catherine L. and Ayse Ayçiçegi. establishing and maintaining relationships. The
“When Personality and Culture Clash: The paranoid personality imparts malicious intent
Psychological Distress of Allocentrics in an into the most benign circumstances; the schizoid
Individualistic Culture and Idiocentrics in a personality is insularly detached from interaction,
Collectivist Culture.” Transcultural Psychiatry, finding quiet introspection preferable to boister-
v.43/3 (2006). ous communion; the schizotypal displays odd
Moriya, Naoki, Yuko Miyake, Kuninao Minakawa, behavior and thought that amounts to a dimin-
Norimasa Ikuta, and Aya Nishizono-Maher. ished version of schizophrenic disorientation.
“Diagnosis and Clinical Features of Borderline Second, the dramatic emotional and erratic
Personality Disorder in the East and West: A cluster include the borderline, antisocial, narcis-
Preliminary Report.” Comprehensive Psychiatry, sistic, and histrionic personality disorders, which
v.34/6 (1993). are all impulsive, explosive, and volatile. The bor-
Nettle, Daniel. Personality: What Makes You the derline personality has severe identity diffusion
Way You Are. New York: Oxford University Press, and cannot maintain healthy relationships with
2009. others; the antisocial personality exploits others,
using them as means to an end; the narcissistic
personality is grandiose and self-absorbed; the
histrionic personality is effusively emotional and
affectively labile. Third, the anxious and fearful
Personality Disorders cluster are all cautious and fretful. The avoidant
personality wants to establish social relation-
Personality disorders are unique among psy- ships but does not have the boldness to do so;
chiatric classifications and diagnoses. What is the dependent personality forms social relation-
pathologized is not a transient dysfunction with ships but is pathologically dependent on them;
a discrete onset but the person as a whole; what the obsessive-compulsive personality disorder is
is pathologized is a set of enduring traits, affects, driven to work excessively while neglecting other
and cognitions that together define the per- life domains.
son in which they reside. Personality disorders
are unique in yet another way. The creation of Personality Disorders and Culture
these categories of mental illness is infused with These 10 personality disorders have an intimate
culturally relative value judgments. The values relationship with culture and society. In some
of a culture, reflected in its creation myths, lit- instances, psychiatric diagnosis is as concrete as
erature, and leaders, inform a healthy ideal, an medical diagnosis. Disorders such as autism and
archetypal cultural form by which others are schizophrenia are cross-culturally recognizable
judged. Accordingly, a character type can be patterns of signs and symptoms. Moreover, such
pathologized or not, depending upon the culture concrete psychiatric diagnoses correlate with
in which it is found. New directions in under- structural and functional brain abnormalities,
standing personality promise greater objectivity such as the enlarged ventricles seen in schizo-
and partial freedom from culturally relativistic phrenic brain imaging and autopsy. Other dis-
diagnosis. By better understanding personality, orders, such as anxiety and depression, are less
scientists are now better able to understand per- concrete. While they are represented in the brain,
sonality pathology. they are more discrete and functional than overt
In the fourth edition of the Diagnostic and and structural. Furthermore, controversy exists
Statistical Manual of Mental Disorders (DSM- as to when such disorders segue from normal
IV), the American Psychiatric Association defines experience to clinically significant diagnosable
three overarching groups, containing a total of 10 pathology.
personality disorders. First, the odd and eccen- First, culture will determine the point at which
tric cluster includes the paranoid, schizoid, and grief and sadness transition from normal suffer-
schizotypal personality disorders, which all share ing to diagnosable disorder. Second, culture will
 Personality Disorders 631

determine whether the depressed person receives In other words, selective neutrality attributes per-
psychiatric treatment and medication or folk sonality variation to random noise that, although
treatment and moral support. The relationship it is phenotypically expressed and genotypically
between schizophrenia and depression is rep- represented, is not meaningfully acted upon by
resentative of a generality; that is, as disorders selection. Nevertheless, more recent research rec-
become less demonstrably physical and structural, ognizes personality as important to survival and
they become more relative. Culturally informed reproduction, and thereby it lies under the opera-
judgments wax as concretely expressed pathology tion of natural selection and sexual selection.
wanes. Personality disorders, more than depres- From an evolutionary perspective, personalities
sion or anxiety, and much more than schizophre- are the way they are because they ensure survival
nia or autism, are culturally relativistic. and enhance the reproductive success of the per-
In the subtext of the personality disorder cri- son in which they reside. Increasingly, personality
teria is an unarticulated Aristotelian mean: a cul- is recognized as strategic.
turally prescribed exemplar, adherence to which In addition to demonstrating the strategy and
denotes normality, and deviation from which functionality of personality, evolutionary perspec-
denotes abnormality. Stitched into the fabric of tives are explaining the diversity of personality
personality disorder diagnosis via the DSM is an types. The concept of niche splitting is integral to
American variety of modern Western values that this explanation. In any environment, resources
exalts individualism over collectivism, agency over are limited. Limited resources compel competi-
dependency, optimism over pessimism, extraver- tion. Competition compels diversification. Ani-
sion over introversion, mutability over stasis, and mals diversify across a variety of behavioral and
balance over specialization. Because in no other morphological traits in order to exploit different
diagnostic domain is the presence of this cultural niches within the environment. In humans, this
ethos so strongly felt, personality disorders exist variation extends to personality. In certain pro-
by way of interpretation as much as by way of portions, dominant and nondominant, extra-
discovery. Personality disorders are constructed verted and introverted, agreeable and disagree-
as much as detected. Therein is the problematic able types will be selected. Any given trait is on a
relativism that has dogged personality disorder continuum; there are two extremes and a range of
diagnosis from its inception. In this way, person- possibilities between them.
ality disorders will never easily coexist with a pos- Before personality was understood from an
itivist understanding of mental illness as concrete, evolutionary perspective, one end or some bal-
cross-cultural, and organic. anced midpoint was deemed a marker of men-
tal health. With this evolutionary perspective,
New Directions each point along the continuum is recognized as
Confusion about what constitutes disordered a viable strategy. Each point has costs and ben-
personality stems from more fundamental confu- efits. Taking the continuum of extraversion and
sion as to the very nature of personality. As the introversion as an example illustrates the point:
nature of personality is elucidated, discriminating extraversion potentiates alliances formation, mat-
between normal personality variation and per- ing opportunities and resource acquisition, but at
sonality disorder becomes more rigorously objec- the same time, it exposes its possessor to conflict,
tive and consequently less relativistic. Drawing on predation, and injury. This view understands the
such diverse fields as evolutionary biology, behav- introvert to be not pathologically insular, but
ior genetics, genetics, and game theory, a new hedging his bets, strategically avoiding gains so
science of personality is being constructed. Per- as to avoid risk. This view is antithetical to the
sonality is not simply described, it is explained. implicit view that there is one healthy personality
Personality was initially neglected by evolution- type, deviation from which is evidence of person-
ary psychology and its related disciplines because ality pathology.
of the influential theory of selective neutrality, The most compelling illustration of such an
which suggests that selective pressures do not evolutionary approach to personality pathology
operate on personality and individual differences. comes from Linda Mealey’s “The Sociobiology
632 Pervasive Developmental Disorders

of Sociopathy,” published in 1995 in Behavioral Further Readings

and Brain Sciences. Mealey went beyond describ- Alarcón, Renato D., Edward F. Foulks, and Mark
ing the adaptive advantage of individual traits to Vakkur. Personality Disorders and Culture:
give a comprehensive evolutionary explanation Clinical and Conceptual Interactions. Hoboken,
to one of the most infamous personality types. NJ: John Wiley & Sons, 1998.
The psychopathic personality, which is akin to Mealey, Linda. “The Sociobiology of Sociopathy: An
DSM-IV antisocial personality disorder, violates Integrated Evolutionary Model.” Behavioral and
all of the standards used to differentiate the nor- Brain Sciences, v.18 (1995).
mal from the abnormal personality; it is extreme, Nettle, Daniel. Personality: What Makes You the
statistically rare, and conspicuously imbalanced. Way You Are. New York: Oxford University Press,
Still further, the psychopath deviates markedly 2009.
from implicit cultural ideals and therefore has
been classified by the American Psychiatric Asso-
ciation as a mental disorder. Mealey understands
the sociopath to be an evolutionarily designed
behavioral-affective pattern formulated specifi- Pervasive Developmental
cally for exploitative exchanges with the larger
population. Disorders
The sociopath is on one hand sensation seek-
ing, having little inhibitory anxiety, and on the Pervasive developmental disorders (PDD) is an
other hand insensitive, having little human empa- umbrella term for developmental disorders related
thy. Such genetically informed cognitive and emo- to socialization, communication, and patterns of
tional dispositions create a complex of traits, a behavior. There are two major diagnostic systems
personality type that is especially good at manipu- for PDD: the International Classification of Dis-
lating others. Although the antisocial is a parasitic eases, 10th revision (ICD-10) and the Diagnostic
burden to society that deviates from the ideals of and Statistical Manual of Mental Disorders, 5th
honesty, conscientiousness, honor, and emotional edition (DSM-5). According to the ICD-10, PDD
restraint, from this perspective, the personality is consists of childhood autism, atypical autism,
not disordered in the strict sense. The sociopath, Rett syndrome, childhood disintegrative disor-
when he cons, like the mosquito when it feeds, is der (CDD), overactive disorder associated with
functioning as he was designed to function. mental retardation and stereotyped movements,
The 10 personality disorders described in Asperger’s syndrome, other pervasive develop-
DSM-IV have yet to be systematically treated by mental disorders, and pervasive developmental
an evolutionary perspective. Nevertheless, such disorder, unspecified.
conceptualizations of personality traits and types The DSM-5, released in 2013, has reclassified
promise to transcend the cultural relativism that PDD as a single diagnosis: autism spectrum dis-
is so prominent in personality disorder diagno- order (ASD). The influx of international media
sis. While still recognizing the role that culture attention and access to information has helped
plays in shaping personality, an evolutionary to raise awareness of PDD (herein referred to as
perspective can provide an objective basis from ASD) throughout the world; however, much of
which personality types can be judged, thereby the current understanding of ASD comes from
separating environmentally instilled personal- research from Western societies. Worldwide
ity pathology from genetically instilled strategic methodological discrepancies in how the disor-
extremes. ders are reported, diagnosed, and treated cre-
ate discrepancies in epidemiological estimates of
Steven Charles Hertler ASD. Psychiatric diagnoses and explanations for
College of New Rochelle behavior are deeply embedded in cultural norms,
expectations for social behaviors and develop-
See Also: Antisocial Behavior; Personality Disorder, mental milestones, gender roles, social stigmas,
Borderline; Schizoaffective Disorder; Schizophrenia. and individual personalities.
 Pervasive Developmental Disorders 633

Autism and regions with little access to appropriate spe-

Autism is characterized by social communicative cialists and services (such as Nigeria and Taiwan),
deficits (emotional understanding and expression) autism is often not recognized as a distinct dis-
and restricted, repetitive, and stereotyped behav- ability; therefore, subsequent diagnoses and inter-
iors, activities, and interests (including sensory ventions are delayed or nonexistent. Symptoms of
abnormalities, unusual attachment to objects, and autism may be interpreted as demon possession
self-stimulatory behaviors such as hand-flapping). requiring the intervention of a traditional or reli-
ASD emerges in early childhood though may not gious healer rather than psychiatric or behavioral
fully manifest until social demands exceed the treatments. Without sufficient services or trained
child’s capacities. Challenges to communication specialists, parents feel isolated and their children
accompany a wide spectrum of intellectual abili- are often considered “mad” and excluded from
ties and may consist of echolalia, inappropriate school. In regions where disabilities carry social
responses to social stimuli, or a complete lack of stigmas (such as in India), families face discrimi-
speech. The ICD-10 identifies that individuals nation when their children with autism cannot
with atypical autism differ in their age of onset or integrate into the larger family unit.
failure to meet diagnostic criteria for autism.
Diagnostic criteria depend on cultural expec- Rett Syndrome
tations for socially appropriate behaviors. For Rett syndrome is a rare neurological disorder
example, in regions where direct eye contact is caused by a spontaneous mutation on the MECP2
valued (such as in the United States), the avoid- gene on the X chromosome. This syndrome is
ance of eye contact is a criteria for diagnosing almost exclusively found in girls worldwide at a
autism. In cultures such as Asia, where averting rate of approximately one per 10,000 to 15,000
one’s eyes is considered respectful and traits of female births. Between 6 and 18 months of age,
introversion are reinforced, poor eye contact or children with Rett syndrome lose motor abili-
socially withdrawn behaviors may not be atypi- ties, especially purposeful hand function and the
cal. Furthermore, in cultures where females are ability to speak. Other symptoms include stereo-
expected to be socially reserved (such as in Saudi typed behaviors (such as hand-wringing), motor
Arabia), the social communication deficits asso- impairments (apraxia), scoliosis, slowed head
ciated with autism may be recognized later for and brain growth, seizures, social withdrawal,
girls than boys. The failure to appropriately apply and sleep and breathing problems. Its rarity and
social rules may be more readily noted in cul- variability of symptoms increase the likelihood of
tures (such as in South Korea) where children are misdiagnosis, as it is easily confused with other
expected to conform to prescribed social roles. disorders such as autism. Insufficient informa-
Though understudied, autism has been noted tion, lack of trained specialists, scarce resources,
in developing regions such as Africa. Differences and limited access to medical care are barriers for
in behavioral characteristics found in African parents seeking a diagnosis of Rett syndrome in
children included less stereotypic movements many regions such as China. While there is no
compared to American and British comparative known cure, some symptoms may lessen as the
groups; however, these differences may be due to child reaches adolescence. Treatments focus on
incomplete developmental histories, the degree physical therapies to improve mobility as well as
of intervention the child has received to reduce the management of behavioral, motor, and health
or eliminate unwanted behaviors, or culturally symptoms. Rett syndrome is no longer in the
biased assessment instruments. DSM due to its genetic etiology.
In the United States and the United Kingdom,
autism is viewed as a genetic, brain-based condi- Childhood Disintegrative Disorder
tion; in other parts of the world, children with sim- and Overactive Disorder
ilar behaviors may be diagnosed with an intellec- CDD is characterized by the gradual or abrupt
tual disability or an attachment disorder believed loss of previously acquired language, social and
to be caused by neglectful or dysfunctional par- self-care (including bowel/bladder control), play,
enting (such as in India). In rural communities and motor skills. The regression usually occurs
634 Pervasive Developmental Disorders

between 2 to 4 years of age and is more common methods of treatment, lack of attention to child-
among males than females. Rarer than autism, hood psychiatry, and underfunded social services.
CDD is considered a variation of autism though Gathering accurate prevalence data is further
distinct in its severity and speed of regression challenged in some countries because of incon-
across various domains of development. CDD is sistent medical reporting, no recognition of ASD,
subsumed under the label of ASD in the DSM-5. and/or the use of other diagnoses.
Overactive disorder associated with mental There is no definitive cause of ASD. Research-
retardation and stereotyped movements is char- ers are focusing on identifying its genetic origins,
acterized by hyperactivity, inattention, motor its relationship with sex chromosomes, and the
stereotypes, and mental retardation without the effects of abnormal brain structures. The effects
social impairments typical of autism. of immunizations, infections, and environmental
factors continue to be studied. While researchers
Asperger’s Disorder have examined the relationship between vaccine
Asperger’s disorder and PDD, unspecified are preservatives and autism, there are no conclusive
variations of autism but do not meet all of its data to support an association.
diagnostic criteria. Individuals with Asperger’s
typically do not have the language delays associ- Treatment Options
ated with autism, although their speech is charac- Ultimately, a long-term positive prognosis is closely
terized by peculiarities such as monotone pitch or tied to cognitive abilities and language, while
an overly formal style. Other symptoms include social difficulties tend to lessen with age. Inter-
problems with the social aspects of language, ventions for ASD involve augmentative and alter-
nonverbal language (such as gestures), and motor native communication devices, speech/language
coordination, as well as some of the other symp- therapies, behavior modification, social skills
toms typical of autism. Following debate whether training, and occupational/physical therapies.
Asperger’s is a distinct disorder or a form of high- Some regions favor alternative treatments such as
functioning autism, Asperger’s disorder is sub- facilitated communication (such as in Israel) or
sumed within ASD in the DSM-5 and a criteria of acupuncture (such as in Hong Kong). Without
severity is used to capture individual variations. intervention, children often fail to develop basic
self-help behaviors or communication skills. Fam-
Prevalence and Causes ily adjustment to an ASD diagnosis is affected by
Evidence of rising ASD rates is evident around the degree of social support, disability stigmas,
the world, and ASD is now considered among and the willingness and resources to seek treat-
the most common developmental disorders. Per- ment. In some cultures, such as in China, parents
ceptions of increasing prevalence worldwide may are judged negatively for their children’s behav-
reflect increased identification of the disorders, iors; therefore, Chinese parents may be reluctant
shifting diagnostic criteria, changing scientific and to receive a diagnosis for fear of the subsequent
cultural views, decreasing stigmas, and improved discrimination. In South Korea, for instance, if
school-based services. ASD is reported within all treatments for children with autism do not work,
racial, ethnic, and socioeconomic groups but are parents may consider the autism incurable and
four to five times more likely to occur in boys than discontinue interventions. Conversely, the recent
girls. Prevalence estimates range across and within neurodiversity movement advocates that ASD is a
regions (such as 1.4 per 10,000 in Oman, 42 to natural variation of human behavior and should
121 per 10,000 in the United States, and 260 per be viewed in a subcultural rather than psycho-
10,000 in South Korea), reflecting differences in pathological context.
inclusion criteria, assessment measures, culturally
specific expectations for behavior and cognition, Ariane Schratter
and access to ASD services. Developing countries Maryville College
have not yet extensively studied ASD, perhaps
due to its low prevalence compared to competing See Also: Adolescence; Attention Deficit
health demands, changing diagnostic criteria and Hyperactivity Disorder (ADHD); Autism; Children;
 Pharmaceutical Industry 635

China; Diagnosis; Diagnosis in Cross-National Growth of Pharmaceutical Companies

Context; Environmental Causes; India; Nigeria; The pharmaceutical industry emerged as a dis-
Refrigerator Mother; Ritalin; South Korea; United tinct industry in the final decades of the 19th cen-
Kingdom; United States. tury, an offshoot of German and French chemi-
cal companies manufacturing synthetic dyes.
Further Readings During the 20th century, the industry rapidly
Bernier Raphael, Alice Mao, and Jennifer Yen. increased in size and became a highly commer-
“Psychopathology, Families, and Culture: Autism.” cial global industry with considerable power. It is
Child and Adolescent Psychiatric Clinics of North now dominated by a small number of large com-
America, v.19 (2010). panies, with expansion resulting from the sales
Grinker, Roy. “What in the World Is Autism? A revenue from a relatively small number of highly
Cross-Cultural Perspective.” Zero to Three, v.28/4 profitable new drugs, along with takeovers and
(2008). mergers, including the acquisition of biotechnol-
Zaroff, Charles and Soo Uhm. “Prevalence of Autism ogy companies, which has led to some consoli-
Spectrum Disorders and Influence of Country dation in the industry. The 10 leading companies
Measurement and Ethnicity.” Social Psychiatry and all have headquarters in the United States and
Psychiatric Epidemiology, v.47/3 (2012). Europe, where sales are concentrated, but their
products are sold and manufactured in locations
around the world. The top 10 companies mea-
sured in terms of prescription sales by value,
such as the U.S.-based Pfizer (world leader) and
Pharmaceutical Industry Swiss-based Novartis (second largest), were esti-
mated to have around 45 percent of the market
The pharmaceutical industry is a highly commer- for all prescribed medicines in 2009.
cial industry, currently dominated by Western However, companies in a number of other coun-
companies that produce and sell prescribed medi- tries are also becoming important and may chal-
cines around the world, though the largest mar- lenge the market leaders. In particular, there are
kets by revenue are in more affluent countries, a number of Japanese companies among the top
with the United States the largest market of all. 20, and companies in India and China are also of
Since the early 1950s, psychoactive medications increasing importance. Sales of medicines, some
intended to treat problems that are judged mat- imported, many produced locally, in these highly
ters of mental health have been an important fea- populous countries will increase with their eco-
ture of the industry, with some psychoactive med- nomic growth. The most successful drugs in terms
ications in certain periods generating the highest of sales revenue (termed “blockbusters” if sales
sales by revenue of all drugs. revenue tops $1 billion) have typically been pat-
Such medicines have also helped to shape psy- ented medicines (patents are for 20 years, though
chiatric thinking about mental illness and psychi- there are ways in which they can be extended) for
atric practice, encouraging a focus on biochemical which higher prices can be charged. They are also
processes in the brain as causes of mental illness, usually drugs for commonly occurring conditions
and the development of what is now described for which the market is potentially quite large; for
as neuropsychiatry, as well as contributing to a chronic conditions requiring long-term medica-
broadening of the boundaries of mental disor- tion, such as high blood pressure and high choles-
der. Prescribed drugs now dominate psychiatrists’ terol; and for the health problems of those living
treatment regimes, with most individuals who are in richer countries where health care systems or
treated by doctors for what are identified as men- health insurance companies usually cover the cost
tal health problems receiving a psychoactive drug, of the medicines.
and sometimes more than one. The new medi- The extensive use of patenting, usually justified
cations have also helped to shape lay ideas and by the industry on the grounds that the research
expectations about problems of mental health and development (R&D) costs of new medi-
and how they can be treated. cines are high (there is evidence that these costs
636 Pharmaceutical Industry

of funding that goes into marketing—around 15

to 20 percent of expenditure, around the same as
on R&D, with some larger companies acquiring
smaller biotechnology companies to short-circuit
or reduce investment in R&D. Most countries do
not permit direct-to-consumer advertising (except
the United States and New Zealand), so much
marketing is targeted at doctors via sales repre-
sentatives, advertisements in medical journals,
and the funding of medical research and confer-
ences (including on occasions the ghost writing of
papers).
However, the wider public is targeted by other
means than direct advertising. The industry makes
extensive use of press releases about new drugs,
with claims as to their efficacy and about the fre-
quency of the medical conditions they are said to
treat. These press releases, which are picked up
by newspapers, magazines, and television, seek
to change the public’s awareness by emphasizing
how common a condition is and the high propor-
tion of cases that are undetected. This is justified
by the industry, with claims that it is important
for the public to be able to detect an illness so that
it can be treated. Frequently, the epidemiological
data are not very sound and the value of identify-
ing additional cases depends on the effectiveness
(often far less than claimed) and side effects (often
more extensive than indicated) of the treatment
that is offered.
A further sign of the commercial nature of
the industry is the extensive production of drugs
This cartoon by Margaret Shear, which illustrates a July 5, 2012, very similar to one another but sufficiently dis-
PLOS Medicine journal article on how medical journals market tinct to allow the alternative to be patented—“me
for pharmaceutical companies, demonstrates the relationship too” drugs. These provide a means for a com-
between medical journals and the pharmaceutical industry. pany to secure a foothold in profitable markets
and increase competition in that sector. Yet, they
reduce product development and innovation in
relation to other conditions for which little in the
are not as high as the industry claims) provides way of treatment is available.
one indication of the industry’s highly commer- The industry is regulated, but the regulation is
cial character. So does the concentration of R&D not very extensive in practice. Drugs have to be
spending on drugs for common health problems approved by a drug regulatory agency such as the
in affluent countries that are held to require long- U.S. Food and Drug Administration (FDA) before
term treatment. The World Health Organization they can be released into the market, but the test-
has estimated that 90 percent of total spending ing requirements are not very stringent in terms
on health R&D goes for diseases or conditions of the length of use that is required in the studies
that generate only 10 percent of the global bur- (some side effects may only be visible with long-
den of disease. Another manifestation of the com- term use), the small sample sizes, and the rather
mercial character of the industry is the high level small size of the difference that needs to be shown
 Pharmaceutical Industry 637

for claims as to effectiveness to be accepted and a though it was not as large or profitable as it was
drug approved. Moreover, companies have been to become by the end of the century. The first of
able to withhold data that do not support their the new psychoactive medicines was chlorproma-
case when seeking approval. Changes are being zine, developed by French company Rhone-Pou-
made, but such loopholes, along with the fact that lenc, which was used for the treatment of schizo-
most of the research is carried out by the compa- phrenia. Like many other drugs, it was identified
nies (research showing that studies carried out by by chance observations by a research scientist in
companies produce more favorable results than a pharmaceutical company, who had been test-
those carried out independently) stack the odds ing a newly synthesized chemical as a potential
in favor of the companies when seeking approval antihistamine but noted its calming (tranquiliz-
for a new medicine. Moreover, once a drug is ing) effects and persuaded psychiatric colleagues
approved for one condition, it can be legally used to try it out on their patients. The U.S. company
off-license for another, even though it has not Smith Kline and French obtained a license for its
been licensed for that condition. sale, and put considerable effort into its market-
ing, sending sales representatives (detailers) to
Early Psychoactive Drugs meet with mental hospital administrators and
All these commercial features are manifest in psychiatrists, emphasizing the cost-effectiveness
the development of psychoactive drugs for the of its use.
treatment of mental health problems—develop- However, the drug, branded as Largactil in
ments in which some research psychiatrists have Europe and Thorazine in the United States and
played an active part. These drugs have played an described variously as a neuroleptic, major tran-
important role in the commercial success of the quilizer and later an antipsychotic, was far from
industry. Medicines for those judged to have men- a miracle cure. Though it suppressed symptoms,
tal health problems are largely a product of the it had severe side effects, with longer-term use
period since the 1950s, although some substances leading to involuntary bodily (extrapyramidal)
were used for the treatment of mental illness well movements in patients, which they strongly dis-
before this. These included various sedatives and liked. The same was true of other neuroleptics
hypnotics (tranquilizers) such as digitalis; mor- introduced in this period, such as reserpine and
phine (isolated in 1806); and chloral hydrate, first haloperidol. However, their success in controlling
synthesized in 1832 and used as a sedative in the symptoms did facilitate, though they did not initi-
second half of the 19th century, particularly for ate, the move away from mental hospitals for those
middle- and upper-class individuals, in an effort with severe mental health problems that began to
to avoid the need for admission to an asylum gather pace in the 1960s. The drugs also encour-
(it was prescribed to Virginia Woolf in the early aged new ideas about the biochemical causation
decades of the 20th century) and had the advan- of schizophrenia, since the pyramidal effects were
tage that it did not need to be injected. known to be associated with dopamine depletion.
Another was the sedative potassium bromide, The argument was that drugs like chlorpromazine
which was considerably cheaper than chloral were inhibiting dopamine production and that
hydrate and therefore more attractive for use in schizophrenia must therefore involve the over-
asylums. Some sedatives were also used in vari- stimulation of dopamine receptors.
ous sleep therapies introduced in the 1930s, in Though chlorpromazine was the leader of the
which individuals were put into a deep sleep, 1950s drug revolution in psychiatry, other psycho-
though these were gradually discontinued when it active medications to treat depression and anxi-
became clear that they were very risky, with some ety were introduced in the mid-1950s. Iproniazid,
patients dying. described as a psychic energizer, was introduced by
However, the use of psychoactive medica- the Swiss company Hoffmann–La Roche to treat
tions within psychiatry was transformed in the what was then called endogenous depression—
1950s. By then, the pharmaceutical industry was severe depression that could lead to admission as
well established, with major successes from the an inpatient. The drug was termed a monoamine
early pain killers, antihistamines, and antibiotics, oxidase inhibitor (MAOI), indicating its chemical
638 Pharmaceutical Industry

action. It was quickly followed by imipramine, not appear to have resisted this wide use, as well
produced by another Swiss company, Geigy, as by psychiatrists.
which was slow to promote it for the treatment It was followed by two minor tranquilizers, the
of depression; and then by another MAOI, ami- use of which became even more common. The
tryptyline, developed by three companies, Merck, first was Librium, a benzodiazepine introduced in
Roche, and Lundbeck, with Merck promoting it 1960 by Hoffmann–La Roche, which wanted a
very actively as a treatment for severe depression. drug that would be as successful as Miltown—
These drugs were known as tricylics, reflecting a company aspiration rapidly realized. The drug
their thee-ringed chemical structure. had some sedative properties, but also produced
Another drug, lithium, a naturally occurring feelings of pleasure. The second, another benzo-
metal that had been isolated in the 19th century diazepine, was Valium, released three years later
and had occasionally been used to treat mania, by the same company. It was more potent than
was approved for use as a treatment of manic- Librium but did not leave such an unpleasant
depression by the FDA in 1970 and has remained aftertaste, and by 1968, its sales outstripped Lib-
in use for what is now called bipolar disorder rium’s, though Librium continued to be widely
since then. However, because it was not patented, prescribed. Valium’s importance is indicated by
it was not a source of significant profit for phar- the fact that it quickly started to generate more
maceutical companies. All these drugs had severe revenue than any other medication available on
side effects and did not provide much in the way the market. In the 1970s, however, it became
of cure. Instead, like chlorpromazine, they con- clear that minor tranquilizers were associated
trolled symptoms that were often chronic, and so with problems of tolerance (the need for a higher
were held to require long-term medication which dosage to maintain the same level of effect) and
added to their profitability if they could be pat- dependence, with marked withdrawal effects such
ented, as most could. as increased anxiety, agitation, sleeplessness, and
stiffness if individuals stopped taking them. Cam-
Drugs for Less Severe Mental Illness paigns by patient groups against the drugs, which
Potentially even more profitable were drugs for were taken up by the media, led to a flattening of
less severe disorders, because of the far larger sales by the early 1980s.
numbers who could be identified as having them. Another psychoactive drug, Ritalin, was
Under the influence of Freudian ideas in the developed by CIBA (now part of Novartis) and
1950s and 1960s, these disorders were termed approved for use by the FDA in 1955 for what
psychoneuroses or neuroses but are now usually was then called hyperkinesis, a disorder of child-
called “common” (frequent) mental disorders. hood, later termed hyperactivity and then atten-
The new drugs introduced in this period to treat tion deficit hyperactivity disorder (ADHD). Rit-
anxiety neurosis, then the most commonly diag- alin is a stimulant that nonetheless seems to have
nosed neurosis, were known as minor tranquil- a calming effect on those with hyperactivity, in
izers, in contrast to the major tranquilizers such certain cases. Its use has increased enormously
as chlorpromazine. The first was meprobamate. in recent years, with children who would for-
It was licensed in 1955 by Wallace Laboratories, merly have been described as naughty—as dif-
a small U.S. pharmaceutical company with little ficult, awkward, and lacking in concentration—
marketing experience, under the brand name being given an ADHD diagnosis and prescribed
Miltown. The company also licensed it for sale the drug, sometimes at very young ages and for
to Wyeth, a far larger U.S. company, which sold long periods of time, even though the effects of
it as Equanil. The drug became very fashionable its long-term use are not well established. The
(it was widely used in the film world), came to drug is now also used by adults who are given an
be known as the “happy pill,” and its use spread ADHD diagnosis.
well beyond those who had been diagnosed as A further broadening of the use of psychoactive
having an anxiety neurosis. The drug required a medications was generated by the development of
medical prescription but could be prescribed by a new group of drugs in the late 1980s, the selec-
general practitioners and family doctors, who do tive serotonin reuptake inhibitors (SSRIs), which
 Pharmaceutical Industry 639

were recommended for the treatment of less severe revenue. However, there are now some efforts to
depression (serotonin was held to be implicated reduce such use.
in the causation of depression). Like the earlier Attempts to develop drugs specifically intended
MAOIs for severe depression, the mode of action for the treatment of senile dementia, such as
was incorporated into the label. The best known Alzheimer’s, which is progressive and currently
of the SSRIs is Prozac (fluoxetine), developed by incurable, have not proven very successful. One
U.S. company Eli Lilly and first licensed for sale drug, Aricept, produced by the largest pharma-
in 1987. It received considerable public attention ceutical company, Pfizer, has been approved for
and was soon widely used, partly as a result of use for this condition, and though it may help
very heavy marketing by the company, and, like with cognitive and behavioral symptoms, particu-
the earlier minor tranquilizers, came to be known larly in those with moderate symptoms, it is not
as a happiness pill because of the pleasant feelings a cure and has some side effects such as nausea,
that it could generate. And just as Valium had diarrhea, and abdominal pain. Despite consider-
earlier, it became the leading medication world- able R&D investment in the development of new
wide in terms of revenue, despite the fact that it drugs for dementia, these efforts have not been
could have an adverse impact on potency and led successful, and the industry is currently cutting
to nausea and vomiting in some patients. It is now back on investment in this area.
off-patent and is no longer yielding the same level Overall, the use of psychoactive medications
of revenue in the face of generic competition (a has enormously increased since the 1950s, encour-
generic nonbranded version now produced by aged by the pharmaceutical industry, particu-
Ranbaxy, an Indian pharmaceutical company, has larly over recent decades, and the proportions of
received FDA approval and is sold in the United patients using them are now high, notwithstand-
States and elsewhere). ing their side effects. Moreover, some individuals
are prescribed more than one drug at a time, even
Atypical Antipsychotics though their possible interaction has not been
The 1990s brought yet another group of psycho- well explored—a person could, for instance, be
active medications—a new generation of antipsy- prescribed an antipsychotic, an antidepressant,
chotics, the “atypical” antipsychotics. The label and a sedative, as well as other drugs to try to
“atypical” was used to differentiate them from control some of the unpleasant side effects of the
the earlier antipsychotics, and some have sug- psychoactive ones. Yet, the evidence supporting
gested that this was largely a marketing device. the effectiveness of these medications is limited.
They have fewer pyramidal side effects than the They can help to control behavior, but they do lit-
earlier drugs but involve far closer monitoring tle to provide a cure, and some of their impact is
because they reduce the white blood cell count. more of a placebo effect than the chemical action
Initially, they were claimed to be more effective of the drug on the body, as has been shown in
than the standard antipsychotics, but these claims recent research on antidepressants.
are now contested. One of the best known is However, the development of psychoactive
olanzapine, developed by Eli Lilly and branded as drugs has had an enormous impact. The drugs
Zyprexa. Although atypicals were not specifically have encouraged biochemical explanations of
approved for use with patients with senile demen- mental illness and increased the focus of psychi-
tia, they began to be used off-license for this pur- atric research on brain processes; they have also
pose because of the way in which they quiet and encouraged lay beliefs that mental illness results
control behavior, and this practice became quite from some chemical imbalance—at best a very
widespread, with some evidence indicating that oversimple view of causation. Their increas-
it was encouraged by the pharmaceutical compa- ing use has also contributed to a broadening of
nies. Given that psychosis is relatively rare (though the boundaries of mental illness by the addition
medication is often used for long periods of time), of new disorders for which they can be recom-
this off-license use may help to account for the mended. In addition, the extensive publicity sur-
fact that in 2010, antipsychotics had become the rounding new drugs helps to shape lay perceptions
second-highest product class globally in terms of that there are drugs to deal with a wide range of
640 Philippines

mental health problems, which in turn generates spends 3.78 percent of its GDP on health, with a
a demand for these apparently easy solutions to per capita government expenditure on health of
any problem that the individual encounters that $39, and neuropsychiatric disorders are estimated
makes them unhappy, distressed, anxious, dis- to contribute to 14.4 percent of the global burden
tracted, or fearful. One consequence is that the of disease in the country.
examination of the social and psychological fac-
tors that can underpin these feelings and behav- Current Mental Health Services
iors has declined, despite their import. The Philippines has an official mental health pol-
icy, most recently revised in 2001, and a mental
Joan Busfield health plan, most recently revised in 2007. This
University of Essex, Wivenhooe Park mental health plan includes efforts to integrate
mental health services into primary care, efforts
See Also: Antidepressants; Atypical Antipsychotics; to shift mental health services and resources from
Minor Tranquilizers; Monoamine Oxidase Inhibitor hospitals to community health centers, and a
(MAOI) Antidepressants; Ritalin; Serotonin Reuptake timeline and funding to carry out these reforms.
Inhibitors; Side Effects. About 5 percent of the total health budget is spent
on mental health services. Primary care physicians
Further Readings and nurses are allowed to both diagnose and treat
Goldacre, Ben. Bad Pharma. London: Fourth Estate, mental health disorders, but as of 2011, most had
2012. not received official in-service training on mental
Healy, David. The Anti-Depressant Era. Cambridge, health in the previous five years. In 2011, there
MA: Harvard University Press, 1997. were 0.38 psychiatrists per 100,000 population
Moncrieff, Joanna. The Myth of the Chemical Cure. working in the mental health sector in the Philip-
London: Palgrave, 2009. pines, along with 0.13 physicians not specialized
Smith, R. “Medical Journals Are an Extension of the in psychiatry per 100,000, 0.22 psychologists per
Marketing Arm of Pharmaceutical Companies.” 100,000, 0.72 nurses per 100,000, 0.02 social
PLOS Medicine, v.2/5 (2012). workers per 100,000, and 0.02 occupational
Tone, Angela. The Age of Anxiety. New York: Basic therapists per 100,000.
Books, 2009. As of 2011, the Philippines had 46 mental
health facilities (0.049 per 100,000 population),
four day-treatment facilities (0.004 per 100,000),
15 community residential facilities (0.016 per
100,000), and two mental hospitals (0.002 per
Philippines 100,000). There were 4,200 beds in mental hospi-
tals (4.486 per 100,000) and 1,457 beds in com-
The Philippines is an island nation in the north munity residential facilities (1.556 per 100,000).
Pacific, with an area of 115,831 square miles The rate of treatment in mental health outpatient
(300,000 square kilometers) and a 2012 popu- facilities was 12.25 per 100,000, with 43 percent
lation estimated at 103.8 million, of which 49 of patients female and 28 percent under age 18.
percent lived in urban areas. Forty percent of the The rate of admissions to mental hospitals was
population is under 18 years of age, and 4 percent 5.49 per 100,000 (38 percent female, 2 percent
above 60 years; life expectancy at birth is 65 years under age 18) and for mental health day-treat-
for males and 71 years for females. In 2011, the ment facilities, 4.35 per 100,000 (44 percent
United Nations Development Programme clas- female, 7 percent under age 18). At year’s end,
sified the Philippines as having medium human 0.6 persons per 100,000 population were stay-
development (second lowest of four categories), ing in community residential facilities (30 percent
and the World Bank ranks the Philippines as a female, 3 percent under age 18).
lower middle-income country (second lowest of Due in large part to U.S. influence (the Philip-
four categories), with a per capita gross domestic pines was a U.S. territory, then a U.S. common-
product (GDP) of $4,100 in 2011. The Philippines wealth, from 1898 to 1946), the Philippines has
 Phobias 641

a history of psychoanalytic practice. One of the Further Readings

first Filipino psychoanalysts was Virgilian San- Kudva, Kundadak Ganesh. “Redefining ‘Amok’ and
tiago, who studied medicine at the University of Other Rampage-Type Culture-Bound Syndromes.
Santo Tomas in the Philippines, graduating in Asia-Pacific Psychiatry, v.3 (2011).
1949, before studying at the Menninger Clinic in Mueller, Yolanda, Susanna Cristofani, Carmen
Topeka, Kansas. He returned to the Philippines, Rodriguez, Rohani T. Malaguiok, Tatiana Gil,
where he established a psychoanalytic practice Rebecca F. Grais, and Renato Souza. “Integrating
serving primarily expatriates. Mental Health Into Primary Care for Displaced
Rodolfo Varies, another pioneer of psycho- Populations: The Experience of Mindanao,
analysis in the Philippines, was trained in psy- Philippines.” Conflict and Health, v.5/3 (2011).
choanalysis in New York City before returning to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC
teach at the College of Public Health in the Philip- 3060114 (Accessed May 2013).
pines. In 1969, Lourdes Lupus published A Study Smeekens, Chantal, Margaret S. Stroebe, and
of Psychopathology, a highly influential work Georgios Abakoumkin. “The Impact of Migratory
that adapted psychoanalytic theory to fit Filipino Separation From Parents on the Health of
culture, and was the first to establish psychoanal- Adolescents in the Philippines.” Social Science and
ysis firmly within the Philippines. However, the Medicine, v.75 (2012).
lack of adequate funding for mental health care World Health Organization. “Mental Health Atlas
and the fact that many in the Philippines still pre- 2011: Philippines.” http://www.who.int/mental
fer traditional approaches to mental health have _health/evidence/atlas/profiles/phl_mh_profile.pdf
hampered further development of psychoanalytic (Accessed April 2013).
practice in the Philippines. World Health Organization (WHO) Regional
Office for the Western Pacific Region. “Mental
Culturally Specific Conditions Health Systems in the Eastern Mediterranean
A variant of the culture-bound syndrome amok, Region: Report Based on the WHO Assessment
known as juramentado, has been identified in Instrument for Mental Health Systems” (2010).
Mindanao among the Moro people. Amok is a http://applications.emro.who.int/dsaf/dsa1219.pdf
condition most often observed in men, and char- (Accessed April 2013).
acterized by a sudden outbreak of violent, aggres-
sive behavior, which may be murderous and/or
suicidal and which is typically performed in a
trance-like state; the phrase going amok is a col-
loquial reference to this type of behavior. Amok Phobias
is generally preceded by a period of social with-
drawal, and after the incident ends, the amok While it is difficult to pinpoint exactly when and
individual often claims to have no memory of the where phobias developed, records of social pho-
events. However, in jurementado, the individuals bic fears date back to the time of Hippocrates in
affected often take a religious oath before enter- 400 b.c.e. Fear is a common part of the human
ing the trance-like state, and victims often seem to experience. Hippocrates differentiated concep-
be chosen deliberately, such as American soldiers, tions of normal fear from symptoms of what is
resulting in assailants being honored by their vil- now known as social anxiety disorder in a man he
lages and suggesting some measure of control by observed displaying avoidance of social situations
the afflicted person. and irrational paranoia of others’ opinions of him.
The term social phobia was not widely used
Sarah Boslaugh until the early 1900s, when psychiatrists began
Kennesaw State University to describe patients who displayed syndromes
of shyness. These patients appeared excessively
See Also: Community Mental Health Centers; timid and specifically expressed the fear of others
Dangerousness; Diagnosis in Cross-Cultural Context; watching them while speaking, writing, or play-
Psychoanalysis, History and Sociology of; Religion. ing the piano. In the 1960s, British psychiatrist
642 Phobias

Isaac Marks proposed that social phobias be clas- escape the trigger situation, he or she may expe-
sified apart from other types of fear-based disor- rience panic and fear, rapid heartbeat, shortness
ders because they differed in levels of distress and of breath, trembling, and a strong desire to get
physical and emotional impairment and therefore away. While many people with phobias do report
presented differently than other fears. such physical manifestations of the disorder, some
people report no physical presentations of fear
Clinical Presentation and anxiety. Instead, they may experience what
Marks’s suggestion was not fully met until the is termed anticipatory anxiety, which is charac-
1980s, when the Diagnostic and Statistical Manual terized by intense worry and dread of a social or
of Mental Disorders (DSM-III and -IV) included performance situation. Instead of displaying this
social phobia as an official clinical diagnosis. This fear and anxiety in a physical manner, one may
was a dramatic shift from earlier DSM represen- completely withdraw and avoid the feared situa-
tations that suggested phobias were the products tion completely.
of deviant instinctual impulses. However, the
DSM-III described social phobia as an intense Cross-Cultural Differences:
and irrational fear of performance situations Historical Understandings
and neglected to mention fears of more informal, Because fear is defined differently across time and
casual social situations. In 1987, the term gener- space, a cross-cultural examination of phobias
alized social anxiety disorder was introduced to can illuminate how manifestations, diagnoses, and
point to a more pervasive and chronic form of the treatments of phobias vary depending on histori-
disorder. In 1994, the term social anxiety disorder cal and geographical context. While experience
replaced the phrase “social phobia.” This change of anxiety and fear is on some level an individ-
reflected a broader, more inclusive view of fears ual issue, phobias are also shaped by larger cul-
in the disorder and did not limit social anxiety to tural conceptions of public and private identity.
performance situations. It is clear that cross-cultural and historical under-
The DSM-IV classifies phobias into three cat- standings of phobias are often generated by cir-
egories: agoraphobia, social, and specific. These cumstances in which people see a certain issue as
categories may also contain subcategories. For taboo and therefore avoid the situation altogether.
example, generalized social phobia and specific It is argued that with this aversion to a certain
social phobia are included in the larger category situation or object come similar feelings of dread,
of social phobia. Agoraphobia is defined as the hatred, and opposition. Culturally, these emotions
generalized fear of going outside, leaving the breed a crisis that reflects a social phobia. A social
home, or leaving some other similar safe space. phobia has the capacity to last for a short or a long
Agoraphobia is commonly accompanied by panic time and can change with cultural sentiment. Pho-
attacks. Agoraphobia may be experienced con- bias are therefore not only individual, diagnosable
currently with specific phobias such as fear of issues but are also broader, dynamic productions
social situations. In this sense, phobias may over- of cultural fears and anxieties.
lap and patients can have multiple diagnoses. For example, in the 16th and 17th centuries,
Social phobia is characterized by fear of other before social phobias were clinically recognized,
people or of social situations. Specific phobias a cultural crisis swept through Europe and carried
involve a trigger—a specific object or situation over into the English colonies in North Amer-
such as heights, water, spiders, or flying—that ica. Fear of witchcraft prompted violent witch
causes panic and fear. hunts, most famously seen in Salem, Massachu-
Because many people experience fear from time setts, in 1692. The irrational fear of witchcraft
to time, it is necessary to distinguish everyday, reflected mass hysteria and anxiety centered on
common fear from that displayed in phobias. In uncertainty of the unknown, economic hardship,
contrast to typical fear, phobic fear is described and opposition to religious difference. With the
as excessive, irrational, and interfering with development of modern science and the improve-
one’s everyday life. Generally, people try to avoid ment of the education of the general public, this
what they are afraid of. However, if one cannot pervasive cultural phobia of witchcraft faded
 Phobias 643

out. The Salem witch hunts exemplify how pub- studies concerning SAD have been conducted in
lic fears both influence individual anxieties and non-Western societies, there is limited research
are reflected by collective thought and practice. for cross-cultural comparison.
This example also shows how social phobias are However, one study of Jewish and Arab stu-
specific to and can change with historical and dents reported that approximately 12 percent of
cultural circumstance. the sample displayed symptoms of SAD. Females
in particular showed higher rates of SAD accord-
Cross-Cultural Differences: ing to the study. Social conditions such as lack of
Contemporary Understandings a spouse and history of psychological treatment
Contemporary American society is much more also contributed to higher SAD scores. While
accepting of what is now called social anxiety much more research needs to be done, the Jewish/
disorder (SAD) than in the 1600s because social Arab student study found that SAD prevalence
phobias are now categorized by modern sci- rates matched those in the United States. Further
ence in the DSM. With the establishment of a studies like this would help increase global knowl-
standardized way to diagnose social disorders, edge of SAD and would combat assumptions and
phobias can be discussed, education programs stereotypes about social phobias.
established, and treatment provided, all of which While some phobias do not appear to be partic-
combine to reduce their stigma. SAD is prevalent ular to any one culture, it is reasonable to expect
in Western society, reportedly affecting at least that some phobias are culturally and historically
10 percent of the U.S. population. Because few specific. For example, fear of weight gain and its

In this 1892 illustration by Joseph E. Baker, a bolt of lightning releases the handcuffs of a “witch” and strikes down her inquisitor
during her colonial-era trial. In the American colonies in the 16th and 17th centuries, fear of witchcraft prompted violent witch hunts.
The irrational fear of witchcraft reflected mass hysteria and anxiety, exemplifying how public fears both influence individual anxieties
and are reflected by collective thought and practice, and how social phobias are specific to and can change with culture.
644 Phobias

manifestation in pathological weight loss may be considering culturally specific definitions of dis-
a phobia specific to contemporary Western cul- order when comparing cross-cultural prevalence
ture. In many Western cultures, the pathological of phobias.
form of the fear of fat or weight gain is known as
anorexia nervosa. Cross-Cultural Differences:
The results of one study showed that weight Lay Conception of Treatment
concerns, when defined as weight loss that is pos- Similar to threshold effects, the method of treat-
itively valued by a culture (as opposed to a fat ment for phobias is also sometimes culturally
phobia), may still meet the criteria of anorexia specific. One study elaborates on this point by
nervosa. Findings also revealed that dissemination investigating the DSM-IV and its assumption of
of Western values of thinness was not much of a the universality of symptoms of illness and dis-
reason behind the development of anorexia ner- order. Although amendments have been made to
vosa in non-Western countries. In fact, results ran the DSM to enhance cross-cultural application,
counter to the Western presumption that intense it is important to consider not only how the pre-
fear of gaining weight (fat phobia) is a standard sentation of disorders varies across cultures but
characteristic of the disorder. The issue of control also how cultural values and practices impact
may be a more likely underlying mechanism. Sub- treatment.
jects of this research study expressed a variety of As with other psychological disorders, the
reasons for wanting to lose weight besides fear of sociocultural implications confound issues of
weight gain. While anorexia nervosa is identified treatment because in some places genetic and
in patients cross-culturally, presentation of symp- family factors may be the putative cause, while
toms and associated values and practices appear social forces may prevail in others. For example,
to vary across cultures. some twin studies have shown that twins raised
Although research is limited, recent stud- in different families still have a 30 to 50 percent
ies have shown the connection between cultural chance of sharing the disorder. However, it is
values and practices and the incidence and pre- unclear exactly what is involved. Studies have
sentation of phobias. One study investigated the shown that children of parents with anxiety
cultural mediators of self-reported social anxiety or depression may have a greater likelihood of
by looking at two community samples of Koreans developing SAD, which may be caused by mecha-
and Euro-Canadians. Western culture typically nisms related to social modeling of the behavior
encourages less passive social behavior with a rather than any genetic predisposition. Treatment
focus on self-promotion. On the other hand, east therefore depends on the assumption underlying
Asian social norms endorse less dominant styles the causal relationships.
of social behavior. The study found that Korean A common fear among parents of young chil-
participants reported a higher rate of social anxi- dren is what is often referred to as “fever phobia.”
ety than did the participants in the Euro-Cana- In the United States, fever is the most common
dian sample. Korean participants also expressed reason parents bring children into the emergency
a higher level of self-criticism compared to the room, even during the middle of the night. This
Euro-Canadian sample. fear of fever, usually unjustified, reflects lay mis-
A possible explanation suggested by research- conceptions of illness and treatment. Knowing
ers is that east Asian cultures likely maintain a that fever phobia affects parents of different cul-
higher threshold for social anxiety in order to tures, one study looked at reactions to and deci-
meet a standard by which it can be considered sions to treat fever in children in German and
social phobia. Shy children in Asian cultures may Turkish mothers. The study conducted in-depth
be more accepted by their peers and therefore per- interviews with Turkish and German mothers
ceived to have leadership qualities such as sensitiv- living in Germany. Similar to American moth-
ity to multiple viewpoints that more extroverted ers, most participants viewed their children’s
children do not. This differs drastically from elevated temperature as a potentially dangerous
Western models of bold, extroverted individu- event. Although mothers’ impulse to provide care
als. These studies shed light on the importance of for their children presents cross-culturally, the
 Phobias 645

type of treatment mothers pursue varied. While to another, however, fear has been a commonly
most mothers expressed a need to do something experienced and documented human emotion.
about their child’s fever, the participants discussed
a variety of methods of treatment varying from Matthew E. Archibald
seeking familial advice to applying domestic rem- Cecilia Conroy
edies. Also, the participants’ belief in the cause Colby College
of fever varied across cultural background; beliefs
of supernatural causes appeared only in the state- See Also: Agoraphobia; Anxiety, Chronic; Cultural
ments Turkish mothers gave. Prevalence; Geography of Madness; Incidence and
Prevalence; Japan; Mental Illness Defined: Historical
Conclusion Perspectives; Religion.
Phobias have been documented throughout his-
tory and are prevalent worldwide. Approximately Further Readings
6.8 percent of the U.S. adult population report Heimberg, Richard G. Social Phobia: Diagnosis,
having a social phobia and an additional 8.7 per- Assessment, and Treatment. New York: Guilford
cent report having a specific phobia. For these Press, 1995.
adults with social phobias, roughly 29.9 percent Hong, Janie J. and Sheila R. Woody. “Cultural
of these cases are characterized as severe, and Mediators of Self-Reported Social Anxiety.”
nearly 22 percent of cases with specific phobias Behavior Research and Therapy, v.45/8 (2007).
are also classified as severe. Although only 0.8 Iancu, I. and E. Ram. “Shyness and Social Phobia in
percent of the U.S. adult population experiences Israeli Jewish Versus Arab Students.” European
the well-known disorder of agoraphobia, in adults Psychiatry, v.26/1 (2011).
who experience it, 40.9 percent of these cases are Kendler, K., L. Karkowski, and C. Prescott. “Fears
classified as severe. While prevalence rates are and Phobias: Reliability and Heritability.”
likely to vary cross-culturally, few definitive epi- Psychological Medicine, v.29/3 (1999).
demiological studies have been undertaken. Some Langer, Thorsten, et al. “Activation of the Maternal
studies have shown that children’s rates of SAD Caregiving System by Childhood Fever: A
vary cross-culturally, from about 2 percent in Qualitative Study of the Experiences Made by
England, Scotland, and Wales to about 7 percent Mothers With a German of Turkish Background in
in the United States and Brazil. the Care of Their Children.” BMC Family Practice,
Nonetheless, cultural factors will impact SAD in v.14/35 (2013).
that sociocultural attitudes toward fear, shyness, Merikangas, Kathleen Ries, Shelli Avenevoli, Lisa
avoidance, and other interactional traits shape Dierker, and Christian Grillon. “Vulnerability
individuals’ relationships. Phobias vary across Factors Among Children at Risk for Anxiety
cultures in physical and emotional presentation Disorders.” Biological Psychiatry, v.46/11 (1999).
and social representation. Inability to develop Rieger, E., et al. “Cross-Cultural Research on
social skills will contribute to SAD through lack Anorexia Nervosa.” International Journal of
of confidence and efficacy, which translates into Eating Disorders, v.29/2 (2001).
experiences of negative interactions. These failed Rocha, F. L., C. M. Vorcaro, E. Uchoa, and M. F.
interactions will lead to lowered perceptions of Lima-Costa. “Comparing the Prevalence Rates
ability and accompanying erosion of a sense of the of Social Phobia in a Community According to
efficacious self. The cycle is perpetuated through ICD-10 and DSM-III-R.” Revista Brasileira De
continued feelings of inferiority and reinforce- Psiquiatria, v.27/3 (2005).
ment of feelings by broader social contexts. Thakker, J. and T. Ward. “Culture and Classification:
Not only do the symptoms of phobias dif- The Cross-Cultural Application of the DSM-IV.”
fer cross-culturally, but the social conceptions Clinical Psychology Review, v.18/5 (1998).
of cause and treatment of phobias also vary. As Xinyin C., K. H. Rubin, and L. Boshu. “Social and
cultural values shift and evolve, beliefs in cause School Adjustment of Shy and Aggressive Children
and treatment of phobias have also changed in China.” Development and Psychopathology, v.7
throughout history. From one historical moment (1995).
646 Placebo Effect

Placebo Effect symptoms. The ethics of this practice is an area of

contention among clinicians and researchers.
The placebo effect, also referred to as the pla- The placebo-control clinical trial, first utilized
cebo response, is the perceived or actual clinical in 1931, is a common practice in the examination
improvement in symptoms observed following of treatment effectiveness. In placebo-controlled
the administration of an ineffective treatment. trials, researchers administer an active treatment
Placebos are treatments thought to be ineffec- to one group of participants (the experimental
tive for a symptom or disease and are commonly group) and a placebo to another group (the pla-
implemented for research purposes. Placebos can cebo group). To control for the potential for those
include pharmacological agents (e.g., pills), physi- in the placebo condition to improve because of
cal components (e.g., manipulations), or psycho- expectation and learning, researchers may choose
logical treatments (e.g., conversational therapies). to employ a design wherein neither the researcher
There are several mechanisms by which the nor the participant knows which condition
placebo effect is thought to occur; these include (experimental vs. placebo) he or she is receiving.
expectation, learning, suggestibility, and certain Such investigations are referred to as double blind
contextual factors. One of the most researched studies. Further, the inclusion of control groups,
and widely known mechanisms is expectation. which allow for the observation of a natural pro-
An individual’s expectations about the effects of gression of symptoms, is beneficial in accounting
a placebo may lead to a cognitive readjustment for phenomena such as spontaneous remission,
that leads to the patient’s expected outcome (e.g., natural regression to the mean, biased reports,
reduction in pain). Learning is another mecha- and other naturally occurring interventions. Fol-
nism by which the placebo effect may occur. This lowing the experiment, the effects of the experi-
phenomenon occurs when the patient learns to mental and placebo conditions are compared to
associate a placebo with the reduction of spe- determine the effectiveness of the active treatment.
cific symptoms. Patients may learn to associate a
reduction in their symptoms with the administra- Research on the Placebo Effect
tion of a treatment and thus expect a reduction Much research has investigated the placebo
in their symptoms when administered a placebo. effect in the pharmacological treatment of mental
Further, placebos are more effective if they are health. Findings indicate that the placebo effect
administered after the patient has previously been is robust for depression treatment for subjective
administered the real treatment. Individuals who reports and objective reports. Recent research
exhibit certain personality traits, such as suggest- has found that the placebos used in depression
ibility, are thought to be more susceptible to the research act on similar brain regions as antide-
placebo effect. Finally, psychosocial contextual pressant medication. Anxiety treatments are also
factors may also affect a patient’s susceptibility to effected largely by placebos. For instance, when a
the placebo effect. These may include, for exam- treatment is administered without patient knowl-
ple, the sights and scents of hospitals, interactions edge, little reduction in anxiety symptoms occurs.
with a physician, and the use of large medical However, when patients are aware of the admin-
machines. istration of a treatment, larger reductions in anxi-
The placebo effect varies largely depending ety are observed, thus highlighting the impor-
on the treated illness or symptoms. The placebo tance of expectation in anxiety treatment. A few
effect has been observed among patients via their studies examining dementia have shown similar
subjective reports of symptoms (e.g., a patient’s results. When a patient is unaware that a treat-
report of pain or anxiety) as well as through ment is administered, the treatment is less effec-
more objective measures (e.g., changes in brain tive when compared to patients who are aware of
structures). Many early medical treatments with the administration of a treatment.
no research or explanation for how or why they In regard to psychotherapy research, it can be
worked are now considered placebos. However, difficult to separate placebo effects from psycho-
some such treatments are still utilized in hope therapy effects. Much debate has occurred regard-
that the placebo effect will provide a reduction of ing whether psychotherapy is simply a reflection
 Poland 647

of the placebo effect. While some argue that ther- national health policy; most mental health expen-
apy is simply a placebo because expectations are ditures are provided through the National Health
what make the therapy effective, others believe Fund, which is administered by the Ministry of
that psychotherapy is far from a placebo effect Health. Among the components of mental health
and that effective psychotherapy works through care specified in legislation are the right to access
other mechanisms of change (e.g., the therapeu- mental health care and community services, the
tic alliance and changes in cognitions or behav- legal rights of mental health service users, and
iors) rather than merely changes in expectations. the accreditation of mental health professionals
However, some of the common placebos used and care facilities. The government of Poland also
have focused on eliminating the interaction with conducts activities to fight stigmatization of and
the therapist (e.g., listening to audiotapes). This discrimination against the mentally ill.
research has demonstrated that the placebo effect Before the 19th century, the mentally ill in
causes changes in different brain regions than Poland were primarily cared for by their families,
those caused by psychotherapy. Much debate still or in institutions run by monasteries and churches;
exists, and it is possible that the effects of psycho- however, the 1347 Statute of Wislica stated that
therapy may be the result of a placebo in some care of the insane was the responsibility of both
instances and active treatments in others, thus their families and communal authorities. Asylums
highlighting the importance of placebo-controlled specifically for the care of the insane were founded
research designs in order to address such empiri- in the 16th and 17th centuries, with the first two
cal questions. such institutions established in Krakow and Vil-
nius. A network of psychiatric hospitals was
Heather Zucosky established in Poland in the 19th century; in 1938,
Hope Brasfield 24.2 percent of all hospital beds were reserved
Ryan Shorey for psychiatric patients, with most of these beds
Gregory L. Stuart in large hospitals. This system of care was largely
University of Tennessee, Knoxville destroyed during the German occupation and
World War II but was rebuilt in the 1953. In 1951,
See Also: Clinical Trials; Mind–Body Relationship; the Psychoneurological Institute in Warsaw began
Psychopharmacological Research; Randomized operation, with the responsibility of constructing
Controlled Trial. a model for professional psychiatric care.
In the 1960s, psychiatric care in Poland was
Further Readings comparable to that available in many western
Benedetti, Fabrizio. Placebo Effects: Understanding European countries, and in 1970, Poland had
the Mechanisms in Health and Disease. New York: 40,500 psychiatric beds in 34 hospitals, as well
Oxford University Press, 2009. as 418 outpatient clinics. The number of hospital
Margo, Curtis E. “The Placebo Effect.” Survey of beds for psychiatric patients was reduced by 20
Ophthalmology, v.44 (1999). percent between 1970 and 1990, a much lower
Rajagopal, Sundararajan. “The Placebo Effect.” reduction than was typical of most Western coun-
Psychiatric Bulletin, v.30 (2006). tries, which shifted their emphasis away from
mental hospitals and toward community care.
Scientific psychology has had a long history in
Poland. University study of psychology began at
the University of Lwow in 1876, with a series of
Poland lectures by Julian Ochorowicz; the first psychol-
ogy research lab in Poland was established by
Poland is a high-income country in central Wladyslaw Heinrich in 1903, and the second was
Europe. Although the psychiatric care system in established in 1910 under the direction of Edward
Poland was largely destroyed during World War Abramowski. The study of psychology became
II, it was rebuilt within two decades. Today, men- popular after World War I, and was commonly
tal health services are included within Poland’s taught in secondary schools and teacher training
648 Police, Sociology of

institutes. However, the influence of Marxism Poland has 5.13 psychiatrists per 100,000
around 1950 led to a devaluing of psychology, people, as well as 17.6 nurses per 100,000, 5.3
which was denounced as serving the interests of occupational therapists per 100,000, and 3.6
capitalism; many psychological clinics and labs psychologists per 100,000 in the mental health
were closed, and psychology was eliminated from sector. Primary care physicians are authorized to
the secondary school curriculum as a university provide psychotherapeutic medicines; however,
major. After 1956, psychological research and as of 2011, most primary care physicians had
practice resumed in Poland, and major institutes not received specialized training in mental health
of psychology were established at universities in services. The rate of treatment in mental health
Warsaw, Krakow, and Poznán. outpatient facilities is 304.1 per 100,000, and the
Psychoanalytic thought has also had a long rate of treatment in mental health day facilities 43
history in Poland. Ludwig Jekels directed a psy- per 100,000. Most (71 percent) of persons admit-
choanalytic clinic in Lvov (now in Ukraine) in the ted to a mental hospital are discharged within one
early 20th century, and Hermann Nunberg also year, while 17 percent are treated as an inpatient
practiced psychoanalysis in that city in the early for one to five years, and 12 percent for more
20th century; the earliest psychoanalytic publica- than five years; the median length of stay in men-
tions in Polish date from 1908. Interest in psycho- tal hospitals is 23 days.
analysis expanded greatly after World War I, with
most Polish analysts training at the Berlin Psycho- Sarah Boslaugh
analytic Institute; notable practitioners from this Kennesaw State University
period include Roman Karkuszewicz and Gustav
Bychowski. Communist rule after World War II See Also: Asylums; Germany; Mental Institutions,
brought a temporary pause to psychoanalytic History of; Policy: Federal Government; Nazi
activity in Poland, but the practice was revived Extermination Policies; Psychoanalysis, History
in the 1950s by several analysts who studied and Sociology of; Psychoanalytic Treatment; Social
abroad, including Jan Malewski, who studied Security; War.
in Prague and Budapest, and Zbignieuw Sokolik
and Michael Lapinski, both of whom studied in Further Readings
Prague. In 1961, the teaching of psychoanalysis Balicki, Market, Stefan Leder, and Andrzej
resumed at the universities of Warsaw, Krakow, Piotrowski. “Focus on Psychiatry in Poland: Past
and Lublin. and Present.” British Journal of Psychiatry, v.177
In 2011, Poland’s total expenditure for health (2000).
constituted 7.13 percent of its gross domestic Puzynski, S. and J. Moskalewicz. “Evolution of the
project (GDP). Per capita expenditure was $643 Mental Health Care System in Poland.” Acta
in 2006, and neuropsychiatric disorders are esti- Psychiatrica Scandinavica, v.104 (2001).
mated to make up 24.1 percent of the disease World Health Organization (WHO) Regional Office
burden. Expenditures for mental health make up for Europe. “Policies and Practices for Mental
5.1 percent of total health expenditures, with the Health in Europe: Meeting the Challenges.”
greatest proportion (73 percent) going to men- Copenhagen: WHO Regional Office for Europe,
tal hospital expenditures; this reflects in part the 2008.
legacy of the hospital-based care system typical of
countries under Soviet rule. Poland has 39.6 beds
in mental hospitals per 100,000 population, 14.3
psychiatric beds in general hospitals per 100,000,
3.2 beds per 100,000 in mental health outpatient Police, Sociology of
facilities, and 0.65 beds per 100,000 in day treat-
ment facilities. Community mobile teams provide Police officers experience stress at levels higher
home mental health care, but their services are than nearly every other occupation. Exhaustion,
only available to only a small proportion of the cynicism, and burnout are the most common
population (estimated at 20 percent or less). forms of stress in law enforcement, although
 Police, Sociology of 649

a segment of officers experiences more serious ethnicity, gender, or sexual orientation. Female
problems such as acute and post-traumatic stress officers with children have a dual problem—trying
disorders (PTSD). This stress can disrupt an offi- to fit into the male-dominated culture of policing
cer’s personal and professional life, manifesting and juggling work with their responsibility as pri-
through dysfunctional behaviors such as aggres- mary caregivers. Officers in rural departments are
sive conduct, absenteeism, job turnover, early also more likely to experience stress from isola-
retirement, domestic violence, divorce, and even tion, probably because the small size of their orga-
suicide. The origins of stress can be classified as nizations places practical limits on the availability
either general work stressors or critical incident of positive interactions with peers.
stress, and many law enforcement agencies and Initiatives to mitigate general work stressors
plice departments are taking proactive steps to focus on human relations and quality control.
manage stress in their ranks. Human relations approaches focus on collabora-
General work stressors, which contribute to tive management techniques, such as improving
the gradual accumulation of occupational stress, discussions and feedback in performance evalu-
are associated with everyday routines. Research ations and enriching jobs through community
indicates that the most significant sources of and team policing techniques. The borrowing of
stress are administrative and management issues. quality control techniques from manufacturing,
Rank-and-file officers complain that promotions such as Deming circles and Six Sigma, incorpo-
are often tied to departmental politics, not merit, rate opportunities for frontline employees to
and new policies and procedures are instituted contribute to organizational change. However,
without their input. They grow despondent if implementing these ideas must be done gradually,
they are always on the receiving end of top-down because even positive organizational change can
commands and if their responsibilities are either induce stress during the transition period due to
too little or too overwhelming relative to their the ambiguity of work responsibilities.
training, experience, and temperament.
This problem intensifies as years of service Critical Incident Stress
increase. Promotions in many law enforcement Critical incidents are events in which the violence
agencies are limited, so older officers can grow or harm witnessed is outside the normal range of
frustrated if they do not receive pay increases a person’s experience. These events are of concern
and other recognition that they feel they deserve. because they may engender PTSD, compounding
Negative reactions to the hierarchical nature of general work stressors with nightmares, flash-
law enforcement have been compounded since backs, and seemingly unwarranted displays of
9/11. The Federal Bureau of Investigation (FBI) aggression. Although officers grow more accus-
provides officers with watch lists of potential ter- tomed to difficult situations than the public at-
rorist suspects with no explanation of why a per- large, certain types of events in the line of duty
son is on the list, or what information should be are historically known to elicit responses in them
sought. An additional topic of management con- as well, such as officer-initiated shootings, attacks
cern has been the physical and emotional toll of on one’s person, viewing the dead body of a child,
shift rotation policies. and mass victimage. Interest in the topic of criti-
Social isolation is also a source of general work cal incident stress has been heightened since the
stress. Law enforcement officers experience high Oklahoma City bombing and 9/11, two events
levels of danger that most people never appreciate. making a profound psychological impact on first
This uniqueness contributes in part to the creation responders.
of a police subculture, nicknamed “the blue wall A critical incident alone does not trigger an
of silence,” behind which aspects of work are dis- extreme reaction. Many officers are resilient after
cussed outside the purview of the public. Because such experiences, but others are not. Estimates of
this subculture has been traditionally white and PTSD symptoms range from 7 to 20 percent of
masculine, officers who do not share these demo- active law enforcement personnel, and an occupa-
graphic characteristics may experience even more tional culture that insists that police remain tough
stress than the typical officer because of their race/ and avoid expressing emotions on the job inhibits
650 Police, Sociology of

A police officer in Toronto, Canada, shouts orders as his unit attempts to contain a crowd of protesters and create a blockade
during the G20 Toronto Summit, June 26, 2010. The stress of a police officer’s job can disrupt his or her life and manifest through
dysfunctional behaviors such as aggressive conduct, absenteeism, job turnover, early retirement, domestic violence, divorce, and even
suicide. Critical incidents, which are outside the normal range of stressors, can engender post-traumatic stress disorder.

the ability of affected officers to seek help. Gener- duration. At times, these debriefings may be group
ally speaking, best practices in assisting officers in oriented: For example, the death of a colleague
trauma include peer support, early intervention, on duty can create a secondary trauma that rip-
complete care, and pre-incident training. ples through a department, even among officers
Peer support receives the most acceptance. In who may not have known the deceased. While
some police departments, it is already a mecha- mandatory interventions are regarded as the best
nism for employee assistance, especially when practice, especially in officer-initiated shootings,
staff struggle with alcohol or substance abuse. there is reason to think that only a segment of
The practice works well with the “blue wall of officers welcome them; for the rest, the annoy-
silence” inasmuch as it favors the proclivity of ance may offset their benefits. Controlled studies
officers to keep job-related problems out of the yield mixed results regarding their effectiveness in
public eye. Peer mentors can take advantage of the short term, and their long-term effectiveness
off-hours get-togethers and departmental gossip, remains untested.
and mentors can “shoulder tap” when recruiting Complete care recognizes that the responses to
new colleagues. stress extend beyond the working environment.
Early intervention usually involves psycho- Because they are expected to look tough at work,
logical debriefings after a critical incident. Ini- law enforcement officers often vent their frustra-
tial meetings are often held within two or three tions at home, and family members are usually
days of the event and may last up to two hours in ill equipped to handle these situations, which
 Policy: Federal Government 651

results in levels of domestic violence and divorce Policy: Federal

in police families at higher levels than the nor-
mal population. At a bare minimum, law enforce- Government
ment supervisors can take the initiative to pro-
vide the family with information about the officer In all societies, members have assigned statuses
and event when a critical incident occurs, though with associated social role expectations. In the
offering formal debriefing and counseling to the United States, difficulties with the fulfillment of
entire family is more advisable. these expectations or complete failure to fulfill
The military, which is leading efforts to under- such expectations for as many as 20 percent of
stand PTSD, is promoting pre-incident training. the population is partially or completely attrib-
The suddenness of critical incidents creates a situ- uted to psychological malfunction from some
ation in which participants are unprepared for form of diagnosable mental illness. Data suggest
the situation. However, these incidents are not striking disparities in income level, health sta-
entirely unexpected. Training in how to respond tus, insurance status, and health services utiliza-
to emergency situations and identify signs of tion between those with severe mental illness and
trauma in oneself appears successful in reducing those without. Life expectancy for individuals
stress levels. with severe mental illness is 25 years shorter than
the general population.
Richard Lee Rogers The failure of significant numbers of individu-
Youngstown State University als to qualify for military service during World
War II because of psychological malfunction and
See Also: Emergency Rooms; Law and Mental the success in treating and/or ameliorating such
Illness; Policy: Police; Post-Traumatic Stress Disorder; malfunction during the war lent credence to the
Stress. claim of medicine/psychiatry that in fact much of
this malfunction should be dealt with as a disease,
Further Readings and that the privileges of the sick role might be
Amendola, Karen L., David Weisburd, Edwin E. accorded to those suffering from such illness. As
Hamilton, Greg Jones, and Meghan Slipka. such, the National Institute of Mental Health was
The Shift Length Experiment: What We Know born, giving the federal government a place for
About 8-, 10-, and 12-Hour Shifts in Policing. the development of research and practice in the
Washington, DC: Police Foundation, 2011. service of those afflicted with such difficulties.
Paton, Douglas, John M. Violanti, Karena Burke, and While the delivery of health and mental health
Ann Gehrke. Traumatic Stress in Police Officers: care had been and continues to be the purview
A Career-Length Assessment From Recruitment to of state policy, federal policies, legislation, and
Retirement. Springfield, IL: Charles C. Thomas, administrative decisions, largely through fiscal
2009. incentives, have created locally based systems of
Roland, Jocelyn E. “Developing and Maintaining care for people with mental illness; have encour-
Successful Peer Support Programs in Law aged mental health workforce development; and
Enforcement Organizations.” In Handbook of with the aid of federal court decisions, federal
Police Psychology, Jack Kitaeff, ed. New York: administrative guidelines, and federally spon-
Routledge, 2011. sored mental health services research, have set
Stevens, Dennis J. Police Officer Stress: Sources parameters defining the nature and scope of men-
and Solutions. Upper Saddle River, NJ: Pearson/ tal health care. Federal policy actions have come
Prentice Hall, 2008. to underwrite and define the nature of the deliv-
Violanti, John M., Luenda E. Charles, Tara A. ery, scope, and character of mental health service
Hartley, Anna Mnatsakanova, Michael E. Andrew, in the United States today. During the past half
Desta Fekedulegn, Bryan Vila, and Cecil M. century, federal policy has enabled the creation
Burchfiel. “Shift Work and Suicide Ideation Among of locally based, publicly operated mental health
Police Officers.” American Journal of Industrial services, and then encouraged the privatization of
Medicine, v.51 (2008). such care.
652 Policy: Federal Government

The impact of policy action is not linear because first major federal fiscal incentive for the develop-
policies influencing mental health care come from ment of a new approach to addressing the needs
various sources, many not directly aimed at cre- of people with mental illness: the Community
ating mental health service actions but doing so Mental Health Centers (CMHC) and Facilities
by creating new opportunity structures for entre- Act. This legislation and its subsequent amend-
preneurial administrations seeking to capitalize ments defined a public health approach to men-
on funding opportunities. Federal mental health tal health care. Bypassing the states to fund local
policy has thus evolved through three overlapping geographic areas (catchments), it offered federal
phases: from a focus on preventing mental dis- matching funds for the construction of facilities,
ease by providing locally based accessible services and subsequently for CMHC staff, which would
to the general population without regard to cli- provide at least five required services (inpatient,
ents’ ability to pay or priority of need; to a focus outpatient, partial hospitalization, emergency,
on limiting publicly provided services to those and consultation and education), and additional
most functionally impaired, with limited financial optional services, including specialized substance
resources and more limited federal investment; abuse and children’s services.
to an emphasis on the efficient use of mental Such services were offered within a preventive
health resources to restore functional role capac- framework for all individuals with psychological
ity through largely federally supported privatized problems within the catchment and were deliv-
delivery systems. ered in a manner emphasizing continuity of care.
The CMHC legislation emphasized continuity
Community Mental Health Movement of mental health care and, though only approxi-
The community mental health care (CMHC) mately half the envisioned centers were actually
movement, phase one spanning 1955 to 1980, established and many ultimately closed, the leg-
created a federal policy based on a public health islation provided a framework for the structure
model of care focused on general population of local mental health services that exists in many
need, emphasizing preventing mental disease and communities today. It also in its preventive efforts
promoting mental health by providing funding opened the area of minority mental health concern
incentives for the provision of publicly provided and funding for minority-focused mental health
local care for all mental health issues. At the point services. These CMHCs needed to be staffed, and
of the release of “Action for Mental Health,” a the NIMH provided fiscal incentives in the form
report emanating from the Joint Commission on of training grants and education fellowships for
Mental Illness and Mental Health, public mental the development of mental health professionals—
health services were primarily centered in state these incentives created a direct service work-
mental hospitals, financed wholly by state general force, including social workers, psychologists,
tax revenue. Improvements recommended by the psychiatrists, and other allied professionals.
commission led to major changes in the quality of While providing a framework and base for
care in these institutions, driving up their costs. local mental health services, the CMHC’s role
Federal court decisions such as Souder v. Bren- was greatly enhanced by the federal fiscal incen-
nan, requiring minimum wage for patient labor, tives associated with deinstitutionalization—nota-
undercut a major source of hospital revenue and bly, Supplemental Security Income (SSI), Medic-
operational efficiency. aid, and Medicare—and the civil rights rulings in
At this time, state hospitals were full-service Wyatt v. Stickney and Olmstead. Prior to the pas-
institutions, providing—in addition to mental sage of SSI—completely federally funded, provid-
health care—health care, long-term nursing care, ing income support for “permanently and totally
and all costs of living for people with severe men- disabled” individuals because of mental illness—
tal illness, most notably for the indigent. No sig- adult individuals with psychological disability
nificant community mental health services existed severe enough to hinder their participation in the
outside of private psychiatry for those who workforce could only rely on local welfare assis-
could afford it. The efforts of the John F. Ken- tance (general assistance) for support, assistance
nedy administration brought forth the nation’s that was largely inadequate. SSI provided income
 Policy: Federal Government 653

to sustain independent living or a special (higher) centers focused on the needy individuals. Giving
rate of support for residence in a supervised resi- up their preventive role, they emphasized care
dential setting (board and care facility). The latter for the indigent with major mental illness. Oth-
source of income stimulated the development of ers with employment were left to seek help from
the private board and care industry, which offered an expanding private health insurance industry,
the first supervised alternative to state hospitaliza- offering limited access to outpatient and inpatient
tion for adult persons with severe mental illness. care. While federal incentives initially sought to
Along with SSI, an adult with severe mental develop an integrated universal care system for
illness gained access to Medicaid, enabling the all mental health problems, phase two, spanning
receipt of health care and, most importantly for 1973 to 1996, created two systems of care: a pri-
individuals with severe mental illness, psycho- vate insurance-based system for those with less
active medications. Medicaid, Title XIX to the severe behavioral health conditions and a public
Social Security Act, is the largest source of funding system for those with severe and persistent mental
for medical and health-related services for people illness, a residual system largely based on a medi-
with limited income in the United States. Medic- cal model of treatment at reduced cost.
aid provides a 50 to 78 percent match of federal The Health Maintenance Organization Act of
funds to state funds for such services. It not only 1973 promoted by the Richard Nixon administra-
impacted the care of those with severe psycho- tion enabled the growth of managed health and
logical disability in the community but also other behavioral health care. In the United States, man-
categorically eligible adults and children (i.e., via aged care refers to a variety of techniques intended
its child health component, the early prevention to reduce the cost of providing health benefits
screening diagnosis and treatment [EPSDT] pro- and improving the quality of care. Though the
gram), it supports outpatient treatment through approach was largely promoted to address rising
publicly funded private practitioners, CMHCs, health care costs, it emerged as a way of addressing
and Medicaid managed care organizations. the progressive decline in funding for public men-
Medicaid has become the major support for tal health services. The managed health care initia-
publicly funded CMHCs in several states. It has tive of the federal government refocused the pub-
provided a stimulus and federal support for the lic health approach that characterized the CMHC
development of general hospital psychiatric inpa- from an emphasis on the equitable distribution of
tient care, which is now the major source of inpa- care resources to diverse populations within geo-
tient care for persons with severe mental illness. graphic catchments to a focus on efficiency and
It provided support for the transfer of care for evidenced-based practice, as well as biologically
seniors from mental hospitals to nursing homes, based conditions. Given the roots of managed care
underwriting their long-term care while suppress- in general health care provision, the refocus was
ing the acknowledgment of their mental health further on the integration of health and behavioral
problems because nursing facilities with more health care (i.e., the combination of mental health
than a 50 percent population of individuals with and substance abuse treatment). It created the
mental illness diagnoses lose their eligibility for managed care organization (MCO), and in doing
federal funding when they are reclassified as insti- so it helped promote the development and major
tutions for mental disease. expansion of behavioral health care within private
insurance plans, giving those with such coverage
Managed Mental Health Care: access to care outside the public system.
Efficiency and Cost Cutting The Medicaid Freedom of Choice Waiver
The CMHC movement, in its education and con- 1915(b), in the 1981 Omnibus Budget and Recon-
sultation capacity, broadened the American view ciliation Act, enabled states to set aside the indi-
of mental health and illness. CMHCs initially vidual choice provisions of Medicaid (provisions
addressed all psychological problems of all mem- allowing a patient to select a service provider) and
bers of a catchment they served—not only indi- permitted states to move those covered by Med-
viduals with severe conditions. As CMHC federal icaid into MCOs. This allowed CMHCs in the
and state sources of funding were reduced, the public system to become behavioral health care
654 Policy: Federal Government

MCOs, separating them from their services func- programs represented bright spots in a rather dis-
tion, enabling them to begin a process of contract- mal picture of care throughout the country for
ing out to private providers—usually nonprofits, those with severe mental illness.
though some for-profits—for the provision of
mental health services at reduced costs, encourag- Integrated Health and Mental Health Care
ing greater efficiency in the provision of such care. Phase three begins with the passage of parity leg-
Following the momentum of deinstitutionaliza- islation in 1996 and continues to date. Up to the
tion, U.S. housing policy under the Reagan admin- passage of the parity laws, private insurers gener-
istration shifted from a supply-side approach ally limited behavioral health coverage for persons
emphasizing increasing the supply of affordable with severe mental illness, leaving such people to
housing to a demand-side approach of providing seek help in the public system. The 1996 Mental
Section 8 vouchers to the poor needing help to buy Health Parity Act, amended by the 2008 Well-
into the rental market. However, housing infla- stone-Domenici Mental Health Parity and Addi-
tion greatly changed the housing market, leading tion Equity Act (MHPAEA), requires that a group
to a shift from a surplus in affordable housing to health plan of 51 or more employees (or cover-
a severe deficit. The limited effectiveness of Hous- age offered in connection with such a plan), which
ing and Urban Development’s (HUD’s) demand provides both medical and surgical benefits and
policies precipitated a homeless epidemic in which mental health or substance use benefits, ensure
those most vulnerable living in single-room occu- that financial requirements and treatment limita-
pancy hotels (SROs) and other housing subject to tions applicable to mental health/substance use
urban renewal joined the ranks of the homeless, disorder benefits are no more restrictive than the
fully a third of them evidencing major mental dis- predominant requirements and limitations placed
orders and upward of 70 percent some behavioral on substantially all medical/surgical benefits.
health condition. The situation made evident The law does not require that all Diagnostic
that successful community care for individuals and Statistical Manual of Mental Disorders (DSM)
with severe mental illness required adequate and conditions be covered, but requires the plan to state
secure housing. The McKinney-Vento legislation which it does cover and offer parity for those—
funded several programs, among which Shelter- major mental disorders such as schizophrenia,
Plus-Care has proven most successful in the fund- bipolar disorder, and major depression are gen-
ing of supported housing for persons with severe erally included as parity diagnoses, among other
mental illness. conditions. Bringing those with severe mental ill-
The Substance Abuse and Mental Health Ser- ness into the system of private health care coverage
vices Administration (SAMHSA), established to under managed behavioral health care has had an
oversee the mental health services functions of the impact by bringing to the fore the high prevalence
federal government as a split-off from NIMH, the of physical illness in this population, and has laid
latter emphasizing its research mission, promoted the groundwork for increased efforts at the pro-
service system development under the federal vision of integrated health and behavioral health
mental health block grant support program that service. While greatly expanding services for the
originated after the sunset of the CMHC legisla- severely mentally ill, parity has the effect of fur-
tion in 1980. Most notable among SAMHSA’s thering the privatization of behavioral health care.
accomplishments has been its advocacy on behalf Temporary Assistance for Needy Families
of consumer-driven services, an approach widely (TANF), created by the Personal Responsibility
embraced because of its focus on recovery, respon- and Work Opportunity Act instituted under Presi-
sibility, antistigma, and modest cost. SAMHSA dent Bill Clinton in 1996, is about restoring people
has also focused on the development and distri- to work and family roles while providing tempo-
bution of model program demonstrations and the rary financial assistance. It was designed to foster
dissemination of service use statistics—both tasks personal responsibility in families receiving pub-
helping to set parameters for standards of care lic assistance in the United States. Though states
throughout the country. While contributing to the vary in its implementation, under TANF, recipi-
development of model programs, generally such ents are required to find work or participate in
 Policy: Federal Government 655

job searches in exchange for their monthly grant. a Medicaid expansion to 133 percent of poverty
Because TANF participants evidence high mental (where government pays all of the costs for new
illness rates and such conditions are viewed as bar- enrollees for the first three years, and the federal
riers to obtaining employment, necessary mental match decreases to 90 percent by 2020), offers
health services including assessment, referral, case subsidized coverage through insurance exchanges
management, and treatment are provided to recip- to those with incomes up to 400 percent of the
ients in conjunction with Medicaid. This TANF poverty line, and prohibits the denial of insur-
use has greatly expanded the role of Medicaid in ance coverage to those with preexisting condi-
funding services to previously eligible individuals tions. These provisions will make approximately
whose seeking of behavioral health care services 30 million more individuals in the United States
has now been incentivized by their necessity to eligible for behavioral health care in both public
maintain eligibility for TANF support. It has also and private systems. The increased eligibility and
contributed to a change in the composition of the the mandate in the ACA to promote integrated
population served by CMHCs. health care (i.e., combined physical and behav-
The Patient Protection and Affordable Care Act ioral health) will change the nature of behavioral
(ACA) of 2010, health care reform or “Obam- health care delivery by virtue of increased demand,
acare,” mandates that all qualified health insur- a greater diversity in the conditions covered, and
ance coverage plans, public and private, comply a more comprehensive service mandate. The
with the Mental Health Parity and Addiction implementation of the ACA in a managed care
Equity Act of 2008—that they cover “mental framework for those with less economic means
health and substance use disorder services, includ- will increase privatization, and particularly the
ing behavioral health treatment.” ACA includes importance of the 501(c)(3) private nonprofit in

“Josh,” shown here in 2012, was suffering from mental illness while unemployed and living in a halfway house. He turned to
Buckelew Programs, a nonprofit providing homes, jobs, and other help to people with mental illness. It is one of more than 200
nonprofit organizations that have received a federal Social Innovation Fund grant. Federal policy has evolved to an emphasis on the
efficient use of mental health resources to restore functional role capacity through federally supported, privatized delivery systems.
656 Policy: Federal Government

the provision of behavioral health care, continu- suicidal or homicidal thoughts, are diverted to
ing the decline in publicly delivered service. general hospital emergency departments, which
The vehicle for the integration of such care is often lack the resources or expertise to care for
likely to be the patient-centered medical home these patients. For the Medicaid beneficiary, this
that offers preventive screening and health ser- may result first in a delay in treatment and then,
vices, acute primary care, behavioral health, when treatment is provided, inadequate care.
management of chronic health conditions, end General hospitals may delay the provision of care
of life care, and access to specialty and hospi- until a bed becomes available or inappropriately
tal facilities. For those with chronic and severe assign them to medical beds.
mental illness, these homes are likely to develop This demonstration will provide up to $75
within the context of organizations, such as con- million in federal Medicaid matching funds over
tractors to public CMHCs that are managing the three years to enable private psychiatric hospitals,
long-term care shelter-plus care arrangements. also known as IMDs, to receive Medicaid reim-
Since only one in two CMHCs has any general bursement for treatment of psychiatric emergen-
health care capacity, and less than one in three cies, described as suicidal or homicidal thoughts
has the capacity to provide the services onsite, or gestures, provided to Medicaid enrollees ages
such organizations will be developing partner- 21 to 64 who have an acute need for treatment.
ships with health care providers, partnerships Historically, Medicaid has not paid IMDs for
that may involve making primary care providers these services without an admission to an acute
available at the mental health facility. For those care hospital first.
with less severe conditions, the mental health care
is likely to occur at the primary care setting. The Beyond Civilian Care: Three Separate
integration of mental health care services and pri- Federal Systems of Mental Health Care
mary health care will also help with the incor- In addition to civilian mental health services, fed-
poration of services considered to be outside the eral policy has created three separate systems of
traditional medical model, such as social support care—the Military Health System, the Veterans
services, income support, and housing for indi- Health Administration, and the Indian Health
viduals with mental disorders. The ACA provides Service (IHS)—to provide health and behavioral
for transformation grants that will enable these health care to eligible populations. These service
new arrangements. systems constitute major federal policy initiatives
Another potentially major contribution to in mental health service provision.
changing the nature of the behavioral health ser- The Military Health System is within the U.S.
vice system is the Medicaid emergency psychiat- Department of Defense, responsible for providing
ric demonstration, established under Sec. 2707 of health and mental health care to active-duty and
the Affordable Care Act. This program will test retired U.S. military personnel and their depen-
whether Medicaid programs can support higher dents. It provides health support for the full range
quality care at a lower total cost by reimburs- of military operations and aspires to sustain the
ing private psychiatric hospitals for certain ser- health of all eligible members. Its subsidiary, TRI-
vices for which Medicaid reimbursement has his- CARE, provides civilian medical care for depen-
torically been unavailable. A major problem for dents of active-duty personnel and for retirees
those with severe mental illness continues to be and their dependents, available with certain limi-
obtaining adequate crisis care, notably the cur- tations and copayments.
rent shortage of crisis beds. Currently, Medic- Distinct from the Military Health System, the
aid does not reimburse psychiatric institutions, Veterans Health Administration (VHA) is a com-
referred to in Medicaid as “institutions for mental ponent of the U.S. Department of Veterans Affairs
disease” (IMDs), for services provided to Med- (VA). It runs the medical assistance program of
icaid enrollees ages 21 to 64. This restriction is the VA through the administration and opera-
known as Medicaid’s IMD exclusion. Because of tion of numerous VA outpatient clinics, hospitals,
the IMD exclusion, many Medicaid enrollees with medical centers, and long-term health care facili-
acute psychiatric needs, such as those expressing ties (i.e., nursing homes).
 Policy: Medical 657

Both of these systems, in addition to addressing shape the access to and breadth of services avail-
all aspects of service-involved health conditions, able to individuals with mental health needs. Dis-
have expanded service and interest in the treat- putes between the proper course of treatment for
ment of post-traumatic stress disorder (PTSD) certain conditions and the relative value and merit
and brain trauma. of treatment with pharmaceuticals, talk therapy,
The IHS, within the U.S. Department of Health or a combination have significant consequences
and Human Services (HHS), is responsible for for both patients and those who treat individuals
providing medical and public health services with mental illnesses. Decisions by policy makers
to members of federally recognized tribes and often shape treatment options for those struggling
Alaska Natives. IHS provides health and behav- with mental illness, as authorization for certain
ioral health care at 33 hospitals, 59 health centers, types of treatment is shaped by these choices.
and 50 health stations. Approximately 34 urban
Indian health projects supplement these facilities Federal Policy Influences
with a variety of health and referral services. A variety of sources influence policy regarding
mental health in the United States. Until recently,
Steven P. Segal only those with adequate means or health insur-
University of California, Berkeley ance were able to afford mental health care.
Through the 1950s, those diagnosed with men-
See Also: Department of Health and Human tal illness were often treated in large institutions.
Services, U.S.; Food and Drug Administration, U.S.; Shortly after taking office, President John F. Ken-
Health Insurance; Medicare and Medicaid; National nedy formed the President’s Panel on Mental
Institute of Mental Health; Social Security. Retardation to examine treatment of those who
were either mentally impaired or suffering from
Further Readings mental illness. The panel ultimately made over
Frank, Richard G., Howard H. Goldman, and 100 recommendations, which led to legislation
Michael Hogan. “Medicaid and Mental Health: Be that increased funding for research into the causes
Careful What You Ask For.” Health Affairs, v.22/1 and treatment of mental illness as well as the pro-
(2003). vision of community-based services for those with
Grob, Gerald N. “Mental Health Policy in America: mental disorders.
Myths and Realities.” Health Affairs, v.11/3 (1992). Beginning in 1965, the U.S. Congress, as part
Rochefort, David A. From Poorhouses to of the Social Security Amendments of that year,
Homelessness: Policy Analysis and Mental Health created Medicaid. Medicaid, part of President
Care. 2nd ed. Westport, CT: Auburn House, 1997. Lyndon B. Johnson’s Great Society program, was
Social Security Administration. “Annual Statistical intended to provide medical coverage for low-
Report on the Social Security Disability Insurance income families and others, including the blind,
Program, 2011.” Washington, DC: Social Security the disabled, and pregnant women. Although it
Administration, 2011. was a federal program, each state was able to
U.S. Department of Health and Human Services. “The set its own eligibility standards for coverage and
Health Care Law and You.” http://www.healthcare determine the extent and range of services cov-
.gov/law/index.html (Accessed May 2013). ered. Each state has developed its own criteria for
determining who is covered and which services
are eligible for reimbursement.
Medicaid has evolved over time to become the
single largest source of reimbursement for men-
Policy: Medical tal health services in the United States. Although
every state and the District of Columbia is per-
Policies related to mental health care, including mitted under the program to determine which
those promulgated or supported by the state and services are covered by its Medicaid plan, each
federal governments, insurance companies, and provides some form of mental health coverage
other organizations involved in medical care, to enrollees. Mental health services covered by
658 Policy: Medical

various state Medicaid programs include early however, insurance companies were able to cir-
and periodic screening, diagnosis, and treatment cumvent the MHPA by increasing premiums,
(EPSDT), which allows mental health profession- copays, and deductibles needed for coverage. The
als to detect and treat mental illness along with a MHPA was also undercut when insurance com-
variety of developmental and other needs. Other panies imposed limits on the number of covered
mental health benefits funded by Medicaid may days for a hospital stay.
include clinical social work services, counseling, In 2008, Congress responded by passing the
medication, therapy, peer support groups, psychi- Mental Health Parity and Addiction Equity Act
atric services, and substance abuse treatment. Ser- (MHPAEA), which superseded the MHPA. The
vices may be offered at medical facilities or, if the MHPAEA corrected the omissions of the MHPA,
state seeks and obtains a waiver, through home forcing insurance companies to guarantee the
and community-based providers. While mental financial requirements on policies be identical
health services are optional for adults enrolled in for medical, mental health, hospital, and surgical
Medicare, EPSDT requires all states to provide benefits. The MHPAEA also extended mandatory
these treatment options to minor children. coverage for addiction therapy, which is often
In 1986, Congress also passed legislation that linked to mental disorders.
required the provision of emergency health care In 2010, Congress passed the Patient Protec-
treatment regardless of an individual’s ability tion and Affordable Care Act (ACA), sometimes
to pay, citizenship status, or documentation of referred to as Obamacare. The ACA aims to
legal status. This legislation, known as the Emer- reduce the number of uninsured Americans and
gency Medical Treatment and Active Labor Act to reduce the escalating cost of health care. Using
(EMTALA), requires the provision of mental an assortment of mandates, subsidies, and tax
health services when necessary, but only in emer- credits, the ACA forces individuals and employ-
gency situations in which the life of the afflicted ers to extend coverage to a greater percentage of
individual is in jeopardy. EMTALA has been the population. Additionally, the ACA requires
criticized as increasing the costs of health care insurance companies to extend coverage to all
for those with medical insurance, although oth- applicants and offer identical rates regardless of
ers refute this, as hospitals can and do attempt to preexisting conditions. Despite constitutional
bill many patients for care once they have been challenges by numerous states and many other
discharged. If a hospital determines that there is entities, in 2012 the U.S. Supreme Court held
no emergency, its obligation to provide care under that the ACA was constitutional, and the legisla-
EMTALA ends. tion was implemented. In conjunction with the
MHPAEA, this extended mental health coverage
Insurance Companies’ Influence to many who had previously not had access.
Insurance companies also make many decisions The ACA’s impact on mental health medical
that affect the availability of mental health care. policy is expected to be immense. The Congres-
Historically, insurance companies have been sional Budget Office (CBO) estimates that the
reluctant to include mental health needs in their number of Americans without health insurance
coverage. In particular, insurance companies will be reduced by over 30 million by 2019, at
have limited the amount of mental health ser- which time the legislation will be fully imple-
vices that an insured could use within a calendar mented. Although this leaves nearly 28 million
year, despite statistical data that indicates that without health insurance, proponents claim that
the lower a state’s unmet mental health needs, the it permits many more individuals to access men-
lower that state’s rates of depression, suicide, and tal health services. After 2019, those who will
a host of other related problems. To prevent this, be excluded from medical insurance will include
Congress passed the Mental Health Parity Act undocumented aliens, individuals who choose
(MHPA) in 1996, requiring insurance companies not to purchase medical insurance, those who
to maintain identical annual or lifetime dollar opt out of Medicaid, and those who live in states
limits to those implemented for medical, hospi- that have chosen to opt out of the Medicaid
tal, or surgical benefits. After its implementation, expansion.
 Policy: Medical 659

State Policy Influences services in the 21st century. While implementa-

A tremendous amount of legislation regarding tion of the act did increase the funding available
medical policy related to mental health has his- to community-based providers of mental health
torically been promulgated by state legislatures services, it is estimated that as many as 1 million
and local government agencies. In addition to set- Californians have mental health needs that are
ting their own thresholds regarding participation not being met. This issue will continue to affect
in and services provided by Medicaid, state gov- state and local agencies as they seek funding for
ernments also shape policies that affect those with various competing needs.
mental health disorders.
For example, in 1967, the California legislature International Policy Influences
passed what is known as the Lanterman-Petris- Other organizations also influence medical pol-
Short Act, which controlled involuntary civil icy. For example, the World Health Organiza-
commitment to mental health facilities within tion (WHO), an agency of the United Nations,
that state. Previously, those suspected of suffer- has undertaken a mental health policy project
ing from mental illness could be indefinitely held designed to encourage improved mental health
against their will. The act was designed to end care in both the developing and industrialized
inappropriate, indefinite, and involuntary com- world. To do this, WHO has examined the eco-
mitment of those suffering from mental illness nomic and social impact of mental illness and
and to instead promote the diagnosis and treat- emphasized that five of the 10 most common
ment of mental disorders. disease burdens are related to mental illness.
Although the act resulted in the deinstitutional- These disease burdens include alcohol use disor-
ization of many, it also contained provisions that ders, bipolar disorder, depression, schizophrenia,
permitted an initial 72-hour hold that allowed and self-inflicted injuries. When these conditions
for observation and diagnosis for those who are managed and treated, the burden on soci-
were believed to be a danger to others, a dan- ety is greatly reduced, with unemployment rates
ger to themselves, or otherwise gravely disabled. decreasing and productivity increasing.
Many states followed California’s lead in provid- WHO seeks to assist policy makers in formu-
ing more community-based services to those with lating and implementing mental health policies
mental illnesses, as it was less restrictive of their and plans that provide and support services to
personal freedom as well as less expensive. individuals from all age groups and income lev-
During the last two decades of the 20th cen- els. To that end, WHO has a guidance package
tury, much of the control over mental health ser- to assist with the planning of legislation that will
vices passed from the hands of state agencies to support improved mental health services. WHO
those of county and municipal authorities. As has also encouraged regional forums and advi-
more and more individuals with mental illness sory networks to permit member states in each of
were provided home care as opposed to institu- the WHO regions to collaborate and share expe-
tionalization, certain communities began to criti- riences. WHO also provides technical assistance
cize the underfunding of mental health services. to member states seeking to improve the quality
In California, for example, many homeless peo- of and access to mental health care for their resi-
ple suffer from some form of mental illness that dents. With over 190 member nations, WHO is
greatly impedes their ability to hold a job or oth- able to provide data collection services and pro-
erwise provide for their own needs. In response, mote publications that assist those seeking better
voters in California approved Proposition 63, mental health services.
which implemented the Mental Health Services WHO has pushed for services to be provided
Act (MHSA). MHSA imposed an additional in a way that supports health equity. While many
income tax on individuals (but not businesses) nations embrace the funding and services WHO
earning more than $1 million per year. Although can provide, its gender-responsive, pro-poor, and
the 2004 passage of this referendum increased human-rights-oriented approaches have caused
funding to California’s mental health system, it resistance in some quarters. However, as mental
also indicated dissatisfaction with mental health health care becomes more readily available, the
660 Policy: Military

WHO and other stakeholders expect ancillary general, policies across the branches are similarly
medical problems to decrease. regulated. Military policy addresses sexual orien-
tation, reporting requirements for mental health
Stephen T. Schroth professionals, domestic violence, mental illness,
Jason A. Helfer sexual assault, confidentiality, and the impact of
Knox College these issues on the careers of military personnel.

See Also: American Psychiatric Association; American Reporting

Psychological Association; Clinical Trials; Costs of The “don’t ask, don’t tell” policy was officially
Mental Illness; Deinstitutionalization; Food and Drug repealed the under the Barack Obama adminis-
Administration, U.S.; Health Insurance; Law and tration in 2011. Prior to the end of this policy,
Mental Illness; Legislation; Medicare and Medicaid; gay and lesbian service members faced official
Pharmaceutical Industry; Policy: Federal Government; investigation and potential discharge from the
Policy: State Government; State Budgets. military if their sexual orientation was revealed
to others. This policy was originally instituted
Further Readings under the Bill Clinton administration, and its
Bodenheimer, T. and K. Grumback. Understanding purpose was to lift the ban on gays and lesbians
Health Policy: A Clinical Perspective. 6th ed. New serving in the military.
York: McGraw-Hill/Lange, 2012.
Feldstein, P. J. Health Policy Issues: An Economic
Perspective. Chicago: Health Administration Press,
2011.
Frank, R. G. and S. A. Glied. Better but Not Well:
Mental Health Policy in the United States Since
1950. Baltimore, MD: Johns Hopkins University
Press, 2006.
Russell, L. B. Educated Guesses: Making Policy
About Medical Screening Tests. Berkeley:
University of California Press, 1994.
Whitaker, R. A. Mad in America: Bad Science, Bad
Medicine, and the Enduring Mistreatment of the
Mentally Ill. New York: Basic Books, 2010.
World Health Organization (WHO). Mental Health
Policy Project: Policy and Service Guidance
Package. Geneva: WHO, 2001.
Young, T. K. Population Health: Concepts and
Methods. 2nd ed. New York: Oxford University
Press, 2004.

Policy: Military
Recent years have seen changes in the way that
the military addresses issues of domestic violence, Two U.S. Marines prepare teaching materials for a suicide
sexual assault, treatment of mental illness, and prevention course at Al Asad Air Base, Iraq, September 1, 2009.
sexual orientation. There may be minor varia- Any condition, including severe depression, that results in a
tions in policy between the branches of the mili- lasting impairment in the ability to perform military duties
tary and between military installations but, in requires evaluation by a mental health professional.
 Policy: Military 661

Military mental health providers have report- (PTSD) often experience feelings of guilt and may
ing requirements that go beyond those of civilian wrongly perceive their actions to be war crimes.
providers. While some aspects of reporting are Military mental health providers are also
similar, military policy mandates the reporting of required to report active problems with sub-
war crimes, spousal abuse, and substance depen- stance use. This includes substance abuse that can
dence. Like civilian providers, military providers interfere with the ability to perform job duties.
are also required to report the abuse of children, The military provides treatment for those with
the elderly, and the disabled. substance-related problems, but they may also
The Department of Defense (DoD) created a face career-related consequences, especially if the
Task Force on Domestic Violence in 1999 under problem is reported by others. Military personnel
congressional mandate. The military has a no- have the option of self-reporting and seeking help.
tolerance policy toward domestic violence. The The DoD has a goal of no sexual assault in the
military’s Family Advocacy Program (FAP) was military and has taken steps to address the prob-
created to help meet this standard. The FAP’s lem of military sexual assault with the creation
mission is to prevent, identify, and investigate of the Sexual Assault Prevention and Response
incidents of domestic abuse. For spouses seeking (SAPR) program. Victim advocates have been
help, there are two reporting options available: made available through this program, and train-
restricted and unrestricted reporting. ing in the prevention of sexual assault has been
Restricted reporting is available for individuals disseminated. The option of restricted and unre-
seeking mental health or medical care who wish stricted reporting has also been made available
to be connected with services but do not want to in cases of rape. A restricted report allows sexual
report the name of their abuser. When a restricted assault victims to seek help without investiga-
report is made, the service member’s command tion. This option was created to address prob-
is not notified, and no investigation is launched. lems with the under-reporting of sexual assault.
There are some exceptions to restricted reports. Medical and mental health treatment is available
When an unrestricted report is filed, the service for survivors of military sexual assault, including
member’s command and the FAP are notified, and emergency medical services. Those convicted of
an official investigation ensues. If a report is made rape are forbidden from enlisting or being com-
and the service member is determined to have missioned in the military.
abused his or her partner, sanctions may include
fines, reduction in rank or pay, or separation from Service Requirements
the military. Current problems with or a history of certain
Military families face many stressors that are diagnoses may exclude individuals from enlisting
unknown in civilian families. Service members in or contracting with the military. These diag-
may experience multiple deployments with long- noses include bipolar disorder, conduct disorder,
term separations from their family members. oppositional defiant disorder, personality disor-
Any deployment can result in the service mem- ders, obsessive-compulsive disorder, dissociative
ber missing developmental milestones of their disorders, substance dependence, post-traumatic
children. Additional stressors can include erratic stress disorder, and psychosexual, somatoform,
work schedules, financial difficulties, and fre- and psychotic disorders. Those with depressive,
quent relocation. eating, learning, anxiety, and sleep disorders may
Military mental health providers are required enlist or contract with the military if they meet
to report information that they learn about war designated criteria. Prior psychiatric hospitaliza-
crimes. Broadly defined, war crimes include the tions for any disorder may also exclude individu-
intentional murder or mistreatment of civilians als from enlisting.
and the destruction of property outside the context The military requires that service members
of a military mission. The reporting of war crimes maintain the ability to complete their duties;
can result in investigation and, if demonstrated, therefore, any condition that results in lasting
may have legal and career implications. Service impairment in ability to perform duties requires
members who have post-traumatic stress disorder evaluation by a mental health professional. Axis I
662 Policy: Police

diagnoses (as described in the Diagnostic and ill include the coordination of interagency ini-
Statistical Manual for Mental Disorders) that are tiatives, police social service teams, generalized
considered to be impairing may result in a Medi- training for officers, and jail diversion.
cal Evaluation Board (MEB). An MEB may result Police derive the authority to deal with men-
in separation or retirement from the military if tally ill individuals in two ways. First, as one of
the service member is determined to be unable to their core functions, they are expected to main-
complete his or her duties. Conditions that last tain public order and safety, which is fulfilled
longer than one year or that require medication through responses to emergencies, as well as by
for longer than a year fall into this category. Con- addressing problems they encounter during rou-
ditions that have two or more episodes that are tine patrols. For this reason, law enforcement is
impairing in a year also fall into this category. frequently involved in situations where a mentally
Axis II diagnoses may result in dismissal from the ill individual is a nuisance or presents a danger to
military. him- or herself or others, even if the behavior is
not overtly criminal. Police are especially likely to
Charity Wilkinson encounter mentally ill individuals in their interac-
University of Texas Health Science Center, tions with the homeless and in arrests for drug
San Antonio possession, the latter including people who self-
medicate because they lack psychiatric prescrip-
See Also: Military Psychiatry; Post-Traumatic Stress tions. In addition, police may deal with mentally
Disorder; Veterans; Veterans’ Hospitals; War. ill individuals as victims—mental impairment
makes one unusually vulnerable to those engag-
Further Readings ing in crime or abusive behavior.
Fassin, Didier and Richard Rechtman. The Empire A second role played by the police, also a core
of Trauma: An Inquiry Into the Condition of function of the job, is community service, and
Victimhood. Princeton, NJ: Princeton University this activity includes identifying at-risk popula-
Press, 2009. tions. Police authority in this role is tied to the
Lifton, Robert Jay. Home From the War: Vietnam long-standing doctrine of parens patriae. Origi-
Veterans—Neither Victims nor Executioners. New nally obligating the state to ensure the best inter-
York: Simon & Schuster, 1973. ests of children, the concept has been extended
Shephard, Ben. A War of Nerves: Soldiers and to cover government responsibilities toward the
Psychiatrists in the Twentieth Century. Cambridge, mentally ill. Police are in a position to identify
MA: Harvard University Press, 2001. mentally ill individuals who may merit public
assistance. Some interactions may occur outside
emergency responsibilities and routine patrol:
Families may request police assistance to trans-
port the mentally ill to health care providers, and
Policy: Police courts may ask officers to execute civil commit-
ment papers.
As first responders, police have been nicknamed While law enforcement has the authority to act
“street-corner psychiatrists” because of their role in the helping of this population, officers usually
in dealing with the mentally ill. Deinstitution- are not equipped to do so. Many situations in
alization, combined with a lack of funding for which a mentally ill person causes a problem or
community mental health organizations, has had disturbance are resolved through “talking down”
the effect of increasing the responsibility of the the person and other conflict resolution tech-
criminal justice system in the identification and niques; arrest is an option in serious instances of
placement of these individuals. While police have crime and disorder. In spite of parens patriae, the
authority to act when they encounter people with major police responses only control symptoms
serious mental illnesses, these interactions rarely and do not assist in addressing the underlying
result in improving the person’s situation. Best psychiatric causes of the behavior of the mentally
practices for police interactions with the mentally ill person. Even when law enforcement desires
 Policy: Police 663

to help, past experiences often discourage offi- 1910s. The expansion of these efforts throughout
cers from doing so. Admitting a person to a care the 20th century focused primarily on women
facility often takes hours of time, and in these cir- and children, and by the end of the century, some
cumstances, the mentally ill person sometimes is departments took on more specialized functions
rejected for care because of the lack of an appro- to address domestic violence and child sexual
priate diagnosis. assault. Many large departments today retain
police social workers or sworn community service
Best Practices officers, and forensic social workers today argue
Contemporary strategies of local law enforcement for an expansion of police leadership in commu-
are shifting police priorities from simple reactive nity mental health by providing on-call support
responses to emergency calls toward proactive services and referrals, forming community alli-
efforts to eradicate the origins of crime and disor- ances, and giving in-service training to officers.
der before they occur. Problem-oriented policing Not every officer is deeply involved in inter-
engages in data analysis and research to identify agency coordination or social service teams, and
the causes of crime hot spots and patterns, and not every community is large enough to have
community policing seeks to improve troubled dedicated staff and facilities for this function. The
relations between police and citizens in the service generalized training of officers is one of the sim-
area. These strategies have increased the visibility plest ways to handle the situation. Officers receive
of mental health issues in several communities. For ongoing continuing education, which can easily
example, repeated 911 calls from a single location incorporate instruction on how to handle men-
may indicate the presence of other issues, such tally ill individuals. The training can be reinforced
as a mental health problem or substance abuse; when departments offer specific recommendations
recurring police brutality may signal an inability and “cop cards” of where to transport individu-
to deal with mentally ill individuals properly. In als if emergency psychiatric services are deemed
the wake of these new techniques, several sugges- necessary.
tions to improve police interactions with the men- As part of booking and intake procedures,
tally ill have emerged, including coordination of many jails now include psychological evaluations
interagency initiatives, police social service teams, to assist in the placement of detainees soon after
generalized training, and jail diversion. arrest. There are two reasons for this procedure:
The model for coordination of interagency ini- jails have a vested interest in identifying inmates
tiatives is the Memphis Crisis Intervention Team who are at risk of suicide, which, if it happens, is
(CIT), which was formed in 1983 to address the most likely within the first 24 hours; and police
use of excessive force against the mentally ill. officers often have suspicions of a person’s mental
Specially trained CIT officers are now called to health problems based on conduct at the scene of
the scene if mental problems are suspected as the the arrest and during transport, and jail screen-
source of an offender’s behavior, and the police ings provide an initial verification of their obser-
work with an emergency psychiatric unit at the vations. If an offender is identified as mentally ill,
University of Tennessee Medical Center. While they can be moved to another facility or psychi-
the specific details of these initiatives vary by atric center specializing in the detainment of this
community, these programs usually have three type of offender. In some jurisdictions, this diver-
essential components: (1) officers, auxiliary offi- sion can also be considered as a feeder for a local
cers, or volunteers who are specially trained in mental health court. Though there are questions
mental health issues and who are available on a over whether jail diversion programs provide
24/7 basis; (2) designated emergency facilities or cost savings, they have been successful in placing
agencies that liaise with police and provide ser- mentally ill offenders into community treatment
vices on demand; and (3) an interagency coordi- programs, which have reduced jail time without
nating team. diminishing public safety.
The history of police departments’ hiring of Some practical considerations are needed to
people to engage in social service functions dates avoid violations of Fourth Amendment search and
to the time of the first Women’s Bureaus in the seizure protections. First, jails are encouraged to
664 Policy: State Government

have policies and procedures in place to cover the state mental health policy development is linked
use of these screens. Ad hoc implementation raises to federal mandates for and national trends in
questions of the constitutionality of the action and mental health care. State mental health policy is a
could inadvertently cause aspects of the case to be complex and evolving field because of the nature
thrown out by the court. Similarly, mental health of the problems specifically addressed and the dif-
professionals are advised to avoid involvement ficulties of implementing policies at the commu-
unless a defense counsel has been appointed. nity level, which requires coordination and sup-
port from local authorities. Policy development in
Richard Lee Rogers the United States has historically been cyclical in
Youngstown State University nature and often reflects the efforts of the state to
remedy weaknesses in existing or prior services.
See Also: Courts; Drugs and Deinstitutionalization; However, ongoing research on mental health and
Homelessness. illness also shapes policy making. Particularly,
studies that contribute to defining mental illness;
Further Readings psychological, social, and biological risk factors
Cordner, Gary. People With Mental Illness. for mental disorders; and the effects of mental
Washington, DC: U.S. Department of Justice, illness on the individual, family, and commu-
Office of Community Oriented Policing Services, nity units’ functioning inform policy makers and
2006. foment development of new policy decisions.
Lamb, H. Richard. “The Police and Mental Health.” Other important considerations include the
Psychiatric Services (October 1, 2002). prevalence and distribution of mental illness
Lamb, H. Richard, Linda E. Weinberger, and Bruce across different racial, cultural, and socioeco-
H. Gross. “Mentally Ill Persons in the Criminal nomic groups. Political and economic consider-
Justice System: Some Perspective.” Psychiatric ations further influence the extent to which soci-
Quarterly, v.75 (2004). ety responds to the needs of individuals diagnosed
Roberts, Albert R. and David W. Springer, eds. Social with mental illnesses. Over the past century, there
Work in Juvenile and Criminal Justice Settings. 3rd has been growing consensus that mental health
ed. Springfield, IL: Charles C. Thomas, 2007. policies and state involvement with mentally ill
Steadman, Henry J., ed. Effectively Addressing the individuals should be as little intrusive as pos-
Mental Health Needs of Jail Detainees. Seattle: sible, which has led to increasing decentraliza-
National Coalition for the Mentally Ill in the tion and fragmentation of mental health services.
Criminal Justice System, 1990. State policy makers must identify the individuals
Steadman, Henry J. and Michelle Naples. “Assessing who are in need of mental health services and
the Effectiveness of Jail Diversion Programs the kinds of programs and services that the state
for Persons With Serious Mental Illness and should make available. They continually clarify
Co-Occurring Substance Use Disorders.” the state’s role in caring for individuals with men-
Behavioral Sciences and the Law, v.23 (2005). tal disorders, identifying gaps in service delivery
and addressing unmet needs.

Mental Health Policy in Early America

Few formal policies pertaining to persons with
Policy: State mental disorders were developed during the colo-
nial period, but of those that were created, public
Government safety and the monetary impacts of caring for the
mentally ill were paramount concerns. The men-
In the United States, state governments promul- tally ill were viewed as dependent citizens because
gate the vast majority of the laws concerning the of their inability to earn a living. If relatives were
prevention and treatment of mental disorders and unable to provide sufficient resources, they were
ensure that mental health services are available eligible for publicly funded poor relief, which
at the state and community levels. Nevertheless, could be in the form of food, clothing, and shelter.
 Policy: State Government 665

The violently mentally ill, however, were incarcer- and psychological conditions caused mental disor-
ated, along with other criminals. Over time, life ders. The medical profession expanded to include
in the colonies became increasingly complex, and a variety of specialists who sought to understand
the continuing growth of both the general popu- the causes of mental illness. During this period,
lation and the number of individuals with mental many physicians endorsed phrenology, which
disorders led to other methods in caring for the held that mental illness was caused by lesions in
mentally ill. the brain, but also believed that emotions and the
In 1641, the Commonwealth of Massachusetts individual’s social interactions acted as catalysts.
was the first colony to enact legislation dealing The Second Great Awakening, a Protestant reli-
with the mentally ill. This legislation was aug- gious revival that swept across the nation during
mented in ensuing years due to unease about the the first half of the 1800s, also radically changed
growing numbers of mentally ill. Other colonies the way that Americans viewed mental illness.
later followed Massachusetts’ example for the The reformers preached that faith in the Bible as
protection of their residents. Beginning in the the sole religious authority and good works were
1700s, again because of both general and men- the means to achieve spiritual salvation. Offshoot
tally ill population growth, communities came to movements were also established before the Civil
view the institutionalization of the mentally ill as War, including the abolitionist, temperance, and
an appropriate societal response to addressing the prison reform groups, and rapidly spread across
needs of this population while maintaining public the country. Doing good works and alleviating
safety. Thus, public officials commonly ordered the problems that reformers believed were caused
the mentally ill to be placed in almshouses, work- by an unjust society—namely, poverty, crime, and
houses, or jails, which exploded in number across mental illness—inspired many, possibly because
the colonies. Because the unusual behaviors dis- these conditions were becoming more visible as
played by the mentally ill stirred fear among other Americans increasingly migrated to urban areas
citizens, such institutionalization was desirable. where living conditions were more crowded.
Little distinction was made between the mentally The reform movements of the early 1800s
ill, the poor, and individuals with other cognitive and the problems associated with institutional-
or physical disabilities; all were institutionalized izing growing numbers of mentally ill persons in
together in sometimes appalling conditions and overcrowded institutions precipitated the estab-
without medical care. lishment of mental asylums, the majority state
During the latter half of the 18th century, the operated and funded. Asylums during this period
first general hospital in Pennsylvania was estab- were considered humane alternatives to jails and
lished, which provided care for both the sick and workhouses and, inspired by reformist values,
the mentally ill. The founding of a second hospital they offered comfortable, peaceful environments
in Virginia soon followed. While publicly funded that could counteract the harmful emotional and
poor relief was still society’s typical response to interpersonal factors believed to cause mental
dealing with the mentally ill, these hospitals none- illness. Such treatment, which included a mix-
theless demonstrate a departure from institution- ture of educational and recreational activities
alizing the mentally ill toward their attempted in a friendly environment, was termed “moral
treatment and cure. Americans of the early 19th treatment.” Dorothea Dix (1802–87), a Boston
century increasingly came to embrace mental dis- schoolteacher, became a prominent champion for
orders as biological and/or psychological in origin the humane care and treatment of the mentally ill
and to reject the antiquated notion that mental after visiting a jail where she witnessed the shock-
illness was a personification of evil. ing neglect and abuse of the incarcerated mentally
ill. She petitioned the Massachusetts legislature to
Moral Treatment Period institute reforms, including state hospital expan-
A number of events occurred during the 1800s sion, and helped establish over 30 asylums in the
that changed the way Americans viewed mental United States and abroad during her lifetime.
disorders and how to care for the mentally ill. By the latter half of the 19th century, historical
First, there was a growing belief that biological data suggest that some asylums were successfully
666 Policy: State Government

treating their mentally ill patients, evidenced by supplies and skilled labor, and living conditions
the fact that few patients remained institution- deteriorated. Consequently, providing therapeu-
alized for more than a year, and relapse rates tic care was unrealistic. Additionally, by the late
remained below 50 percent. 1800s, almshouses, which had been used for cen-
Americans were not careful to distinguish turies to care for the indigent elderly, were gradu-
between people with mental disorders and indi- ally disbanded by local governments that could
viduals with learning disabilities who were usu- no longer afford to maintain them. State mental
ally described as “idiots” or “feebleminded.” hospitals increasingly became the havens of last
Individuals with learning disabilities were often resort for the indigent elderly, who were conve-
institutionalized with the mentally ill and subse- niently labeled insane by local officials when, in
quently benefited from the improvements in care, reality, they suffered only from the normal ill-
especially newly created educational programs nesses of old age.
offered to the mentally ill. In 1846, the Massachu-
setts legislature authorized Samuel Gridley Howe State Mental Health
to determine the number of feebleminded persons Policy in the 20th Century
who might benefit from special educational pro- Besides the accepted theory that mental disorders
grams, and in 1848, he established the first special were caused by heredity, Americans of the early
education program for poor feebleminded chil- 1900s gradually adhered to the new concept of
dren in Waltham, Massachusetts, the Massachu- Social Darwinism, which postulated that society
setts School for Idiotic Children, with a $2,500 should rid itself of people society deemed unfit.
appropriation from the Massachusetts legislature. These views led to the development and increas-
In subsequent years, other states followed suit by ing use of surgical procedures such as forced
establishing special educational programs. sterilization (since heredity was viewed to be the
cause of the problem). By 1926, more than 20
Late 19th Century states had enacted involuntary sterilization laws,
It became increasingly apparent to many Amer- and many states also had legislated restrictive
icans throughout the course of the 1800s that, marriage laws over concerns that individuals with
in many instances, moral treatment was unable mental disorders would pass their problems down
to effect long-term cure of people with mental to other generations. Because prevailing theory
disorders. Many people became cynical about held that the insane could not be cured, only con-
the overall efficacy of psychological interven- trolled, another surgical procedure, the lobotomy,
tions and determined that mental disorders were was developed in 1935, to attempt to subdue the
hereditary. As more and more indigent foreign- bizarre behaviors and violent outbursts of the
ers migrated to the United States, state hospi- insane. This procedure involved destroying a por-
tals saw their censuses rise dramatically; they tion of the patient’s cerebral prefrontal cortex,
were increasingly comprised of foreigners, who, which, while it may have achieved its desired out-
because they were culturally and linguistically come, frequently had the consequence of perma-
different, were viewed with distrust and fear by nently incapacitating the patient.
the indigenous population. Physicians developed These procedures and others such as electro-
a preference for medications and mechanical shock therapy and insulin-coma therapy were also
restraints to treat patients over therapeutic inter- endorsed by reformist supporters of the new socio-
ventions. The public expressed little concern for political Progressive movement (1890s–1920s).
these patients, however, since they were increas- Just as the Second Great Awakening inspired
ingly viewed as dangerous and unfit for society. Americans in the 1800s, Progressivism rekindled
Verbal and physical abuse of patients by brutal the notion for many that mental disorders were
attendants was routine. influenced by psychological, social, and environ-
Although state mental hospitals continued to mental conditions. Progressivism contributed to
grow in number, they were overcrowded. State the rise of the mental hygiene movement, which
legislatures failed to provide adequate funding sought to improve the conditions of asylums and
for their maintenance, hospitals were short on create preventive services and care for discharged
 Policy: State Government 667

patients. While state mental institutions contin- National Institute of Mental Health (NIMH) to
ued to be the primary vehicle to address the needs oversee the research and training activities outlined
of individuals with mental disorders, the early in the Mental Health Act.
1900s also experimented in small measure with In 1955, Congress enacted the Mental Health
community-based care in the form of psychiatric Study Act and appointed the Joint Commission
hospitals for short-term stays and outpatient clin- on Mental Illness and Health to study the epi-
ics for the first time. demiology of mental illness and make recom-
mendations on how to improve state mental
Community Mental Health Movement hospitals and reduce admissions. The establish-
and Deinstitutionalization ment of community outpatient clinics and other
World War II marked a turning point for mental community-based services to reduce hospital
health policy. With alarmingly high numbers of admissions were key recommendations of the
young men who were either rejected for or dis- commission. In 1963, Congress passed the Com-
charged from military service because of mental munity Mental Health Centers Act to establish
disorders, the American public could no longer community mental health centers (CMHCs) with
ignore the mentally ill. Further, the war dem- federal funds, including centers in underserved
onstrated that mental disorders had no regard racial/ethnic neighborhoods, to overhaul the U.S.
for socioeconomic status, race, or culture. Mili- mental health system. While psychiatric care was
tary psychiatrists effectively created new thera- still available as needed, the centers also elevated
pies and tranquilizing drugs and, because of the status of a variety of professionals, such as
the nature of war, could directly observe how clinical psychologists and social workers, who
environmental conditions influenced the course helped patients deal with intrapersonal and envi-
and treatment of mental illness. Scientific stud- ronmental conditions that triggered or worsened
ies and a nationwide series of journal articles mental disorders. The centers also provided care
on state mental hospitals followed and alerted for individuals at risk for hospitalization and the
Americans to the often deplorable conditions recently discharged.
and inadequacy, if not meanness, of patient care. By 1975, mental hospitals saw a drastic decline
Additional psychiatric and sociological studies in their censuses, and while the deinstitutional-
following World War II consistently found that ization process was begun by community mental
mental disorders were more prevalent among the health movement advocates, lawsuits concerning
poor, leading to a renewed interest in the social individual rights to treatment in the least restric-
causes of mental illness. tive settings and the passage of other federal social
From the early 1900s until the years immedi- welfare programs such as Medicare and Medicaid
ately following the war, the practice of psychiatry played an even greater role in the process. The
had been dominated by the theories of Sigmund passage of Medicare and Medicaid made it possi-
Freud and his method for treating individuals ble to move many elderly and disabled individuals
with mental disorders—psychoanalysis—or “talk” to nursing homes, which were more appropriate
therapy. Psychoanalysis, however, was a costly and for these individuals, and contributed to an explo-
impractical treatment that was unattainable and sion in the number of nursing homes available.
unsuited for many citizens and was a questionable Deinstitutionalization, however, did not occur
therapy for institutionalized patients. In 1946, the without problems. Besides merely transferring
federal government enacted the Mental Health Act many patients to alternative institutional settings,
to address the problems of the state mental hos- the CMHCs still did not have enough profession-
pitals and the failure of psychiatry to prevent or als with the expertise to treat the seriously men-
ameliorate mental illness. tally ill and avoid readmissions to state mental
Its purpose was to determine the causes of men- hospitals. Moreover, families who had to care for
tal illness, find new methods to prevent and treat mentally ill kin were ill equipped to provide care,
mental disorders, and train mental health practi- frequently leading to mental decompensation and
tioners with the goal of reducing hospital admis- patient readmission. The CMHCs Act did not
sions. The federal government also established the provide clear guidelines to collaborate with state
668 Policy: State Government

hospitals to ensure that patients received care Prevailing Mental Health Systems
after discharge, and aside from funding CMHCs, Since 1963, state mental health systems have
the federal government did not provide additional gone from state mental hospitals as the pri-
funding that would have allowed states to estab- mary provider of mental health care to highly
lish many sorely needed programs and services fragmented and decentralized systems. They
to maintain the mentally ill in the community. are diverse marketplaces of public and private
Readmissions to state hospitals and other inpa- treatment providers, including general hospital
tient units, homelessness, and criminal behaviors inpatient and outpatient programs, psychiatric
leading to the incarceration of the mentally ill in hospitals, office-based practices, case manage-
jails and prisons where mental health treatment is ment, assertive community treatment teams and
woefully inadequate are some of the serious prob- other field-based services, and managed health
lems that have been created by deinstitutionaliza- care. In the 1980s, the Ronald Reagan admin-
tion and the lack of planning and funding. istration turned control over the CMHCs to the
states after reorganizing the NIMH. With this
Considerations of Civil Commitment shift, the state mental health authority (SMHA,
Laws in State Mental Health Policy the lead agency for mental health services in the
Although state and local commitment laws state) has become central to the coordination and
existed prior to the 1960s, the new community integration of services at the community level.
mental health system demanded that politicians The SMHAs are responsible for the contracting,
take a fresh look at this important topic. The state licensing, and certification of facilities, programs,
is typically concerned with individuals who are and mental health professionals; setting stan-
incapable of caring for themselves and protecting dards and rates; providing quality assurance; and
society from potentially dangerous individuals. are conduits for federal funding.
Today’s state mental hospitals generally consist of Since 2000, the SMHAs have initiated a num-
civil and forensic units to safely provide appropri- ber of new policies, including efforts to provide
ate treatment for both groups of mentally ill. Most better mental health care in the criminal justice
states currently include some language regarding system, reducing the use of seclusion and mechan-
risk of harm to self or others as a prerequisite for ical restraints in state hospitals, improving con-
commitment. State mental health policy has been sumer empowerment and creating peer support
defined and expanded by various lawsuits in state programs, increasing the cultural competence
and federal courts from the 1960s to the present of mental health professionals, and integrating
day, which have resulted in state legislators grap- health and mental health because individuals with
pling with such issues as the due process rights of mental disorders are at greater risk for develop-
those committed, guardianship, the right to treat- ing a number of health-related conditions such as
ment and the right to refuse unwanted or specific substance abuse, obesity, diabetes, and smoking-
treatments, discharge procedures, and treatment related illnesses.
standards including benevolent treatment, appro-
priately trained staff, and individualized treat- Julie L. Framingham
ment plans. Florida Department of Children and Families
States took on additional civil commitment
powers, beginning in the 1990s, by legislating See Also: Community Mental Health Centers;
new laws to deal with individuals deemed by the Deinstitutionalization; Mental Institutions, History
courts to be sexually violent predators. These laws of; Policy: Federal Government; State Budgets.
place tough constraints on sex offenders after
their sentences have been completed. They allow Further Readings
the state to forcibly commit the sex offender to a Grob, Gerald N. “Mental Health Policy in America:
state mental facility after his/her prison sentence Myths and Realities.” Health Affairs, v.11/3 (1992).
is served, if he/she has a “mental abnormality” or Hudson, Christopher G. and Arthur J. Cox, eds.
personality disorder, and there is strong reason to Dimensions of State Mental Health Policy.
believe the individual will reoffend if released. Westport, CT: Praeger, 1991.
 Polypharmacy 669

Mazade, Noel A. and Robert W. Glover. “State necessary to prescribe multiple medications when
Mental Health Policy: Critical Priorities more than one condition is present. There is a
Confronting State Mental Health Agencies.” growing use of polypharmacy in the treatment of
Psychiatric Services, v.58/3 (2007). mental health disorders, and it is important to be
Mechanic, David and Richard C. Surles. aware of this practice in terms of symptom man-
“Challenges in State Mental Health Policy and agement, medication adherence, and risks that
Administration.” Health Affairs, v.11/3 (1992). may be associated with this practice.
Rochefort, David A. From Poorhouses to It has been reported that 20 to 25 percent of
Homelessness: Policy Analysis and Mental Health Americans identify themselves as having a men-
Care. 2nd ed. Westport, CT: Auburn House, 1997. tal health condition. Approximately 30 million
adults over the age of 60 are taking five or more
medications daily, a percentage that has increased
from 22 to 37 percent in the decade leading up
to 2012. Some of the increase is the result of the
Polypharmacy use of physician specialists as well as advances in
identifying and prescribing treatment for certain
Society has always played a role in defining norms conditions. Another reason is that patients are
of behavior. There is often pressure for members being prescribed medications by multiple doc-
to fit in and avoid acting in ways that are non- tors. For mental illness, one possible explanation
conforming or indicative of mental instability. A for polypharmacy is societal pressure to rapidly
variety of approaches are used to help individuals eliminate behaviors that interfere with a person’s
cope with community expectations when they are functioning in the community.
identified as mentally ill, including psychosocial In addition, there has been an increase in the
and recovery-based treatments as well as cogni- identification or diagnosis of some behaviors as
tive, behavioral, or family therapy. Some psychi- abhorrent. An example is the increased identifi-
atric illnesses are treated with medication or in cation of attention deficit or conduct disorders
combination with some form of therapy to reduce in children or an increase in identifying anxiety,
symptoms. depression, and adjustment disorders in adults.
Psychotropic or neuroleptic medications are The American Psychiatric Association’s Diagnos-
not able to cure mental disorders. They help to tic and Statistical Manual of Mental Disorders,
improve an individual’s quality of life by reducing used for categorizing behavior as abnormal, has
disabling symptoms. Some people respond so well added numerous labels over the years to include
to medication that they only need to take them many behaviors that people have routinely been
for a short time, while others may have difficulty experiencing. As a result, behaviors such as
becoming stabilized on medication and require grieving, spending, cleaning, eating, or adven-
additional interventions for symptom reduction. ture seeking become pathological and therefore
Many factors affect how medication works on a diagnosis when it is determined to be in excess.
individuals, including the type of mental disorder, Pathology or abhorrent behavior is often cultur-
genetics, age, sex, physical condition, or habits ally determined, and in most societies, giving a
such as smoking or substance use. A combina- behavior a diagnostic label risks attaching stigma
tion of medications is frequently used to improve to the behavior and creates an urgency to extin-
treatment outcome. guish it.

Polypharmacy Definition and Prevalence Why Is Polypharmacy Used?

Polypharmacy is the use of more than one medi- When treating a complex mental health disor-
cation for treating a person’s medical or psychi- der, medications may be used in combination to
atric condition. When a single illness presents treat the various clinical symptoms. Therefore,
with complex clinical problems, doctors often if a person has been diagnosed with a mood
prescribe more than one medication as a way to disorder with psychotic features, he or she may
control symptoms. It is also possible that it will be be prescribed an antidepressant as well as an
670 Popular Conceptions

antipsychotic medication. Depending on the diag- communication and education regarding the geri-
nosis and symptom picture, the person may also atric population, pharmacist intervention, and
be prescribed a medication for mood stabiliza- computerized medication databases to alert phy-
tion. In addition, some of these medications have sicians of potential drug interactions.
side effects, so there may be another medication
to reduce the side effects or possibly as an aid Eileen Klein
for sleep. This medication combination does not Ramapo College of New Jersey
include any consideration for taking medications
for a physical problem. It has been shown that See Also: Age; Drug Abuse; Drug Abuse: Cause
some psychiatric medications can create meta- and Effect; Drug Development; Drug Treatments,
bolic disturbances such as diabetes, hypercholes- Early; DSM-5; Food and Drug Administration, U.S.;
terol, or hypertension, all of which require medi- Marketing; Mind–Body Relationship; Pharmaceutical
cation to control. Industry; Psychopharmacological Research;
Psychopharmacology.
Potential Problems or Risks
There are several factors to be aware of when Further Readings
polypharmacy is used. One important issue con- Guo, J. J., et al. “Exposure to Potentially Dangerous
cerns the actual medications being prescribed. Drug–Drug Interactions Involving Antispcyhotics.”
Are all of the medications being prescribed by Psychiatric Services, v.63/11 (November 2012).
one physician, or is the patient coordinating care Janssen, Birgit, Stefan Weinmann, Mathias
among physicians? If there is no provider commu- Berger, and Wolfgang Gaebel. “Validation of
nication, there can be interactions among medica- Polypharmacy Process Measures in Inpatient
tions, making them harmful to the patient. Drug Schizophrenia Care.” Schizophrenia Bulletin,
interactions are dangerous and have been known v.30/4 (2004).
to cause clinical problems, both physical and psy- Sinclair, Lindsey I., Simon J. C. Davies, Graham
chological. Some drugs potentiate, or enhance, the Parton, and John P. Potokar. “Interactions in
effects of other drugs, making dosage problematic General Hospital and Psychiatric Inpatients
or even fatal. Adverse reactions can occur with Prescribed Psychotropic Medication.”
any age group, but an elderly person is two to International Journal of Psychiatry in Clinical
five times more likely to have an adverse reaction Practice, v.14/3 (September 2010).
with polypharmacy because of their age-related West, Joyce, et al. “Patterns and Quality of Treatment
biologic and physiologic changes. for Patients With Schizophrenia in Routine
Another area of concern is the administra- Psychiatric Practice.” Psychiatric Services, v.56/3
tion of the medication. In some cases, a person (March 2005).
is on several medications at various times during
the day, which requires him or her to be able to
understand all of the directions, dosages, and tim-
ing of the medication delivery. Will the medica-
tion always be convenient to take at those times, Popular Conceptions
and will the individual remember to take the med-
ication as prescribed? Will the person be able to How people experience the world is highly influ-
take the medications independently, or will there enced by the meanings ascribed to health and ill-
be resistance to taking these medications because ness. Such meanings are generated in part through
of side effects or a complicated dosage plan? popular imagery and representations found in
While modern medicine is able to battle many film, television, music, magazines, popular fic-
health and mental issues more effectively than tion, and the Internet. Studies of media depic-
before, it may incur some unintended conse- tions are important in understanding how com-
quences that must be considered. When multiple mon ideas about mental illness are generated and
medications are used, preventive strategies should reproduced, particularly where those ideas have
be considered, including improved provider negative social impacts. Even though there is no
 Popular Conceptions 671

factual evidence of increased rates of violence negative ways, more implicit methods are also
among persons with mental illnesses, this associa- deployed. For instance, media commonly depict
tion is one of the most common themes running such people as lacking markers of social identity:
though media portrayals of mental illness. Given There are rarely references to friends, a family,
the pervasiveness of such depictions, most people or any social group to which a person with a
mistake this myth for fact, often with negative mental illness belongs. Other researchers have
consequences. found that persons with mental illness are gen-
The media hold influence over public attitudes erally portrayed as having no specified occupa-
and beliefs. Those who watch a significant amount tion, no particular age, no definite marital status,
of television hold more negative views of mental and therefore no social identity. Thus, popular
illness than people who watch very little. Yet, media representations construct persons with
while the mass media are among many influences mental illness as detached from the usual fabric
defining and generating meaning about mental ill- of society. Such portrayals can contribute to the
ness, their audiences are not simply empty vessels public’s tendency to view persons with mental
waiting to be filled with meaning: Not everyone illness as different and unlike most other people.
believes that persons with mental illness are vio-
lent. It has been proposed that media depictions
linking violence to mental illness have held par-
ticular sway with the public because of the degree
to which mental illness conjures up broad social
fears about safety and security. However, some-
one with direct experience with a person who has
a mental illness will be less influenced and reject
media misinformation. People actively medi-
ate images in relation to other sorts of informa-
tion generated by families and peer groups and
through personal experience.

Negative Portrayals
That people with mental illness are portrayed
negatively—as different, deviant, helpless, and
evil—is the most common finding of research-
ers concerned with media depictions of mental
illness. As early as the mid-1950s, studies found
that negative depictions of mental illness in the
media had a role in informing public perceptions.
Most commonly reported, however, is the associa-
tion between mental illness and violence. Portray-
als of persons with mental illness as violent are
most apparent in the context of narratives about
sin and horror, in which mental illness goes hand
in hand with unpredictability and dangerousness.
Projects focusing on feature films have also found
that persons with mental illnesses are portrayed
as villains of a sadistic, menacing, and evil nature.
In fact, some researchers have shown that they A 1992 promotion by Pharmacists Planning Services encourages
are often represented as devils and demons, inher- the use of medications to treat depression. Public perception of
ently depraved and insatiable. mental illness as encompassing depression and anxiety rather
While a host of media techniques charac- than simply psychoses may be the result of the pharmaceutical
terize persons with mental illness in explicitly industry’s success at medicalizing sadness and fear.
672 Popular Conceptions

Because mental illness is already associated with indicates the success of the pharmaceutical indus-
strong negative stereotypes, when the media say try and the medicalization of sadness and fear, or
almost nothing, their silences permit audience whether shifts in the media have contributed to
members to reproduce the negative ideas that positive changes, greater acceptance, and a better
they already hold. understanding of mental illness.
Often, in media representations, being mentally Patterns in Australian media suggest that at
ill is the dominant quality attributed to the per- least in some cases, media reporting strategies are
son talked about, reducing a person with a mental changing for the better. For example, in television
illness to “a mentally ill person” or one of “the news reporting, there is evidence of an effort to
mentally ill.” In some cases, this master status locate the person with the experience of mental ill-
is conflated with portrayals of other stigmatized ness at the center of the story, rather than produce
groups, which serves to underscore that persons a dehumanized account in which others (such as
with mental illness fundamentally differ from professionals) talk about them in absentia. Aus-
most other people. Several studies, for instance, tralian public discourse is also shifting away from
have shown that mental illness is commonly por- generic terms such as mental illness and toward
trayed through talk about homelessness. More- more precise language.
over, media reports that focus on homelessness Despite such evidence that media reporting
often imply that homeless people have mental ill- techniques are changing, most of the ways that
nesses and consequentially are violent. Also, the media talk about mental illness continue to be
association of mental illness with homelessness negative. It has been pointed out that this trend
supports the perception that persons with mental may have some unintentionally positive outcomes;
illnesses are irresponsible, out of control, and eco- at least in one case, media messages associating
nomically dependent on the rest of society. mental illness with violence generated public sup-
port for funding programs to expand housing and
Cross-Cultural Studies treatment services and thereby improve acces-
Looking to studies set in other countries, few sibility and quality of life. Even so, inaccurate,
deviations from the American trend appear. In sensationalist, and negative reporting has more
the United Kingdom, stories about mental illness often accomplished the converse: These reports
commonly associate it with violence. In the New predominantly generate an increase in “not in my
Zealand media, the principle negative connotation backyard” activity and decrease public endorse-
is with danger; the German media rely on sensa- ments of community care.
tionalism. Another interesting study on Ameri-
can media examined programming intended for Riley Olstead
children to find that a significant number of the St. Francis Xavier University
portrayals of mentally ill people were negative.
Media across many Western cultures and oriented See Also: Dangerousness; Homelessness; Mass Media;
to audiences of different ages consistently rein- Movies and Madness; Stereotypes; Stigma; Television.
force the message that persons with mental illness
are dangerous, criminal, and violent. Further Readings
In the United States, recent studies have found Day, D. and S. Page. “Portrayals of Mental Illness
that the tendency to report on the dangerousness in Canadian Newspapers.” Canadian Journal of
of persons with mental illnesses has decreased, Psychiatry, v.31 (1986).
though negative portrayals continue to far out- Mathieu, A. “The Medicalization of Homelessness
number positive ones. Another interesting phe- and the Theatre of Repression.” Medical
nomenon is that the perception of what consti- Anthropology Quarterly, v.7/2 (1993).
tutes a mental illness has changed in the public Nunnally, J. Popular Conceptions of Mental Health.
mind. People used to associate mental illness New York: Holt, Rinehart and Winston, 1961.
with psychosis, but more recently they conceive Wahl, O. “News Media Portrayal of Mental Illness:
it as encompassing such disorders as depression Implications for Public Policy.” American
and anxiety. The question remains whether this Behavioral Scientist, v.46 (2003).
 Post-Traumatic Stress Disorder 673

Post-Traumatic re-experiencing of the traumatic events (such as

flashbacks, recurring dreams, feeling the experi-
Stress Disorder ence is recurring), avoidance of events or objects
associated with the trauma (such as avoid-
Increased focus on trauma reactions began fol- ing thoughts or having conversations about the
lowing World War I and World War II, when trauma, decreased interest in activities, feelings of
army soldiers returned from the war and exhib- hopelessness), and increased physiological arousal
ited symptoms such as increased anxiety, auto- (such as sleeping problems, anger, feeling jumpy,
nomic arousal, and reliving the trauma. Military and memory and concentration problems). The
psychiatrists were treating conditions referred traumatic event often results in extreme horror,
to as “battle shock” or “shell shock.” The first helplessness, or fear.
edition of the Diagnostic and Statistical Manual The onset of PTSD symptoms can occur at
of Mental Disorders (DSM-I), which was devel- any time. The diagnosis of PTSD can be given if
oped in 1952, included a category called “gross the symptoms have been causing significant dis-
stress reaction,” which was defined as a stress tress for the duration of one month. Individuals
syndrome that occurred in response to excep- who experience symptoms for less than a month
tional physical or mental stress such as a natural can be diagnosed with an acute stress disorder if
catastrophe or war. However, the diagnosis was symptoms later subside. If the symptoms last for
omitted without explanation from the DSM-II longer than three months, PTSD is considered
published in 1968. chronic in nature. In some cases, individuals may
In 1980, the American Psychiatric Association not experience symptoms immediately follow-
added post-traumatic stress disorder (PTSD) to ing a traumatic event. For example, in children
the third edition (DSM-III). Controversy arose who experience childhood sexual abuse, approxi-
regarding the definition of a stressor and symp- mately 30 percent are asymptomatic following
toms resulting from a stressor. The definition of the event; however, some individuals may have
stressor was broadened to include a wide range late-onset symptoms.
of potential traumatic experiences such as car Complex PTSD, also known in the DSM-IV as
accidents or witnessing violence. Diagnostic cri- “disorder of extreme stress not otherwise speci-
teria were revised for the DSM-IV in 1994, refin- fied,” has been proposed as a more complicated
ing the definition of a stressor. There continues to symptom picture associated with trauma. The
be debate on whether the definition of stressor is concept of complex PTSD came about when
overinclusive. researchers observed the high comorbidity rates
between PTSD and other conditions such as anxi-
Diagnosis, Symptoms, Onset, ety disorders, depression, substance abuse, and
and Complexities personality disorders. Symptoms may appear
Post-traumatic stress disorder is considered a men- more complicated and individuals can present
tal illness that may develop following an extreme with physical complaints, dissociation, impulse
traumatic event. Types of traumatic events may control problems, interpersonal or relationship
include, but are not limited to, events such as difficulties, and self-harm behaviors. Given the
physical or sexual assault, military combat, kid- severity and complexity of symptoms, individuals
napping or being held as a prisoner, car accidents, with chronic PTSD may require longer treatment.
or experiencing a natural disaster. In order to meet
diagnostic criteria for PTSD, a person must have Prevalence Rates
experienced, witnessed, or been confronted with High rates of traumatic exposure have been found
an event involving actual or threatened death, in the general population. Not all individuals who
serious injury, and threat to safety. have experienced a traumatic event are diagnosed
Individuals who experience PTSD can have a with PTSD. The DSM-IV reports that the lifetime
wide range of reactions or symptoms. The main prevalence for PTSD in the general population is
characteristics of symptoms that could derive 8 percent, although research has shown that when
from exposure to a traumatic event may include participants are given a broad range of events and
674 Post-Traumatic Stress Disorder

stressors to select, exposure to traumatic events by the study for PTSD diagnosis. Among recent
tends reach approximately 70 percent. U.S. Army and Marine soldiers deployed to Iraq
Researchers have assessed PTSD among at- and Afghanistan, approximately 18 to 20 percent
risk populations. Higher rates of PTSD have been have been found to have developed PTSD. The
noted in sexual assault survivors, military combat presentation of symptoms can vary depending on
veterans, and individuals in war-torn populations. the age, severity, duration, and proximity of the
Across various empirical studies, rates of PTSD individual to the traumatic event.
among rape victims range from 34 to 78 percent. Demographic variables have been assessed
Much research has been conducted on veterans when evaluating rates of PTSD, including gen-
and their trauma symptoms following combat. In der differences between men and women. Recent
Vietnam veterans, rates of PTSD have ranged from research has found that approximately 20 per-
15 to 31 percent, depending on the threshold used cent of women and 10 percent of men were likely
to develop PTSD following the experience of
a traumatic event. PTSD can begin at any age,
including childhood and adolescence. However,
symptoms may present differently across the life
span. For example, young children with minimal
verbal skills may exhibit their trauma symptoms
through play or nightmares. Boys tend to pres-
ent with more externalizing symptoms (such as
aggression, fighting, and running away) and girls
tend to present with more internalizing symptoms
(such as depression, anxiety, and self-harm). With
regard to race and ethnicity, studies have shown
that ethnic minorities fare worse after a traumatic
event, especially those minority groups with low
socioeconomic status.

Trauma Across Cultures, Races,

and Ethnic Groups
PTSD occurs across various cultures and racial
and ethnic groups. Individuals around the world
may be exposed to different types of stressors that
may not be as common in the United States. Indi-
viduals with low socioeconomic status and mini-
mal access to resources are more vulnerable to
experiencing symptoms of PTSD when exposed
to a traumatic event.
Natural disasters have been a significant trig-
ger of PTSD internationally. With earthquakes in
Indonesia, tsunamis in Thailand, and Hurricane
Katrina in the United States, more attention has
been paid to the short- and long-term effects of
natural disasters on the well-being of citizens in
affected countries. Rates of secondary trauma by
Former Air Force Senior Airman David Sharpe embraces his dog family and friends tend to be higher following
Cheyenne at his home in Arlington, Virginia, September 22, natural disasters because of the potential of death
2011. Sharpe is the founder of the nonprofit Pets 2 Vets, which or serious injury to the survivors. The effects of
pairs shelter animals with veterans suffering from post-traumatic trauma can be long standing, as countries have
stress disorder. He credits Cheyenne with saving his own life. to rebuild access to basic resources such as food,
 Post-Traumatic Stress Disorder 675

water, and shelter, which may be limited. Interna- However, complex PTSD may need longer
tional relief programs have been developing bet- treatments because of the self-identity, self-regula-
ter protocols to help assist individuals following tory, and relational deficits. There are some limi-
natural disasters and aid with mental health care. tations to the use of CBT with complex PTSD.
Rates of trauma also appear to be higher First, these methods may not be suitable for indi-
among war-torn countries and those experiencing viduals with severe dissociation. Additionally,
terrorist acts. Individuals may have higher, more individuals with complex PTSD may face some
frequent exposure to torture, which is often used problems with prolonged exposure and cognitive
to punish, obtain information, take revenge on a restructuring and may be harmed by the use of
person or members of their family or community, these techniques if applied too early in treatment
and create fear. Individuals may be subjected to without attention to safety and the ability to cope
extreme forms of physical torture, psychological with strong emotions.
abuse, or sexual abuse, and/or witness the abuse Other therapies such as psychodynamic ther-
of others. Acts of terrorism may not only impact apy, exposure therapy, systematic desensitization,
victims directly but also others who may have and eye movement desensitization and reprocess-
witnessed the act. ing (EMDR) have proven to be effective for those
Another issue that has more recently come with PTSD. No single treatment modality is more
to international attention is human trafficking, effective than others. Also, individuals may not
which is the illegal trade of individuals typically respond to one form and may require long-term
for the purpose of sexual exploitation or slavery. treatment through other techniques. Symptoms
Approximately 30 percent of human trafficking may subside over time, but some individuals may
victims are children. Other vulnerable popula- need “booster” sessions to help address symp-
tions such as immigrants are often forced into toms if they reoccur. Additionally, pharmacother-
labor. Victims are often exposed to poor living apy is often used in conjunction with traditional
conditions, limited financial resources, separa- psychotherapy to address many of the physiologi-
tion from family, and, most commonly, physical cal symptoms associated with PTSD.
and sexual abuse. Unfortunately, due to difficulty Treatment can also be difficult for treatment
in findings these victims, it is difficult to estimate care providers. Vicarious traumatization, also
the worldwide prevalence of human trafficking. known as secondary traumatization or compas-
More organizations are becoming available to aid sion fatigue, is defined as when a therapist or
individuals who are rescued from human traffick- caretaker vicariously experiences aspects of a
ing and torture. person’s trauma as if it happened to them. For
example, survivors of Hurricane Katrina were
Treatment Options and Treatment Providers not having their basic needs for food, shelter,
Currently, several modalities are commonly used and water met in some areas. While disaster
for the treatment of PTSD. Cognitive behavioral relief workers may feel a great sense of empa-
therapy (CBT) has been found to be an effec- thy and compassion, the situation may be hard
tive and commonly used form of treatment for for them to relate to, and guilt may ensue. Field-
those with PTSD. CBT has been found to be workers often work for long hours and see many
highly successful in the treatment of PTSD in a people during a short time period, but their feel-
relatively short period of time. The treatment ings are often neglected and not acknowledged
typically involves two components: prolonged immediately. Individuals who experience com-
exposure (the repeated, imagined reliving of the passion fatigue have been shown to experience
trauma) and cognitive processing or restructuring a number of physical symptoms, such as chronic
(addresses the negative automatic thoughts and exhaustion and fatigue, insomnia, headaches,
the dysfunctional beliefs about oneself and the loss of physical agitation or retardation, and fre-
world). A minimum of six to 12 sessions are usu- quent sickness. It is important for mental health
ally needed, but individuals with severe trauma or care professionals to maintain adequate self-care
individuals who have experienced more frequent while they are providing treatment for others.
traumatic events may require longer treatment. Supervision or debriefing meetings can be used
676 Prevention

to deal with thoughts and feelings when working is extreme or pathological in one culture may
with victims. be acceptable, ordinary, or even highly prized in
another. These variations are normal and desir-
Apryl Alexander able. On the other hand, a core subset of mental
Florida Institute of Technology health–related phenomena are disabling and dis-
tressing and of significant duration in every cul-
See Also: Anxiety, Chronic; Children; Cognitive ture. Although mental health problems are com-
Behavioral Therapy; Cultural Prevalence; Depression; plex, with many causal factors, certain strategies
Disasters; Dissociative Disorders; DSM-IV; and characteristics, called protective factors, are
Intervention; Military Psychiatry; Policy: Military; known to reduce the likelihood of a person devel-
Psychopharmacology; Shell Shock; Sleep Disorders; oping mental health problems. Other measures
Stress; Trauma: Patient’s View; Trauma, Psychology reduce symptoms or promote recovery. Men-
of; Veterans; Violence; Vulnerability; War. tal illness prevention strategies often focus on
building a person’s resilience to stress by increas-
Further Readings ing exposure to protective factors and decreas-
Barlow, David, ed. Clinical Handbook of ing exposure to risk factors. The required type,
Psychological Disorders: A Step-by-Step Treatment intensity, and duration of prevention program-
Manual. 4th ed. New York: Guilford Press, 2008. ming depends on the particular issue, the level
Courtois, C. A. “Complex Trauma, Complex of risk within the targeted population, and the
Reactions: Assessment and Treatment.” context of the effort.
Psychotherapy: Theory, Research, Practice, Public health workers use a multilevel, compre-
Training, v.41/4 (2004). hensive approach to disease prevention. The first
Meyer, Robert and Christopher Weaver. The consideration is the stage of the disease within
Clinician’s Handbook: Integrated Diagnostics, the target population. Primary prevention efforts
Assessment, and Intervention in Adult and focus on people who do not yet have a disease.
Adolescent Psychopathology. 5th ed. Long Grove, Within primary prevention, universal measures
IL: Waveland Press, 2007. target the general population. Antismoking pub-
Norris, Fran, Sandro Galea, Matthew Friedman, and lic service announcements are a universal primary
Patricia Watson. Methods for Disaster Mental prevention strategy. Selective measures target
Health Research. New York: Guilford Press, people at significantly higher risk of developing a
2006. problem based on known biological, psychologi-
Rothschild, Babette. Help for the Helper: Self-Care cal, or social risk factors. Needle exchange pro-
Strategies for Managing Burnout and Stress. New grams are selective measures to reduce potential
York: Norton, 2006. infections among drug users. Indicated measures
target people experiencing minimal, but detect-
able levels of a potentially serious health issue. A
prescribed diet and more exercise may be an indi-
cated measure for a person with elevated blood
Prevention sugar levels.
Secondary prevention seeks to lower the rate
People seek to prevent mental illness as they do of established cases (prevalence) of a disorder or
any health problem. This is a difficult proposi- illness in the population through early detection
tion because mental illness is a complex bundle and treatment. Examples include neonatal blood
of biopsychosocial phenomena and because brain tests and eye exams. Tertiary prevention addresses
function can seldom be directly assessed. Certain people already experiencing symptoms and peo-
mental disorders are normal emotions or experi- ple with chronic recurring conditions. Tertiary
ences that have greater or lesser intensity or dura- measures aim to reduce the disabling effects of a
tion. People are highly complex, with substantial condition, promote recovery, and prevent relapses
variations of capacity, temperament, and per- and recurrences of the illness. Examples of ter-
sonality. Cultural expectations also vary. What tiary prevention include Alcoholics Anonymous
 Prevention 677

and other mutual support groups for people with norms and harm themselves or the people around
addiction. them. Prevention efforts aim to detect and inter-
Epidemiologists have adapted the logic of the rupt this dynamic. Stress is not wholly bad. Peo-
contagious disease model as they study what ple who learn healthy ways to handle the difficul-
works to prevent mental illness. The contagious ties they encounter in life actually gain resilience.
disease process involves a pathogen (something Program designers aim to build up resilience,
that causes a disease), a method of transmission reduce exposure to triggers, and devise interven-
(e.g., bloodborne, inhaled, through touch), and tions that intercept and interrupt the destructive
a susceptible host. Health workers identify and process.
target vulnerabilities related to each of these three
elements. For example, a flu shot targets the sus- Historical Prevention Efforts
ceptible host by rendering a person immune to Public health and social work outreach efforts
infection. Sanitation practices eradicate patho- became well established in major American cit-
gens in the environment. Hand washing disrupts ies by the late 1800s. These efforts addressed
the method of transmission. drunkenness and other challenges facing poor
Certain mental illness symptoms result from and lower-class families and aimed to improve
contagious diseases such as tuberculosis, syphi- the urban environments in which poor children
lis, and HIV. Such cases have been largely elimi- lived. The modern era of organized mental illness
nated in the industrialized world in modern times. prevention began in earnest just prior to World
Today, most mental health disorders involve a War I. Clifford W. Beers (a former psychiatric
complex interplay between genetic factors, envi- patient who wrote a best-selling book about the
ronment, personal development, traumatic expe- abuse he suffered when hospitalized), together
riences, and social factors. All of these factors and with several influential psychiatrists, founded
more affect how a person thinks, functions, feels, the National Council for Mental Hygiene (the
communicates, relates to others, and experiences forerunner of today’s Mental Health America) in
the world. Research into risk and protective fac- 1909. This group sought to improve conditions
tors is difficult because people are complex and in mental hospitals, prevent mental illness, and
dynamic. What one knows about mental health in popularize psychiatric concepts. This group and
the abstract may or may not benefit or even apply others focused prevention efforts on children,
to any particular person. The high causal density believing that early childhood experiences influ-
of mental health and mental illness and ethical enced a person’s life course. This belief arose from
considerations limit rigorous experimentation. the “dynamic psychiatry” of Adolf Meyer and the
Even today, the mental health prevention litera- psychoanalytic theories of Sigmund Freud. Both
ture often consists of nonexperimental paradigms theories posited that early experiences were des-
supported by patterns identified within limited tined to play out in adulthood. Over time, the
data sets. Fortunately, recent experimental data mental hygiene movement shifted emphasis back
is supplemented by thousands of years of human and forth between strategies that reacted to estab-
experience. lished problems and proactive strategies that pro-
Mental illness prevention program design often moted health or prevented problems.
tracks the interplay of resilience and triggers Some prevention efforts have been harm-
or stressors. Resilience is a quality that is built ful, pointless, or abusive. The eugenics move-
up through life experiences. Patterns of think- ment aimed to reduce rates of mental illness and
ing, relationships, and social norms help people development disorders within the general popu-
handle the ordinary events of life. Stress, on the lation. Approximately 60,000 people with dis-
other hand, can have a forceful, cumulative, or abilities underwent compulsory sterilization in
deteriorating impact on a person’s capacity. As the United States. The largest number of these
stress takes its toll, the person becomes less able occurred during the 1920s through the 1950s. A
to resist destructive impulses. People who focus variety of social work practices have also been
narrowly on relieving their personal distress can criticized as religiously biased, culturally out of
disregard or willingly violate deep-seated social tune, or even oppressive. The current emphasis on
678 Prevention

evidence-based prevention is at least partially a of life success. Large data sets accumulated over
reaction to these criticisms. the course of decades show that some 60 percent
Academic research in the prevention field began of U.S. children experience secure attachment,
in earnest in the 1920s and was soon reflected in which connects with greater resilience throughout
the daily work of schools and other public insti- life. It accounts for children raised in poverty who
tutions, and especially within the juvenile justice succeed, and children in good homes who do not
system. Child guidance clinics initially focused succeed.
on the most troubled children and families but Another primary prevention strategy com-
later came to address the psychological health mencing in early childhood involves reducing
of middle-class families. By the 1930s, the men- children’s exposure to trauma. Adverse child-
tal hygiene movement gained influence within hood events (which happen more frequently to
teacher education systems. By the time the United children living in poverty) impact brain function.
States entered World War II, education reform- The child’s stress system is overloaded through
ers had begun to criticize American education as the same mechanism that causes post-traumatic
inconsistent with knowledge about child develop- stress disorder. Anxiety and depression are the
ment. Following World War II, American parents emotional impacts. Decreased executive function
began incorporating psychological approaches (the inability to deal with confusing and unpre-
into parenting, spurred on by advice contained in dictable situations) is the cognitive impact. Early
physician-written parenting books. treatment of childhood mental health problems is
Today’s primary prevention strategists con- a primary prevention strategy to reduce substance
tinue to emphasize the importance of early child- abuse during adolescence.
hood experiences. Careful analysis of decades A variety of primary prevention strategies
of data reveals that stress and resilience are the are seen in childcare centers, youth programs,
common hidden factors within many studies that and schools. One example involves curricula
show that children raised in families experiencing designed to foster character strengths or noncog-
poverty have less satisfactory life outcomes. nitive skills like grit, integrity, and perseverance.
These are markers of capacity to complete a task,
Prevention Strategies postpone a reward, find one’s way through dif-
One primary prevention strategy used across the ficulty, and stick with a plan. Another example
United States is parenting support for new moth- is the developmental asset strategy. Developmen-
ers, usually delivered during brief home visits tal assets are factors that children have in their
by public health workers. The attentiveness and lives that are associated with better life outcomes.
comfort that children receive from their mother Attending church, doing homework, playing a
or another caregiver is linked to future success. musical instrument, having positive friends, and
Early positive experiences calibrate the developing having a sense of personal power are examples
stress response system. The body’s stress response of developmental assets. The research behind the
system works best in short bursts, with long rests developmental asset strategy, conducted by the
in between. Too much activation and the stress Search Institute, informs the work of the YMCA,
reaction becomes self-reinforcing, inefficient, the Boys and Girls Clubs, and 4H Clubs. Many
always set to trigger. Stress hormones put addi- school and community groups offer simple, prac-
tional wear and tear on the body, affecting infant tical activities like mentoring, tutoring, homework
growth patterns and eventual life functioning. A help, cooking classes, and crafts that emphasize
mother’s fast response to an infant’s experience kindness, problem-solving, positive relationships,
of stress allows the stress reaction system to turn and stability, delivered by nonprofessionals and
off when it needs to. As the child learns that his through social experiences.
mother will respond to help him overcome stress, Case-finding initiatives such as school-based
that understanding produces secure attachment, depression screening programs are examples of
a close emotional bond between the infant and secondary prevention activities. The earlier in life
his mother or other caregiver. Researchers have problems are detected and properly addressed,
found that secure attachment is a key precursor the more likely a child’s life course will be altered
 Prevention 679

for the better. The decision to begin treatment at the screening instrument determines what hap-
an early age is somewhat complicated because it pens next. If the screening tool indicates high risk,
also involves exposure to new risks related to the people take action. For example, people entering
nature of the course of treatment. jails facing certain types of criminal charges (e.g.,
Today’s tertiary prevention strategies range a young person facing first offense driving-under-
from low intensity, widely available informal sup- the-influence charges after an accident, a person
port groups, Internet message boards, blogs, and charged with a scandalous or shameful offense,
other social media to greater-intensity activities or a parolee facing a return to prison) are rou-
such as clubhouses, assertive case management, tinely placed under suicide watch. Suicide watch
and, in limited circumstances, court-ordered involves frequent or constant close observation of
medication. the person.
Effectively reducing the immediate risk of
Suicide Prevention suicide involves eliminating access to potential
Suicide prevention is also based on research that instruments of harm and treating the person’s
matches known risk and protective factors to the mental illness or substance abuse disorder. Every
population involved. It is very difficult to design state has procedures for providing this treatment,
suicide prevention programs for certain popula- whether or not the person consents.
tions. For example, improving outreach to men at
risk for suicide is particularly challenging. Because Violence
more than 90 percent of people who die by sui- Violence has a set of risk and protective factors.
cide have histories of depression or substance People usually encounter two types of violence in
abuse, suicide prevention concentrates on effec- civilian life: instrumental violence and expressive
tive treatment of mental health conditions and violence. Instrumental violence is used to gain
maintaining sobriety. Reducing access to firearms control over others. This is the violence of assault,
reduces the potential lethality of suicide attempts. robbery, and terrorism. People are initiated into
Prevention groups have even developed guidelines instrumental violence through exposure to vio-
for bridge construction. Certain jail environments lence and violent communities. Prevention efforts
are also designed to be suicide-proof. protect children from exposure to violence, or
To a certain extent, suicide is contagious. Expo- increase the perceived risk of punishment in order
sure to the suicidal behavior of others, such as fam- to interrupt the cycle of violence. Instrumental
ily members, peers, or even media figures makes violence that is fueled by delusional thinking can
suicide seem less of a boundary or barrier to cross, be as well planned as a bank heist. Prevention
and perhaps even an acceptable option. News orga- of this type of violence involves treatment of the
nizations restrict their coverage of suicide cases in underlying mental health condition or detection
order to prevent or limit this contagion effect. of an event during its planning stage.
Improving the recognition and treatment of The other type of violence, expressive violence,
mental disorders and other suicide risk factors in is the failure of self-control. People break down
primary care settings is a key strategy to prevent and strike out, or anger and frustration build up
suicides of older adults and women. Older adults to a violent outburst. Most people with mental
and women who die by suicide are likely to have illness never become violent. People with severe
seen a primary care provider in the year prior to mental illness but no substance abuse and no prior
their suicide. High-risk patients seldom bring up violence have a very low probability of becoming
suicide or depression at these doctor visits. Doc- violent, but risk factors add up. The risk of vio-
tors initiate suicide prevention screenings whether lence increases if the person has more than one
or not the person brings the topic up. psychiatric disorder. The higher the number of
Suicide risk-assessment protocols have been co-occurring psychiatric disorders, the greater the
developed for known high-risk environments, risk of violence. The combination of substance
such as jails and prisons. The most effective abuse and major mental illness is more volatile.
screening protocols require action even when Another key predictor of future violence is past
people deny that they are suicidal. The score on violence.
680 Primary Care

Risk skyrockets after someone commits their from feeling isolated and helps build resiliency.
first act of violence. For example, nearly a third People are unlikely to ever know if the steps they
of people with schizophrenia also abuse alcohol take to support a friend have prevented a suicide
or drugs and are twice as likely as the average or interrupted a developing course of violence.
person to become violent. If such a person com-
mits a violent act, their likelihood of future vio- Paul Komarek
lence doubles yet again. In community settings, Independent Scholar
people with paranoid delusions are more violent
than people in other mental illness categories. See Also: Community Mental Health Centers;
Their violence is well planned, aligned with their Depression; Family Support; Help-Seeking Behavior;
delusion, and aimed at individuals or institutions. Social Class.
These individuals are likely to commit the most
serious crimes because they can gain access to Further Readings
weapons, stay relatively well connected to reality, Goldsmith, S. Reducing Suicide: A National
and maintain an ability to plan. Imperative. Washington, DC: National Academies
There are many other patterns of violence con- Press, 2002.
nected to mental illness symptoms. People with National Prevention Council. National Prevention
depression can react to despair by striking out Strategy. Washington, DC: U.S. Department of
at other people. Parents may kill their children Health and Human Services, Office of the Surgeon
prior to a suicide, especially mothers of young General, 2011.
children. Courts will order treatment if a person National Public Health Partnership. The Language
with mental illness represents a substantial risk of Prevention. Melbourne: National Public Health
of physical harm to others, as manifested by evi- Partnership, 2006.
dence of recent homicidal or other violent behav- Rosenberg, T. Join the Club: How Peer Pressure
ior, evidence of recent threats that place another Can Transform the World. New York: W. W.
in reasonable fear of violent behavior and seri- Norton, 2012.
ous physical harm, or other evidence of present U.S. Department of Health and Human Services
dangerousness. (HHS). Preventing Drug Use Among Children and
The public has a role in preventing crisis, sui- Adolescents: A Research-Based Guide. Rockville,
cide, and violence. Vague, ambiguous signs of MD: HHS, 2003.
trouble show up well ahead of a point of crisis.
There may never be enough identifiable risk fac-
tors to support a mental health diagnosis. Some
risk factors are merely circumstantial. For exam-
ple, returning members of active-duty military Primary Care
have higher rates of suicide or domestic violence
simply because of the difficult nature of military Primary mental health care has been defined as
deployment. Other examples include the loss of a first-contact care provided in the community to
job or the onset of ill health. Social support from people experiencing or at risk of experiencing
friends or others in the community may increase mental illness. Primary health care is the favored
resiliency just enough to prevent a person from option for dealing with disorders such as depres-
acting impulsively. In most of these situations, sion and anxiety, but given widespread deinstitu-
prevention is the responsibility of family, friends, tionalization, it is increasingly being used to sup-
coworkers, and neighbors. Even if reported, port people with disorders such as schizophrenia
emergency responders cannot act forcefully if the and mood disorders in the community.
risk is not immediate and serious. Sometimes, the The World Health Organization (WHO)
police or a crisis team may be able to make a safety views primary health care services as a means
check visit to a person’s home. If there is low risk of addressing an unmet need for mental health
of imminent trouble, the best thing anyone can do care and argues that the provision of primary
is to support their friend. This helps prevent them care is more cost effective than specialist mental
 Primary Care 681

health services, a factor that is becoming increas- to primary mental health care. The first cycle of
ingly important given fiscal constraints arising reforms allowed patients to claim psychological
from the global financial crisis arising from the interventions through Medicare and promoted
early 2000s. Primary care services are viewed as referral to allied health professionals for people
more holistic, enabling management of physical with high-prevalence disorders such as depression
and mental comorbidities, and as less stigmatiz- and anxiety through the Access to Psychological
ing than mainstream mental health services. In Services component of the scheme. This was sup-
addition, primary care can be provided closer to plemented in November 2006 through the Better
the individual’s community, making it more geo- Access program, which enabled patients to claim
graphically accessible. services by psychologists, as well as some social
workers and occupational therapists, under the
Provision of Services Medicare Benefits Scheme (MBS) upon referral
Primary care services are provided in a number by a general practitioner. MBS support was with-
of ways. In the United Kingdom (UK), for exam- drawn for social work and occupational therapy
ple, primary care largely occurs through general services from July 2010, and the 2011 budget
practice. Recent data demonstrate that approxi- lowered the number of subsidized psychological
mately 80 percent of mental health–related con- consultations available through the Better Access
sultations across 51 primary care trusts occurred programs.
in primary care as opposed to specialist services, General practice is also the primary site for
with 62 percent of these consultations occur- delivery of mental health care in the United States,
ring with a general practitioner. Service funding with up to two-thirds of people with mental health
impacts the delivery method, with services in the
UK delivered free of charge through the National
Health Service with service delivery, until
recently, underpinned by separation of purchas-
ing from provision of services. The responsibility
for purchasing primary health services currently
lies with primary care trusts that are also respon-
sible for coordinating primary health care deliv-
ery at a regional level. In addition, there are 58
mental health trusts with responsibility for pro-
vision of support for people with mental illness.
From April 2013, responsibility for purchasing
of services will reside with clinical commission-
ing groups, largely comprised of general practi-
tioners under the Health and Social Care Act of
2012, effectively reinforcing medical control of
primary care services.
General practice is also the site for delivery
of primary care in Australia, which has a mix-
ture of public and private service delivery. Health
care delivery is supported through partial rebates
from the universal health care system, Medicare,
for medical and selected allied health and nurs-
ing services either upon referral from or working
alongside general practitioners. The delivery of
mental health care through primary care has been Mission House in Jacksonville, Florida, is a primary care facility
supported by Better Outcomes in Mental Health offering food and counseling services to the homeless in the
Care (BOiMHC), which was launched in July Jacksonville area. Primary care facilities provide first-contact
2001 with the expressed goal of improving access community mental health care for those at risk of mental illness.
682 Primary Care

and substance use issues seen in general practice being particularly problematic when primary care
rather than by mental health services. Rates of is provided on a fee-for-service basis. In a Cana-
successful referral to specialist mental health ser- dian study, affordability of services accounted for
vices are low at approximately 50 percent. Reli- 9.7 percent of unmet need for services. Access
ance on family physicians as primary caregivers is to services is also limited by candidacy, which
more evident in rural areas, where specialist men- Marija Kovandzic and colleagues define as the
tal health services are less readily available. One formulation of a belief in the eligibility to use par-
study found that 52 percent of rural family physi- ticular services. They argue that understanding
cians were seeing mental health clients, compared of what constitutes mental illness is a significant
to 40 percent of urban family physicians. social barrier to accessing primary care services
Other contexts use alternate means to deliver for mental health care.
primary care. Canada, for example, favors deliv- A second factor is the acceptability of the ser-
ery of primary care through multidisciplinary vices provided. The WHO views primary care
teams. Like the United States and Australia, Can- services as less stigmatizing and a more palatable
ada has a federal system, and between 2000 and means of delivering mental health care. How-
2006, initiatives to develop integrated care deliv- ever, Nelson and Park found that 80 percent
ery were supported by federal funding through of unmet need for mental health support could
the primary health care transition fund. Conse- be accounted for by the lack of acceptability of
quently, primary care for mental illness is less any health services, with 38.7 percent of partici-
focused on general practice than other countries, pants—more commonly women (42.8 percent)—
with recent data suggesting that 35 percent of indicating that they would prefer to manage the
people with mental illness receive primary care problem themselves. Lamb and colleagues have
through general practice only, 25 percent through identified unwillingness to access mental health
general practice and other mental health care pro- care among refugee and some ethnic minorities,
viders, and 40 percent solely through other men- an attitude they associate with discrimination and
tal health care providers. the construction of distress as the result of social
rather than illness processes. As a consequence,
Critiques and Barriers these groups often forgo service delivery of any
There are a number of critiques of the capacity kind for mental illness, preferring to manage the
of primary care to meet the needs of people with issue themselves.
mental illness, dependent in part on the fund- Kovandzic and colleagues view the acceptabil-
ing mechanisms used to support primary mental ity of services through the lens of concordance,
health care. Researchers Connie Nelson and Jun- which they define as “the match between users’
gwee Park argue that because of poverty, stigma, and practitioners’ narrative and resources.” There
and social exclusion, community-based care leads is ample evidence that primary care may be poorly
to greater vulnerability of having unmet mental prepared for the delivery of services to people
health care needs than institutional care. They with mental illness. Service delivery is often siloed.
associate nonuse of health services by people with There is a perception by psychiatrists that physical
mental illness with the accessibility, acceptabil- health matters should be the province of referring
ity, and availability of those services. Accessibil- doctors, while nonpsychiatrists are reluctant to
ity relates to fiscal, social, and physical barriers treat people with mental health disorders. Lamb
to service access; acceptability of the perceived and colleagues note a dependence on prescription
limitations of the services to meet care needs; and of antidepressant medication in general practice.
availability to geographical accessibility. Prescription of antidepressants, along with lack of
The affordability of services is one barrier to time and specialist knowledge, have been identi-
mental health services provided through primary fied as barriers to seeking assistance for mental
care. Jon Lamb and colleagues identify access to health problems from general practice.
material resources as a barrier to help seeking and In addition, many countries experience poor
capacity to manage mental illness among disad- integration of primary care with mental health ser-
vantaged groups, with affordability of services vices. In the United States, difficulties in accessing
 Prison Psychiatry 683

outpatient mental health services for mental ‘Silent Suffering’ to ‘Making It Work.’” Social
health patients has been associated with lack of Science & Medicine, v.72 (2011).
or inadequate health insurance, lack of avail- Lamb, Jon, et al. “Access to Mental Health in
ability of specialist services, and barriers arising Primary Care: A Qualitative Meta-Synthesis of
from health plans. While this has been addressed Evidence From the Experience of People From
in part by the Patient Protection and Affordable ‘Hard-to-Reach’ Groups.” Health, v.16/1 (2012).
Care Act (which has temporarily extended health Nelson, Connie and Jungwee Park. “The Nature
insurance to people with existing health condi- and Correlates of Unmet Health Care Needs in
tions who have been uninsured for six months), Ontario, Canada.” Social Science & Medicine, v.62
current reimbursement practices such as separate (2006).
payment structures for mental and physical health World Health Organization (WHO). Integrating
and low payment levels for mental health condi- Mental Health Care Into Primary Care: A
tions do not support integrated care delivery. Global Perspective. Geneva: WHO and World
In the UK, poor integration of services is associ- Organization of Family Doctors, 2008.
ated with poor information sharing and discharge
planning, while in Australia, integration is con-
founded by management across multiple levels of
government and governmental departments and
by a lack of structural links between private and Prison Psychiatry
public mental health services.
A final aspect of capacity to deliver mental The mental health care of prisoners is a contempo-
health care via primary care is the availability of rary public health issue that is both recent and of
services. The use of primary care services is viewed substantial importance worldwide. The develop-
as a means of decentralizing care delivery, but ment of epidemiological data and qualitative data
reliance on fee-for-service delivery through gen- provided by social sciences, such as the anthropol-
eral practice depends on availability. Rural and ogy of prisons, remains difficult depending on the
outer metropolitan regions frequently experience political regime in the country in question and the
poorer access to general practice. In addition, not degree of access to public institutions for inquiry.
all general practitioners have the necessary exper- However, the conditions of detention in prison are
tise. Lack of expertise is particularly problematic not favorable to mental health and can aggravate
in rural areas where access is poorer, resulting in preexisting disorders as well as lead to forms of
service users traveling significant distances when depression, self-mutilation, and even suicide. Also,
they do not have a local general practitioner with since the shutting down of mental hospitals, there
an interest in and knowledge of mental health. has been a high rate of mental illness in the prison
population. Finally, since the 1980s, prison psy-
Julie Henderson chiatry has increasingly played the highly contro-
Flinders University versial role of managing and rehabilitating cases of
dangerous and severe personality disorder (DSPD).
See Also: Australia; Canada; Care, Sociology of; The majority of social science studies of prisons
Community Mental Health Centers; Community have focused on inmates’ experiences and have
Psychiatry; Family Support; Medicalization, shown the impact of the institution on prisoners,
Sociology of; Medicare and Medicaid; Policy: not only in terms of the break with the outside
Federal Government; Policy: State Government; world, but also in terms of the negative or patho-
Psychiatric Treatment, Pathways to; United Kingdom; genic effects inherent to this sort of institution of
United States; Urban Versus Rural; World Health confinement. These include inequalities in condi-
Organization. tions of incarceration; rites of degradation and
depersonalization; isolation or lack of privacy;
Further Readings sexual deprivation or violence; and the use of psy-
Kovandzic, Marija, et al. “Access to Primary Mental choactive medication, either begun or continued
Health Care for Hard-To-Reach Groups: From in prison. The impact of the prison environment
684 Prison Psychiatry

on the state of health of prisoners, and more become a last resort asylum. The hypothesis of
specifically those with a mental disorder, is now asylums and prisons as “communicating vessels”
increasingly well documented. is often formulated, but it is difficult to test.
The mentally ill have been present in prisons The deinstitutionalization that began in the
since the 18th century (notably in the United United States and in Europe after World War II,
Kingdom), but there is great disparity between carried forward by therapeutic and pharmaceuti-
countries and between the different facilities pro- cal progress and policies rationalizing health care
vided by prison medicine. Its mission is to con- expenditure, now leaves many patients without
sider the prisoner as a patient with the same right continuity of, or access to, care. In certain West-
to treatment in prison as in the outside world, ern countries, the number of incarcerated men-
while taking into consideration the specificities of tally ill people reaches 25 percent. This rate is not
prison living conditions. The question of prison- well known in non-Western countries, although
ers’ access to health care in the penitentiary envi- certain studies in Brazil and India indicate higher
ronment has become a public health issue. For figures. On the one hand, a fraction of these ill
a decade now, greater attention seems to have people no longer seem to be filtered by psychiat-
been garnered because of cases of suicide and ric evaluations, and yet the main function of such
self-mutilation. evaluations is precisely to distinguish between the
In many Western countries, the suicide rate in patients who are responsible for their actions, and
prison is at least three times greater than in the subject to a prison sentence, and those who are
general population, with substantial variations not responsible for their actions and require treat-
between countries (e.g., in 2009, it was 6.5 times ment. On the other hand, the treatment of drug
greater in France, as opposed to four times in Bel- addicts in prison medicine has shown that the
gium or Austria). These disparities should be con- use of psychoactive substances goes hand in hand
sidered in relation to the specific characteristics of with psychiatric comorbidity, which causes diffi-
each penal system and in relation to the psychiatric culties in providing care. The prevalence of psy-
care available in detention. Many official and inter- chiatric comorbidity is two to three times greater
national reports have drawn attention to prisoners’ among drug users in prison than in the general
poor health and the suicide risk in Great Britain or population. Globally, the percentage of prisoners
in France, for example, because of their conditions suffering from a mental health problem and/or
of detention including insufficient access to care, drug addiction has been estimated at between 60
violence between prisoners, overpopulation, and and 65 percent.
lack of prospects or rehabilitation projects when Debates and controversies continue in the medi-
they leave prison. Humanizing prison has thus cal world about the right place for delinquents suf-
become a priority for many in the West. fering from mental disorders. Certain specialists
approve the transfer of prisoners suffering from
Prevalence of Mental Disorders serious mental illnesses to psychiatric hospitals
In many countries across the world, imprison- (particularly when prisons are not authorized to
ment is the moment when people suffering from treat prisoners without their consent). Others, on
mental disorders are first treated, having not the contrary, consider that the hospital is not an
previously had access to systems of community appropriate space in which to treat a delinquent
health care. There has therefore not only been because care provision for dangerous patients
a rise, worldwide, in the morbidity rate of psy- requires a specifically adjusted framework. A new
chiatric disorders among the prison population, health care space therefore developed within the
but this rate is also far higher among prisoners prison in the security-focused context that has
than in the general population. For example, in structured mental health care in the United States
the United Kingdom, 72 percent of convicted men and Europe since the 1980s. An intolerance toward
and 70 percent of convicted women suffer from the mentally ill took root in a social fear of violent
several mental disorders, whereas this percent- behavior judged incomprehensible, unpredictable,
age reaches 5 and 2 percent, respectively, for men and irrational. The question of providing medical
and women in the general population. Prison has care is therefore subordinate to security-based or
 Prozac 685

criminological imperatives, rather than therapeu- specialize in managing repeat sexual offenders. It
tic concerns. While prison may be an inadequate now remains for the social sciences to evaluate the
place in which to treat the mentally ill, in reality, long-term pathogenic effects on inmates of these
this is the role increasingly attributed to the insti- new methods of confinement.
tution by contemporary societies.
Samuel Lézé
Managing Social Dangerousness Ecole Normale Superieure de Lyon
Since the beginning of the 1980s, there have been Fabrice Fernandez
criticisms of the clinical method of prison psychi- École des Hautes Études en Sciences Sociales
atry, and the rise instead of actuarial methods for
evaluating the risk of violence. Clinical practice See Also: Dangerousness; Forensic Psychiatry;
consists of diagnosing and treating disorders that Law and Mental Illness; Right to Treatment; Social
emerge in the prison environment (e.g., depres- Control.
sion and breakdowns), preventing suicide and
violence, and rehabilitating sexual delinquents Further Readings
and drug addicts, particularly by ensuring con- Burki, Talha. “Grasping the Nettle of Mental Illness
tinuity of care after release. The actuarial prac- in Prisons.” Lancet, v.376 (2010).
tice of statistical predictions regarding the risk of Fernandez, Fabrice and Samuel Lézé. “Finding the
repeat offenses, on the other hand, gives the psy- Moral Heart of Treatment: Mental Health Care
chiatrist the role of evaluator in a criminological in a French Prison.” Social Science & Medicine,
framework; the aim is the management of prison- v.72/9 (2011).
ers’ social dangerousness. Kumar, Goyal Sandeep, et al. “Psychiatric Morbidity
High-security units have been created in prisons in Prisoners.” Indian Journal of Psychiatry, v.53
and special hospitals in all industrialized countries (2011).
in order to manage cases of personality disorders, Ponde, Milena P., Antonio C. C. Freire, and Milena S.
including sexual delinquents and particularly Mendonca. “The Prevalence of Mental Disorders
pedophiles. In this way, Great Britain has devel- in Prisoners in the City of Salvador, Bahia, Brazil.”
oped a new diagnosis of dangerous and severe per- Journal of Forensic Sciences, v.56 (2011).
sonality disorder (DSPD), which it has applied to Seena, Fazel, Grann Martin, Kling Boo, and
over 2,000 individuals (98 percent male). Today, Hawton Keith. “Prison Suicide in 12 Countries:
the debate focuses on the nature of this dangerous- An Ecological Study of 861 Suicides During
ness, whether it is psychiatric or social. More than 2003–2007.” Social Psychiatry & Psychiatric
90 percent of admissions in special hospitals in Epidemiology, v.46 (2011).
Great Britain have had previous psychiatric treat-
ment. In all cases, these individuals are judged to
pose imminent risk of dangerousness or causing
serious harm to others and thus need high secu-
rity. These institutions of social exclusion have a Prozac
very particular status, at the boundary between
the penal and the medical. In some facilities, the Prozac is the medication that comes to most peo-
prisoners are locked away for an indefinite period, ple’s minds when they think of serotonin or antide-
according to the evaluation of the risk of repeat pressants. It featured prominently in news media,
offense, even once they have served their original literature, and entertainment as selective serotonin
sentence. They are therefore preventively detained. reuptake inhibitors (SSRIs) came into their own
The aim of supermaximum prisons in the United and soon became a metonym for antidepressants
States and the United Kingdom is therefore to in general. While Paxil and Zoloft also became
manage prison violence; they are a prison within a household names, they never achieved the same
prison. More than 60 such facilities house a total cultural salience as Prozac. Scientists at the phar-
of well over 20,000 people in the United States. In maceutical company Eli Lilly developed fluoxetine
France, there are preventive detention centers that (trade name: Prozac) in the early 1970s; however,
686 Prozac

it took another decade for it to gain Food and few years of promising, but unpublished, clinical
Drug Administration (FDA) approval, at which trials in Chicago and Indianapolis. They enlisted
point Lilly began marketing it intensely. When the psychiatrist John Feighner to carry out clinical
drug was first developed, there was little hope for studies in his private clinic in California. After
its success, but over the following 13 years (1988– three years, Feighner began to report positive
2001), until the patent ran out, Eli Lilly made a results showing fluoxetine to be as effective in
total of $21 billion in sales. treating depression as TCAs and with far fewer
Pharmacologist Ray Fuller joined Eli Lilly in side effects. In 1987, Lilly gained FDA approval
1971 with a strong interest in the role of neu- and gave it the trade name Prozac. The next few
rotransmitters in the development of affective years saw an influx of positive results from a vari-
disorders. However, he encountered difficulty in ety of clinical trials, and within three years, it was
convincing the leadership at Lilly to fund research the most commonly prescribed psychiatric medi-
that examined these theories. The same year that cation in North America.
Fuller arrived, Lilly honored the biological psy-
chologist Solomon Snyder and invited him to The Happy Pill
speak. His lecture focused on the importance of During the 1990s, Prozac became a household
increased research programs on neurotransmis- name through extensive coverage in media and
sion. Snyder outlined a procedure for conducting popular culture. “The Happy Pill” made the front
this research, which the team at Lilly eventually page of prominent publications such as the New
used in their synthesis of fluoxetine. Fuller, work- York Times (“With Millions Taking Prozac, A Legal
ing closely with biochemist David Wong, suc- Drug Culture Arises,” 1993), Newsweek (“How
ceeded in getting Lilly’s approval for a serotonin- a Treatment for Depression Became as Familiar
depression study team along with pharmacologist as Kleenex and as Socially Acceptable as Spring
Robert Rathbun and organic chemist Bryan Mol- Water,” 1994), and Time Magazine (“How Mood
loy. Their goal was to synthesize a compound Drugs Work . . . and Fail,” 1997). Peter Kramer’s
that could more specifically inhibit the reuptake 1993 book Listening to Prozac lauded the medica-
of serotonin and at the same time be free of the tion and introduced the term better than well to
adverse side effects seen with tricyclic antidepres- describe the results people achieved with Prozac.
sants (TCAs). The focus on serotonin was partially This mantra was both taken up and mocked in the
due to the shift away from the catecholaminergic national media; Newsweek titillated its readership
theory of depression, which had postulated that a with the possibility of a new, better personality in
deficiency in the catecholamines, specifically nor- a pill, but The New Yorker and the New Republic
epinephrine, in the intersynaptic cleft was instru- satirized it in cartoons. Elizabeth Wurtzel’s best-
mental in the development of affective disorders. selling autobiography, Prozac Nation, in 1994,
The serotonergic theory, which attributed depres- echoed the refrain as she described her struggles
sion to a serotonin deficiency, had begun to gain as a young woman with major depression and
credence in the 1970s. her eventual treatment and recovery with Prozac.
Noting the antidepressive activity of certain Soon, Prozac was part of popular culture, appear-
antihistamines, especially diphenhydramine, ing everywhere from medicine cabinets and bedside
Molloy and Rathbun developed an analogue, tables to greeting cards and magnets. In response to
phenoxyphenylpropylamine, 55 derivatives of complaints of a hard day, instead of being offered
which Wong chose to test in vitro. In 1972 Jon- commiseration, people might now be asked if they
Sin Horng, a member of Wong’s team, discov- had remembered to take their Prozac. Accepted as
ered that, of these derivatives, fluoxetine chlor- not just a drug for people with mental illness but
hydrate was the most effective selective serotonin for anyone who was finding daily life a chore, by
inhibitor. Additionally, it only weakly inhibited 1994 Prozac was, behind the heartburn medication
the reuptake of other neurotransmitters, which Zantac, the second-best-selling prescription drug
encouraged hope that it would be free of the side overall worldwide.
effects associated with the TCAs. In 1980, Lilly In 2000, psychiatrist Joseph Glenmullen pub-
put its full support behind fluoxetine, following a lished Prozac Backlash, in which he chronicled
 Psychiatric Social Work 687

the side effects of Prozac (and similar drugs) in Psychiatric Social Work
his patients, discussing symptoms such as Parkin-
sonian-like effects, memory problems, sexual dys- From the development of voluntary aftercare ser-
function, and severe withdrawal, as well as the vices in the 19th century to the multidisciplinary
previously discussed side effects. He, along with community mental health team of the late 20th
psychiatrists Peter Breggin and Loren Mosher, century, psychiatric social work has performed
became well-known critics of treatment with a key support role in the expansion of mental
Prozac and similar drugs and were often cited health services beyond the institution. Yet as the
by members of the psychiatric survivors’ move- community has emerged as the main site for care
ment. Meanwhile, disturbing reports had begun of those with mental health problems, psychiat-
to emerge about serious potential side effects of ric social workers, trained in the social sciences,
Prozac and the other SSRIs, including akathi- have found themselves increasingly at odds with
sia (a feeling of intense and unpleasant inner medically trained psychiatric workers over phi-
restlessness), suicidality, and aggression. These losophies of care and treatment. Such conflicts
effects were of special concern in adolescents and are arguably not only epistemological in nature
young adults. In 2007, the FDA issued a recom- but also denote an ongoing conflict over pro-
mendation for the makers of all antidepressants fessional expertise and control of jurisdiction.
to update their black box warnings to include Within sociology, psychiatric social workers can
the increased risk of suicide during the first few thus be theorized as both a threat to the power of
months of treatment in youth 18 to 24. Yet, Pro- psychiatric professionals as well as an unwitting
zac remained popular; many people credit the ally in the proliferation of expert discourses on
drug with dramatically improving their lives and mental health into new areas of public and pri-
feel that any side effects they have experienced vate life in neoliberal society. By utilizing a socio-
have been a small price to pay. historical analysis it is also possible to problema-
Eli Lilly’s patent on Prozac ran out in 2001. In tize psychiatric social workers as agents of social
response to clinical studies suggesting fluoxetine control responsible for the policing, regulation,
is effective in treating premenstrual dysphoric dis- and management of those classified by psychiatry
order (PMDD), Lilly licensed it for this indication as mentally ill.
and rebranded Prozac as Serafem. Prozac, both Psychiatric social work emerged in the late
brand name and generic, continued to be widely 1800s and, as it became more specific and nuanced
prescribed for a variety of indications in the first to keep pace with growing legal requirements and
decade of the new millennium and appeared likely priorities, grew in responsibility and power into
to be a drug of choice in psychiatry for some years the 20th century. In the 21st century, however,
to come. the profession has grappled with its increasingly
contradictory position as well as subsequent con-
Rebecca Wilkinson troversies in an era defined by increasing “risk.”
University of California, Los Angeles
Historical Background
See Also: Antidepressants; Mood Disorders; The origins of social service professionals can
Serotonin Reuptake Inhibitors; Stigma; Tricyclic be found in the last quarter of the 19th century
Antidepressants. and understood as a societal response to the
increase in social problems brought about by
Further Readings rapid industrialization and urbanization, includ-
Elkes, J. “Psychopharmacology: Finding One’s Way.” ing poor housing, poverty, ill health and disease,
Neuropsychopharmacology, v.12/2 (1995). and alcohol abuse. Tied to middle-class concerns
McClean, B. “A Bitter Pill Prozac Made Eli Lilly.” of the need to control the all-too-visible “danger-
Fortune Magazine (August 13, 2001). ous classes” in the growing industrial towns and
Meichenbaum, D. Cognitive Behavior Modification: cities of Europe and America, powerful chari-
An Integrative Approach. New York: Plenum ties of the time began to place voluntary work-
Press, 1977. ers (mainly females from middle- and upper-class
688 Psychiatric Social Work

Janet Mott, a case manager with Duffy’s Opportunities Project in Hyannis, Massachusetts, sits with a client named William and his
dog Alberta, after William eventually allowed Mott to put him up in a motel room supplied by Duffy. After years of living alone in the
Massachusetts woods, he sees his case manager regularly for his behavioral health needs. Psychiatric social workers acknowledge the
social causation of mental illness, including the relevance of poverty, discrimination, and violence on the emergence of mental distress.

backgrounds) within working class communities and the financial position of the household) and
as “friendly visitors” offering various forms of monitor the patient when he or she returned to
social support to the “worthy poor.” the family setting. In this way, these early mental
Similarly, psychiatric social work originated health social workers served not only a social role
in the voluntary work carried out on behalf of in offering community-based care and support for
charities, mainly from within the psychiatric the patient and their family but also a “parole”
institution. As asylums for the insane expanded function in monitoring and managing madness
throughout the century and became the dominant beyond the institution. Interestingly, in 1924,
response to madness, subsequent needs were iden- the U.S. Census Bureau explicitly acknowledged
tified by both hospital staff and charity organiza- that the growth in the “parole system” for mental
tions for social support of the patient and their patients was the direct result of the employment
family during the period of hospitalization as well of social workers in many state hospitals.
as for additional aftercare services to help the As the number of patients in psychiatric insti-
person reintegrate into society and avoid further tutions continued to grow in the early decades of
relapses. Thus, the new medicine required work- the 20th century, the need for support workers
ers who could assist patients beyond the institu- within the mental health system increased. Along
tion and make appropriate assessments for further with notable figures in public psychiatry (such as
medical and social intervention within the com- the Adolf Meyer, the future head of the American
munity. At the institution, these workers made Psychiatric Association), powerful charities such
assessments of new patients for additional eco- as the State Charities Aid Association (SCAA)
nomic and social support but they also made vis- in the United States and the National Confer-
its to the family home (to observe family and rela- ence of Charities and Corrections (NCCC) in the
tives, the general state of the home environment, United Kingdom lobbied government authorities
 Psychiatric Social Work 689

for a comprehensive mental health care response acknowledge the social causation of mental ill-
outside the hospital. Aided by the expansion of ness, including the relevance of poverty, discrimi-
social state provision, outpatient care was even- nation, and violence on the emergence of men-
tually formalized through legislation that made tal distress. Psychiatric social work has therefore
community (or aftercare) responses to mental argued that medically informed discourses of
health mandatory. A notable part of such initia- diagnostic assessment are reductionist and do not
tives involved the inclusion of state-funded psy- account for the effects of social disadvantage on
chiatric social workers. As a part of the growing the development of mental illness. It has critiqued
professionalization of psychiatric social workers, psychiatry’s attempt to reduce symptoms through
formal training of mental health social workers pharmacological interventions in the absence of
began in the 1920s through social science depart- psychosocial interventions aimed at improving
ments at universities, including the University of an individual’s social environment and access to
Chicago and the London School of Economics. resources.
With an emphasis on practical application and However, the notion of psychiatric social work
individual case management, the training drew as a distinct profession within mental health ser-
on the social science disciplines of sociology, vices, and its capacity to offer a psychosocial per-
social policy, law, psychology, philosophy, his- spective, is diminishing because of changes to both
tory, and economics. professional structures and shifts within agency
Over the course of the 20th century, psychiat- cultures that have become increasingly inter-
ric social work training became more specific and ested in neoliberal discourses of “risk.” Within
nuanced in line with the growing legal require- mental health agencies, positions previously held
ments and priorities placed on the profession. exclusively by social workers have been replaced
By the 1980s, psychiatric social workers were by generic mental health worker positions. For
required to have additional training within the example, in the United Kingdom, ASWs have
mental health area to become fully qualified; they been replaced by approved mental health pro-
are known as licensed psychiatric social workers fessionals (AMHPs), opening the role up to a
in the United States and approved social work- range of other professionals such as nurses and
ers (ASWs) in the United Kingdom. This reflected psychologists, which has meant that psychiatric
the growing responsibility and power of the social work has become less differentiated from
profession within the mental health field as the other mental health professions. This lack of pro-
community response succeeded the institutional fessional differentiation has reduced the capacity
response to mental illness in the latter half of the of social work to assert its position regarding the
20th century. social causation of mental illness.
The current context of psychiatric social work The development of generic case management
is shaped by the increasingly contradictory posi- roles has meant that psychiatric social workers
tion of the profession within the mental health employed within CMHTs are heavily involved in
system, which is simultaneously engaged in both the diagnostic assessment process and the ongo-
a critique of and a participation in psychiatric ing “monitoring” of symptoms rather than in
hegemony. psychosocial interventions. Consequently, psychi-
atric social work has become increasingly influ-
Current Context enced by the medical model of mental illness.
In the 21st century, psychiatric social workers The medicalization of psychiatric social work
are distinct within their multidisciplinary com- has also occurred within a context of workplaces
munity mental health teams (CMHTs) because that are increasingly risk averse, technorational,
of their training in the social sciences, which and intolerant of uncertainty. Psychiatric social
contrasts with the biomedical training of other workers have been involved in a shift in emphasis
mental health professionals such as psychiatrists, within mental health care from the assessment of
psychologists, and nurses. Unlike their colleagues illness to the assessment of risk. Within this para-
who understand mental illness largely in terms of digm, symptom identification continues to occur
biological functioning, psychiatric social workers but is linked inextricably to the assessment of risk
690 Psychiatric Social Work

in order to determine the level of involuntary care Similarly, the “recovery” perspective, which
imposed on individuals. Risk assessment is now a initially aimed to recognize the expertise held by
primary and compulsory component of the work patients regarding their own well-being in order
conducted by psychiatric social workers. to redress psychiatry’s coercive practices, has
The salience of risk assessments—in particular, largely been subsumed into conventional psychi-
the documentation of risk to protect the reputa- atric discourses. It has been reframed from a dis-
tion of agencies—as well as the strain produced course of rights to a discourse of punitive prac-
by exceptionally high workloads (known as case- tices in which patients are expected to engage in
loads) has rendered the role of psychiatric social practitioner-led “recovery” objectives (such as
workers as increasingly bureaucratic and coercive. finding employment).
This has reduced the relational possibilities of the On a broader level, with the deinstitutional-
role, including the provision of support, counsel- ization of mental health care in the latter half of
ing, and interventions relating to the reduction of the 20th century, psychiatric social workers are
social stressors. Additionally, an intolerance of now employed predominantly to provide outpa-
uncertainty has led to psychiatric social workers tient care within CMHTs. Although community
being expected to limit their work to the provision care arguably offers a less restrictive intervention
of interventions that are accepted as evidence- compared to an institutional response—which is
based (with “evidence” being defined as informa- confined only to those considered most “risky”—
tion produced through quantitative research and it has meant that psychiatric social workers have
randomized controlled trials), resulting in the per- assisted psychiatry in extending its reach far
vasive use of standardized and prescriptive inter- beyond the institution. As a result, statutory or
ventions by psychiatric social workers, which are involuntary mental health care is able to be car-
imposed inflexibly onto patients. ried out indefinitely following the completion of
Within the context of the increasing medical- inpatient treatment as well as for individuals who
ization of their work, psychiatric social workers are considered in need of “early intervention” or
have articulated alternative conceptualizations of “preventative” mental health care.
mental illness based on discourses of justice and
rights. However, such attempts have been largely Conclusion
ineffectual in shifting the dominant medical dis- While psychiatric social workers have frequently
course and have in fact contributed to the expan- critiqued the biomedical reductionism within psy-
sion of psychiatric hegemony. For example, psy- chiatric accounts of mental distress, they have
chiatric social workers have been fundamental in significantly contributed to psychiatric hegemony.
proposing the “normalization” thesis (that is, the Within a contemporary context, their capacity
notion that mental health symptoms are a normal to articulate socially informed understandings of
part of human experience), with an aim to reduce mental illness has largely been marginalized. From
the stigma experienced by people who have been their early parole tasks to their contemporary role
diagnosed with a mental illness. Despite its com- as community mental health workers who moni-
mendable intentions, the normalization thesis tor risk, psychiatric social workers are involved in
has resulted in an increased perceived relevance a similar perpetuation of social control functions
of psychiatric knowledge to realms of everyday as performed by other psychiatric professionals.
experience previously beyond the reach of psychi-
atry. It has, for instance, become “commonsensi- Bruce Macfarlane Zarnovich Cohen
cal” to understand everyday problems of living University of Auckland
(such as relationship problems) through psychiat- Emma Tseris
ric language in ways that were previously not pos- University of Sydney
sible, and psychiatric “experts” are called upon to
assist with these concerns. Thus, the attempt to See Also: Asylums; Case Managers; Case Records;
reduce the capacity of psychiatry to colonize the Community Mental Health Centers; Community
ways in which distress is understood has actually Psychiatry; Dangerousness; Deinstitutionalization;
contributed to its increased attempts to do so. Integration, Social; Legislation; “Normal”:
 Psychiatric Training 691

Definitions and Controversies; Patient Rights; Policy: programs in the United States require that stu-
Federal Government; Policy: State Government; dents have a working knowledge of cognitive
Psychiatric Training; Psychopharmacological behavioral therapy (CBT, a short-term treatment
Research; Psychopharmacology; Psychosocial used mostly for anxiety disorders), psychody-
Adaptation; Randomized Controlled Trial; Social namics (in-depth talking), and supportive thera-
Causation; Social Control; Social Support; State pies (basic talking and life support), although the
Budgets; Stigma; Violence. focus of training is on diagnosis and medication
treatment in most U.S. programs.
Further Readings After their training, psychiatrists take written
Coppock, Vicki and Bob Dunn. Understanding Social and then oral board examinations in order to
Work Practice in Mental Health. London: Sage, practice. Many psychiatrists choose to do a fel-
2010. lowship following their residency for extra train-
Fawcett, Barbara. “Mental Health.” In Sage ing, which typically lasts one to four years. For
Handbook of Social Work, Mel Gray, James instance, if a psychiatrist wishes to specialize in
Midgley, and Stephen A. Webb, eds. London: treating children or the elderly or is interested
Sage, 2012. in forensic psychiatry or public psychiatry, she
Karban, Kate. Social Work and Mental Health. would need a fellowship for those kinds of train-
Cambridge: Polity Press, 2011. ing. During their internship and residency years,
psychiatrists are trained in the diagnosis of men-
tal disorders per the American Psychiatric Asso-
ciation’s Diagnostic and Statistical Manual of
Mental Disorders (DSM).
Psychiatric Training Because of the nature of the hospital setting,
psychiatrists are rarely offered more than brief
Psychiatry is a branch of medicine. As any medi- training for in-depth talk therapy. Though a psy-
cal doctor must, a psychiatrist completes pre- chiatrist might see a few patients for talk ther-
medical requirements, including biology, organic apy, in the hospital setting, the psychiatrist’s role
chemistry, chemistry, and physics before applying revolves primarily around medication checks,
to medical school and taking the Medical Col- while psychologists and social workers are more
lege Admissions Test (MCAT), the standardized likely to be responsible for talk therapy. This
entrance exam required to attend most medical also means that psychiatrists are likely to treat
schools. Once accepted to medical school (about (and are best equipped to treat) the most severely
22,100 students enter per year, according to the ill patients in the hospital, as these patients are
Association of American Medical Colleges), stu- likely to be prescribed antipsychotic or mood-
dents spend the first two years engaged in inten- stabilizing medications. If a psychiatrist is inter-
sive coursework in biochemistry, genetics, phar- ested in becoming a talk therapist, they can train
macology, anatomy, and physiology. The third for it following the attainment of their clinical
and fourth years consist of clinical rotations in degree in psychodynamic psychotherapy or psy-
areas such as internal medicine, general surgery, choanalysis; however, unlike in the 1970s and
pediatrics, psychiatry, and obstetrics and gynecol- earlier, talk therapy is no longer provided in psy-
ogy. During (or before) these rotations, students chiatric schooling.
make a decision about what type of medical spe-
cialty they will pursue. Learning to Diagnose
Being trained in medicine (or in any field)
Licensing and Training involves the induction into what Ludwik Fleck in
After successfully attaining a medical degree, 1935 called a thought community, where people
students must become licensed in order to prac- exchange ideas and share intellectual material.
tice medicine in the United States. In psychiatry, Thought communities provide thought styles that
this includes an internship year and a residency direct the perception of members of the group;
that lasts three years. All accredited psychiatric thought styles focus attention and teach members
692 Psychiatric Training

to observe and classify events, people, actions, Second, it defines the duration of symptoms nec-
emotions, and much more in particular ways. essary for a diagnosis. And third, it identifies the
Psychiatric training can be seen as the acquisi- specific symptoms, which assesses the severity of
tion of a set of cognitive structures or schemas the condition.
that help students interpret their patient’s trou- The DSM provides for psychiatry the same kind
bles. Supervisors and textbooks provide schemas; of threshold measurement used in other branches
because mental illness is seen as arising from bio- of medical practice, which all seek to identify not
logical malfunctioning, psychiatrists learn to see only disease itself but also risk factors for future
patients’ problems as stemming from neurotrans- illness. It is this diagnostic system into which psy-
mitters and chemical imbalances. Because there is chiatrists are socialized in medical school and dur-
such little training in talk therapy in psychiatry ing their residency. The DSM is a tool of the medi-
residencies (entirely the opposite leading into to cal model and contemporary psychiatrists regard
the 1980s, when psychoanalysis dominated the the manifestations of these mental processes
field), the majority of psychiatrists emerge from (symptoms) as the basis of treatment. Thus, medi-
residency with a heavy emphasis on diagnosis and calization is at the heart of the diagnostic system;
treatment with medication. If psychiatrists want because psychiatry equates psychiatric symptoms
to be proficient talk therapists, additional training with medical disorders, mental illnesses can be
is often necessary. discussed in medical terms and treated with medi-
Residencies today revolve around diagnosing cations. T. M. Luhrmann, whose ethnographic
patients with the standard criteria of the DSM work was with psychiatry residents, describes res-
and prescribing medications. The latest edition, idencies as training psychiatrists to see illness as
DSM-5 (and the previous edition, DSM-IV-TR) birdwatchers spot great snowy owls or dog lovers
are tools of biological psychiatry, which emerged spot various canine breeds.
in the 1980s. With the release of DSM III in 1980,
a game change was under way in American psy- DSM-IV-TR Criteria for Major
chiatry. In contrast to the emphasis in psycho- Depressive Episode
analysis on comprehending symptoms in the con- A patient must have a total of five of the symp-
text of patients’ life histories, mental illness was toms below for at least two weeks. One of the
now viewed as biologically borne and chemically following symptoms must be depressed mood or
driven. The biological paradigm is concerned with loss of interest:
disorders of the brain that produce symptoms
identified in systematic ways and treated with • Depressed mood
medication. Biological psychiatry reconceptual- • Markedly diminished interest or pleasure
ized as organic illness conditions that were, in the in all or almost all activities
dynamic tradition, considered a basic part of the • Significant (greater than 5 percent body
human psyche. Mental pain and suffering became weight) weight loss or gain, or increase
something diagnosable and something located in or decrease in appetite
the physical brain, and was therefore treated with • Insomnia or hypersomnia
alterations in the chemical properties of the brain. • Psychomotor agitation or retardation
This is the paradigm now taught to psychiatrists • Fatigue or loss of energy
during their training. • Feelings of worthlessness or inappropri-
The DSM III and its subsequent editions focus ate guilt
on specific symptoms, many of which are physical. • Diminished concentration or being
For instance, there is the diagnostic category for indecisive
major depressive disorder (the most severe form • Recurrent thoughts of death or suicide
of depression and the most commonly diagnosed
mental illness in the United States today), which The following interaction between psychiatry
accomplishes three crucial tasks at the heart of resident Robert Klitzman and one of his supervi-
the biological model. First, it distinguishes panic sors is prototypical of his (and others’) experience
disorder from other kinds of anxiety disorders. in a prominent psychiatric residency program:
 Psychiatric Training 693

Klitzman: “She says she’s depressed” [in refer- means for treating illness. In fact, the socialization
ence to one of his patients]. of psychiatry residents into the DSM model is one
of the primary ways the biological model main-
Supervisor: “That’s not enough for a diagnosis.” tains its place as the dominant treatment modal-
ity in the United States. The salience of the DSM
Klitzman: “She looks kind of depressed, too.” model can lead to a narrow view of what illness
and treatment are. Diagnostic categories become
Supervisor: “Lots of people say they’re so much a part of the psychiatric worldview that
depressed, but if she doesn’t meet these crite- they are internalized by practitioners who feel as
ria, we don’t have target symptoms to follow though they are classifying natural, objectively
for marking her progress, and if we don’t, it’s observable phenomena. The DSM also offers a
not worth treating her . . . remember to always sense of scientific rigor in a discipline in which the
DSM-III’r your patients in the beginning.” Freudian legacy is often ridiculed by other medi-
cal fields for its lack of rigor.
The DSM model is central for logistical rea- The legitimacy of the psychiatric diagnosis is
sons as well; a diagnostic system provides clear entirely dependent on the identification of symp-
ways for understanding symptoms, which makes toms and the diagnosis of an illness based on
it easier to enact a treatment plan. Additionally, these standards—on the consistent perception of
medicine is an uncertain profession. Patients pres- certain symptom clusters as illness, even in the
ent with troubling, sometimes painful symptoms, absence of a visual, tangible lesion. Unlike with
and doctors are responsible for accurately iden- an arterial blockage that indicates the need for a
tifying their source and finding a treatment and cardiovascular procedure or a cancerous tumor
hopefully a solution to it. Renée Fox pointed to that indicates the necessity of a surgical proce-
medicine’s inherent uncertainty, which is precisely dure, mental illness is invisible. Therefore, psychi-
what makes evidence-based medicine so impor- atric diagnosis rests solely on very specific sets of
tant for doctors and even more so for psychia- criteria in lieu of a “real” marker. Especially given
trists, who do not have the same objective mea- the fear that different psychiatrists might see dif-
sures as those in cardiology or oncology. There ferent symptoms in patients and identify them as
are very few markers of disease in psychiatry, and different conditions, diagnostic criteria are strictly
even when illness is successfully identified, psy- adhered to. This was commonly the case in early
chiatrists and other mental health specialists only psychiatry and led to antipsychiatry movement
have treatments; there is no cure. critiques such as D. L. Rosenhan’s 1973 study of
In short, diagnosis is particularly important for the mislabeling of psychiatric inpatients that led
psychiatrists in the absence of any other “scientific” to unnecessary hospitalization.
marker of illness. The DSM works to control the
possibility that different clinicians, coming from Conclusion
different backgrounds, with different training, In the 1980s, psychiatry became a modern medical
might perceive their patients’ symptoms in differ- field. Though they are mental health profession-
ent ways. However, it has yielded mixed results in als, psychiatrists first and foremost learn the tools
terms of its unifying effect on psychiatric and psy- of the medical trade: diagnosis and prescribing.
chological practice; on one hand, it creates a stan- In adhering to medical standards, psychiatrists
dard model for identifying and classifying illness, become a part of the world of “hard science” and
yet on the other, the DSM is seen as oppressive and legitimize both their profession and their own
restrictive, and it is often condemned as the source identity as doctors. Psychiatrists learn what any
of all that is wrong with psychiatry today. medical doctor does, and once their coursework
As new practitioners are socialized into the dis- is over, their internship and residency training is
course and practice of their field, psychiatry resi- largely focused on recognizing specific symptoms
dents are rarely taught that the diagnostic method as part of particular illness categories and treat-
is one possibility in a range of treatment forms, ing those illnesses with the main technology of the
but rather that the medical model is the only field: medication.
694 Psychiatric Treatment, Pathways to

Though there is still some training in talk therapy Psychiatric Treatment,

in some medical programs, the reality for the field
of psychiatry is that if it is to maintain evidence- Pathways to
based practice, a DSM diagnosis is crucial because
there are no lesions to uncover in detecting mental Estimates are that anywhere between 20 per-
illness. Standardization also helps doctors organize cent and 33 percent of individuals in the United
their thinking and make decisions. However, this States will have a diagnosable mental health con-
has consequences for practitioners who are trained dition in their lifetime. Nonetheless, only about
in very little except the medical model and for one-third will enter treatment. Previously, social
patients who often express frustration with medi- scientists used sociodemographic characteris-
cal diagnoses and report feeling treated as though tics (such as socioeconomic status and gender)
they are their illness rather than human beings. to explain whether individuals entered mental
health treatment. Later, researchers used more
Dena T. Smith dynamic models that examined a variety of fac-
Goucher College tors affecting how people accepted treatment,
including society’s reaction (stigma), variations in
See Also: Clinical Psychologists, Training of; social networks, and “illness behavior” (how the
Medicalization, Sociology of; Psychoanalytic individual monitored and interpreted symptoms).
Treatment. Now, sociologists are developing theories about
the pathways, or routes, that people use to seek
Further Readings treatment for mental health disorders. Although
Fox, Renée C. “The Evolution of Medical these conceptual models are still being developed,
Uncertainty.” Health and Society, v.58/1 (Winter some empirical trends have emerged. Adults who
1980). find their way to treatment are most often treated
Harris, Gardiner. “Talk Doesn’t Pay, So Psychiatry by their primary care provider.
Turns Instead to Drug Therapy.” New York Times Nonetheless, a sizable proportion of those who
(March 5, 2011). http://www.nytimes.com/2011/ are imprisoned or jailed have mental disorders.
03/06/health/policy/06doctors.html?_r=3&seid Similarly, those who are homeless exhibit rela-
=auto&smid=tw-nytimeshealth&pagewanted tively high rates of mental illness but have diffi-
=all& (Accessed May 2013). culty entering treatment. Depending upon their
Klitzman, Robert. In a House of Dreams and Glass: age (and diagnosis), children with serious emo-
Becoming a Psychiatrist. New York: Simon & tional disturbances tend to be treated by their
Schuster, 1995. schools, physicians, or increasingly in the juvenile
Light, Donald. Becoming Psychiatrists: The justice system.
Professional Transformation of Self. New York: Although rates vary across different stud-
W. W. Norton, 1980. ies using various definitions and methods, the
Luhrmann, T. M. Of Two Minds: An Anthropologist National Comorbidity Survey Replication, a
Looks at American Psychiatry. New York: Vintage nationally representative study using diagnostic
Books, 2001. tools to assess prevalence of psychiatric disorders,
Pena, G. P. “The Epistemology of Ludwik Fleck and found that 26.2 percent of U.S. adults had a diag-
the Thought Community of Banff.” American nosable disorder in a year. Among these, almost
Journal of Transplantation, v.11/5 (May 2011). 10 percent had a mood disorder (including major
Porter, Roy. The Greatest Benefit to Mankind: A depressive disorder, dysthmic disorder, and bipo-
Medical History of Humanity. New York: W. W. lar disorder). In addition, 18.1 percent had an
Norton, 1997. anxiety disorder. Many adults have more than one
Rosenhan, D. L. “On Being Sane in Insane Places.” psychiatric disorder at a time; of those diagnosed,
Science, v.179 (1973). almost half (45 percent) could be diagnosed with
Shorter, Edward. A History of Psychiatry: From the two or more disorders. Furthermore, in any given
Era of the Asylum to the Age of Prozac. New year, 5 to 7 percent of adults had a serious men-
York: John Wiley & Sons, 1998. tal illness (any mental disorder recognized by the
 Psychiatric Treatment, Pathways to 695

American Psychiatric Association’s diagnostic of reasoned action) combined sociodemographic

categories that results in a functional limitation in characteristics with social psychological factors
at least one area of the individual’s life). such as the individual’s sense of efficacy, intention
Despite these relatively high rates, only about to pursue a health behavior such as seeking treat-
one-third of those with a diagnosable disorder ment, social norms, and the influence of signifi-
(i.e., a disorder that could be, but is not neces- cant others.
sarily already, diagnosed) enter treatment. Con- Surveys of the public have shown that many
versely, research has also shown that those who think that mental illness is untreatable or is syn-
enter treatment are not necessarily in greatest onymous with incompetence or dangerousness.
need. The Epidemiological Catchment Area Study Although 49 states have some type of public men-
(ECA), a multisite longitudinal study, found that tal health education campaign and/or an anti-
half of those who received treatment did not have stigma program, public perception lags behind
any detectable disorder. Given all these trends, these efforts. As a result, given these mispercep-
it is important to understand the pathways that tions and the resulting stigma, individuals with
people take when obtaining treatment. mental illness often report not seeking or delaying
treatment.
Background Characteristics The effect of social networks is substantial.
Research on whether and how people enter psychi- For example, John Clausen and Marian Yarrow’s
atric treatment has gone through several phases. seminal study on schizophrenic men demon-
Initially, researchers examined the background strated that family, friends, and others spent years
characteristics of service users. For example, supporting and encouraging the men before they
while research and clinical data consistently show secured treatment. More recent work, however,
that women are more likely than men to receive suggests that the effects of social networks may
mental health treatment, analysts point out that be more complex: They may not only enhance the
this difference may not only reflect different rates individual’s choice to enter treatment, but alter-
of psychiatric symptoms but also reflect gender nately they may be coercive or even create addi-
differences in interpreting emotional distress as tional uncertainty. For example, individuals with
psychological disturbance and the propensity to bipolar disorder and those with larger and more
seek emotional support. Other research suggests intimate social networks have reported greater
that the rates for mental illness are the same for coercion to enter treatment.
women and men but that the types of illness dif- Finally, research on illness behavior has exam-
fer. Racial minorities are less likely to seek mental ined the ways in which individuals interpret
health treatment than whites, even when control- symptoms and take (or do not take) action based
ling for differences in symptoms and diagnoses. on those understandings. These studies have iden-
Older and younger age groups show lower rates tified common steps associated with how indi-
of entering mental health treatment. viduals decide to seek care for a mental health
Higher rates of mental health treatment are condition, in which individuals: recognize that a
found among those with more formal education. problem exists, define it as a mental health issue,
Having either public or private insurance that believe that mental health treatment might help,
covers mental health treatment makes a substan- decide to seek mental health treatment, and con-
tial difference in whether or not individuals enter tact a mental health provider or organization.
treatment. Among adults with serious mental dis- Some have criticized such models for, among
orders, those who have private insurance are 2.5 other things, assuming that individuals pass
times more likely to enter treatment than those sequentially through every stage.
who are uninsured. Similarly, those who have
publicly funded insurance (Medicare or Medic- Help Seeking and Network Models
aid) are six times as likely to seek care. Since the 1990s, R. Andersen’s Sociobehavioral
In moving beyond single predictors of mental Model of Health Care Utilization has been used
health treatment utilization, early theories of help (and revised) extensively, particularly in research
seeking (e.g., the health belief model, and theory on help seeking for somatic disorders. The model,
696 Psychiatric Treatment, Pathways to

while complex, relies on three clusters of fac- treatment, community-based patients most often
tors: need for service, predisposing factors, and went to their primary care physicians’ offices (80
enabling resources. Individuals must perceive the percent), followed by outpatient hospital care
need for health care; sufficient predisposing fac- (11.8 percent), and emergency departments (7.5
tors must exist, including gender, age, race, and percent). A general finding across these major
beliefs about the efficacy of treatment; and indi- studies is that primary care providers tend to be
viduals must have access to enabling resources, at the front line in diagnosing and triaging their
including availability of services, travel time, and patients’ mental health care needs.
financial ability. These major longitudinal studies, however,
More recently, others have criticized Ander- overlook mental health services that are provided
sen’s model and the theory of reasoned action to non-community-dwelling adults, including
for not adequately explaining the processes by those who are homeless or incarcerated.
which individuals decide to seek health (and Yet, higher rates of diagnosable psychiatric dis-
mental health) care. Critics note that the models orders are found among those who are incarcer-
emphasize rational decision making, downplay ated than in the general population. For example,
the role of culture in how illness is experienced, 6 to 18.5 percent of inmates have serious lifetime
neglect structural aspects of health care (with the psychiatric illnesses such as schizophrenia, bipo-
exceptions of insurance and income), and unduly lar disorder, and major depression. Some attri-
emphasize patient choice in entering treatment bute these higher rates to criminalization of the
when many people who receive psychiatric treat- mentally ill, or the increased likelihood of incar-
ment experience either coercion or uncertainty. cerating those with mental illness because of the
In response, among the newer models is B. Pes- combined effects of treating the mentally ill in
cosolido and C. Boyer’s (2010) network-episode the community, restrictive commitment laws that
model (NEM), which examines how people’s limit mental health treatment options, and the
social connections connect them to time and place, fear and stigma attached to mental illness. Oth-
across many social levels including individual’s ers say that there is not enough evidence to sup-
interpersonal interactions, interactions within port the criminalization thesis. For example, high
groups, and interactions with larger structural arrest rates may be because of a small cadre who
institutions. This model maps the structure of an revolve in and out of both the mental health and
individual’s relationships in seeking treatment and criminal justice systems. An alternate (criminal-
thus combines elements of the illness career (how ity) thesis is that the mentally ill are more likely
individuals understand their self through episodes to commit dangerous crimes. Most arrests of the
of illness), their social support system, social ser- mentally ill, however, are for nonviolent misde-
vice agencies, and the larger treatment system. meanors, similar to the rest of the population. Fur-
thermore, the proportion of the mentally ill who
Pathways for Adults commit violent crimes tends to be relatively low
While conceptual models are still being devel- (approximately 10 percent of men and 2 percent
oped, research has documented trends in the of women). Although not found in every commu-
pathways, especially the initial entry point that nity, specialized programs to divert the mentally
people take to receive mental health services. The ill from incarceration into treatment include crisis
ECA found that of the 20,000 adults in the study, intervention teams and court diversion programs.
6.4 percent received mental health services from Similarly, while estimates vary (between 22 and
physicians and 5.9 percent from specialty men- 31 percent), those who are homeless suffer dis-
tal health or addictive services. A decade later, proportionately from mental illness. The increase
however, the National Comorbidity Study found in mental illness among the homeless began in
that individuals tended to obtain mental health the 1970s and was exacerbated by the escalating
services from mental health specialty providers at cost of housing. Today, although the supply does
slightly higher rates than they did from general not meet the need, supportive housing programs,
practitioners. The 2008 Behavioral Risk Surveil- including the Pathways to Housing model, have
lance Study found that for those who received shown promise. The majority (80 percent) of those
 Psychiatry and Neurology 697

who are eligible and are accepted into programs, The National Center for Mental Health and
live in supportive housing for at least one year and Juvenile Justice partnered with the Council of
show reduced use of mental health and substance Juvenile Correctional Administrators to conduct
abuse services, including emergency room visits. a study on mental illness among juvenile delin-
After receiving housing, residents are offered coor- quents. This large, multistate, multilevel (deten-
dinated and tailored supportive services, including tion, corrections, and community-based pro-
mental health services, substance abuse treatment, grams) study found that 70 percent of youth in
employment training, and educational programs. juvenile justice systems had at least one mental
disorder. Female juveniles tended to have higher
Pathways for Children and Adolescents rates of mental health disorders than males.
According to the U.S. Surgeon General, approxi-
mately 20 percent of children and adolescents Deborah A. Potter
have a mental health problem during a single year, University of Louisville
and 5 percent have “extreme functional impair-
ment” in a major area of their lives. The National See Also: Help-Seeking Behavior; Homelessness; Jails
Co-Morbidity Survey–Adolescent Supplement and Prisons; Self-Help; Stigma: Patient’s View.
(NCS-AS), a longitudinal study of a nationally
representative sample of adolescents aged 13 to Further Readings
18, found that the lifetime prevalence of mental Clausen, John A., Marian Radke Yarrow, Sheila
health disorders with severe impairment was 22.2 Calhoun Deasy, and Charlotte Green Schwartz.
percent. In addition, there is increasing evidence “The Impact of Mental Illness: Research
that lifetime psychiatric disorders often first occur Formulation.” Journal of Social Issues, v.4 (1955).
during childhood or adolescence. These trends McAlpine, Donna D. and Carol A. Boyer.
underscore the importance of understanding how “Sociological Traditions in the Study of Mental
children enter mental health treatment. Health Services Utilization.” In Mental Health,
Children receive mental health services from Social Mirror, William R. Avison, Jane D. McLeod,
a variety of sources: schools, specialty mental and Bernice A. Pescosolido, eds. New York:
health services, general medical services, juvenile Springer, 2007.
justice, and child welfare agencies. The Great Mechanic, David. “Sociological Dimensions of Illness
Smoky Mountains Study (GSMS), a longitudi- Behavior.” Social Science & Medicine, v.41/9
nal epidemiological study of adolescent mental (1995).
health service use, found that over half of all chil- Pescosolido, Bernice A. and Carol A. Boyer.
dren who received mental health services in their “Understanding the Context and Dynamic
lifetime entered through the educational system. Social Processes of Mental Health Treatment.”
These children, however, were the least likely to In A Handbook for the Study of Mental Health:
receive additional care from other sources, even Social Contexts, Theories, and Systems, Teresa
when controlling for type and severity of diagno- L. Scheid and Tony N. Brown, eds. Cambridge:
sis, a trend that was attributed, in part, to insuf- Cambridge University Press, 2010.
ficiently developed collaborations in community-
based systems of care to meet the diverse needs of
these children.
In the GSMS, the second most common treat-
ment source for those who were 14 years or Psychiatry and
younger included inpatient and outpatient men-
tal health services. These children tended to have Neurology
the most serious diagnoses and to receive services
from additional sources beyond their first con- Knowledge and beliefs regarding neurological and
tact. In contrast, the second most common source mental conditions have been recorded since antiq-
for older adolescents (14 to 16 years old) tended uity. Psychiatry and neurology emerged as spe-
to be the juvenile justice system. cialties in private practice, hospitals, and medical
698 Psychiatry and Neurology

schools in the mid-19th century. Their relation- Neurologists and Psychiatrists in Conflict
ship has been contested since, never entirely sepa- After the U.S. Civil War, Hammond, Mitchell, and
rate, yet never merged. Differing over time and George M. Beard initiated the private practice of
from place to place, their configurations have neurology as an exclusive specialty. Their diag-
been shaped by scientific discoveries, patterns of nostic expertise brought them referrals of patients
medical practice, philosophical considerations, with baffling pains, movement disorders (from
and external factors such as foundation support. paralysis to chorea), and epilepsy. Lacking access
In early 19th-century Europe and the United to large hospital wards, they used these private
States, “madness” and “madhouses” were rei- patients as clinical material. Hammond published
magined as “mental illness” and “insane asy- the first English-language neurology textbook,
lums,” respectively, as physicians increasingly intending to integrate basic and clinical science.
asserted authority over this social domain. Physi- Most of their neurological patients presented
cians assumed that mental disorders were physi- as “nervous.” Beard diagnosed them as neur-
cal illnesses based in the nervous system. How- asthenia (nervous weakness), a physical (not
ever, Anglo-American asylum physicians became mental) disease of the nervous system that was
known mainly for “moral treatment.” “functional” in the physiological sense. Therapy
In Great Britain, the Royal College of Psychia- included physical applications, including electric-
trists was founded in 1841 as the Association of ity, and “moral treatments” such as Mitchell’s
Medical Officers of Asylums and Hospitals for severe “rest cure.”
the Insane, changing its name to the Medico-Psy- New York neurologists and their friends orga-
chological Association in 1865. It was chartered nized themselves in 1872 into the New York
in 1926 and became a royal medical college in Neurological Society and, in 1874, the American
1971. The American Psychiatric Association was Neurological Association. The Boston Medico-
formed in 1844 as the Association of Medical Psychological Society formed in 1880 to study
Superintendents of American Institutions for the the science of “psychiatry and neurology,” and
Insane. It began admitting nonsuperintendents in the Philadelphia Neurological Society followed
1892, reorganized as the American Medico-Psy- in 1883.
chological Association in 1895, and took its pres- Many neurologists saw the study of nervous
ent name in 1921. diseases as key to understanding normal and
Wilhelm Griesinger, German physician and asy- abnormal mental function and even social prob-
lum reformer, taught that all mental illness was dis- lems. The New York Neurological Society and its
ease of the brain, locating psychiatry within medi- members were active in public issues such as asy-
cal science. The Society of German Doctors for lum reform and the case of President James Gar-
the Insane was chartered in 1864 and became the field’s assassin, Charles Guiteau.
German Society for Psychiatry in 1903. Anatomic The main object of the New York neurolo-
and physiological research in mid-19th-century gists’ 1878 asylum-reform campaign was to gain
Europe revealed much about the normal function access to institutions containing potential “clini-
of the nervous system and its disorders. By mid- cal material.” They contrasted their own scientific
century, medical scientists (including the Berlin credentials and aspirations with the managerial
neurologist Moritz Heinrich Romberg) worked to concerns of asylum superintendents, whose 1895
integrate laboratory and clinical research. reorganization was in part a response, undercut-
In 1862, hospital-based neurology developed ting neurologists’ claims to possess the exclusive
in France, with Jean-Martin Charcot at the scientific approach to insanity.
Salpêtrière in Paris; in England, with John Hugh- Exposing themselves to intense scrutiny, how-
lings Jackson at the National Hospital for the Par- ever, neurologists confronted their limited ability
alyzed and Epileptic in London; and, less success- either to define and treat insanity or convince the
fully, in the United States, where Surgeon General public they could. In the mid-1880s, a new gener-
William Alexander Hammond assigned S. Weir ation of neurologists began to step forward who
Mitchell to a Philadelphia U.S. Army hospital for focused more narrowly on organic and functional
injuries and diseases of the nervous system. (nonmental) diseases of the nervous system. In
 Psychiatry and Neurology 699

both Boston and Philadelphia, in contrast, neu- Consolidation of Specialty Differentiation

rology was openly interested in mental pathology In 1925, the Rockefeller Foundation became
into the 20th century. interested in the interface of biology and psychol-
The divergence within neurology is illustrated ogy in relation to medicine and public health.
by a cohort of four physicians—among them Adolf Meyer, consulted by Abraham Flexner, now
Sigmund Freud—who worked in Theodor H. advocated stricter separation between psychiatry
Meynert’s neurological laboratory and psychiat- and neurology, although recommending training
ric clinic in Vienna between 1882 and 1884. Ber- in both fields for those planning to practice either.
nard Sachs and M. Allen Starr became American The General Education Board helped the Har-
Neurological Association presidents. Philosophy vard Medical School establish a small independent
and psychology had led Sachs into medicine; he neurology department at the Boston City Hospi-
adopted Meynert’s view that neurology and psy- tal under Stanley Cobb, who sought to integrate
chiatry should be united, and translated Meynert’s psychiatry (including psychoanalysis) and neurol-
Psychiatrie. Starr set up a neurohistology labora- ogy. However, seeking broader influence, the larg-
tory at home and practiced and taught neurology. est Rockefeller Foundation grants bypassed U.S.
Gabriel Anton’s cerebral palsy work led him to medical schools to fund Emil Kraepelin’s Institute
ally with psychiatrists around eugenics. of Psychiatry in Munich.
Breakthrough work on neurons and synapses In the 1930s, the Rockefeller Foundation
around 1904 promised insight into functional dis- funded a model Department of Neurology and
orders. This, and Freud’s 1907 visit to the United Neurosurgery and a brain-research institute under
States, provoked sharp debates among neurolo- Wilder Penfield at McGill University in Toronto,
gists over whether to embrace private patients Canada, with an affiliated 50-bed hospital. Addi-
with “psychoneuroses” (or “psychasthenia”) or tional funds established a Department of Psychia-
to abandon them to psychiatrists, pursuing neu- try in 1943 under D. Ewen Cameron, who later
ropharmacology and neurosurgery instead. engendered controversy for his work at McGill’s
By 1914, a neurological continuum from “per- Allan Memorial Institute on the CIA MKULTRA
manent damage” to “functional derangement” to project for experimenting on patients without
“mental disorder” was evolving into a dichotomy informed consent and for his broad claims that
between organic versus functional (now meaning psychiatrists should supervise government and
“mental”). Psychiatry was challenged by the rise social institutions. Between 1952 and 1966, Cam-
of psychology and the mental hygiene movement. eron served as president of the Canadian, Ameri-
Some psychiatrists, under pressure to reform their can, and World Psychiatric Associations, the
specialty, chose to embrace eugenics. American Psychopathological Association, and
Wartime conditions united neurologists and the Society of Biological Psychiatry.
psychiatrists in neuropsychiatry as they treated The American Board of Medical Specialties,
shell shock and fought official marginalization. founded in 1933, called the question on the
Adolf Meyer and others promoted this unity after relationship between neurology and psychiatry
the war, an international trend that found the in medical education and hospital practice. The
noted Berlin brain researchers Oskar Vogt and professional organizations vied to institutional-
Cécile Vogt-Mugnier participating in the 1923 ize their respective standards, resulting in a 1935
All-Russian Congress for Psychoneurology. compromise in which neurology and psychiatry
However, postwar reform of medical educa- became distinct specialties regulated by one com-
tion raised the stakes, as young physicians had bined board. The American Board of Neurologi-
to choose among postgraduate training programs cal Surgery followed in 1940.
in psychiatry, neurosurgery, or internal medicine. Most who sought board certification in psy-
Medical school professors vied for funds to estab- chiatry and neurology chose both certificates or
lish full-time teaching and research units. The psychiatry alone. Still, many of those certified
clinical neurology/neuroscience divide grew as only in neurology treated mainly patients diag-
basic medical sciences went on a full-time basis in nosed with psychoneuroses, incipient psychoses,
universities, while clinicians remained part time. or psychoses.
700 Psychiatry and Neuroscience

In the 1930s, Tracy Putnam and H. Houston Scull, Andrew, ed. Madhouses, Mad-Doctors, and
Merritt gave leadership to a new generation of Madmen. Philadelphia: University of Pennsylvania
neurologists by seizing on developments in neuro- Press, 1981.
histology as the key to clinical neurology, show-
ing in the case of epilepsy treated with Dilantin
that psychological and organic pharmaceutical
effects could be differentiated. Their research
helped propel neurology toward the study of dis- Psychiatry and
ease principally as a treatable entity rather than as
a window on normal function. Neuroscience
After World War II, growing numbers of psy-
chiatrists had private practices. Antibiotics trans- Psychiatry is not only a medical specialty devoted
formed neurological wards, emptying them of to treating mentally ill patients, it is also a pos-
cases of tertiary syphilis and bacterial meningitis. sible object of investigation for the social sciences
Medical neurologists became principally consult- and humanities, affording an understanding of
ing specialists, teachers, and researchers, sup- contemporary cultural conceptions of subjectiv-
ported by the new National Institutes and private ity and personhood through the analysis of the
foundations such as the March of Dimes. shifting boundaries between the normal and the
As the 20th century came to an end, psychia- pathological, or between the mind and the brain.
try’s increasingly biological orientation and the Through its application and popularization,
rise of behavioral neurology revived interest in the sum of this knowledge has transformed the
reuniting psychiatry and neurology as neuropsy- moral language used to speak of oneself and of
chiatry. In 1995, Harvard University faculty orga- relationships to others. The genealogical analysis
nized a Neuropsychiatry and Behavioral Neurol- inspired by Michel Foucault, along with Arjun
ogy Service at McLean Hospital to demonstrate Apaduraï’s cultural analysis of “the social life
the practical possibility of integrating the practice of things,” which can also be combined with an
of psychiatrists, neurologists, and neuropsycholo- ethnographical approach, therefore aim to study
gists without infringing on disciplinary autonomy. the course run by psychiatric knowledge as it has
Neurology and psychiatry training and certifi- become established in the social world: from the
cation requirements vary widely among countries, locus of its theoretical and experimental forma-
notably regarding whether neurologists need psy- tion to the consequences of its uses in clinical
chiatric training. The World Psychiatric Associa- practice, the experience of patients, and its place
tion and the World Federation of Neurology are in popular culture.
attempting to standardize their respective spe- This is how the impact of the neurosciences on
cialties, the relationship between which remains psychiatry began to be studied by the social sci-
problematic. ences and humanities, moving progressively away
from the conditioned reflex of the expected yet
Bonnie Ellen Blustein weak criticism of biological reductionism, or the
West Los Angeles College apocalyptic and alarmist diagnoses that habitually
define the rhetoric of naïve technophobia. For this
See Also: American Psychiatric Association; reason, a very precise theoretical angle currently
Eugenics; Freud, Sigmund; Neurasthenia; Shell Shock. informs this research: the success of the “brain” as
a cultural and moral category. On the one hand,
Further Readings neurobiology seems to show the mind as it is: The
Ropper, Allan H. “Two Centuries of Neurology and highly colorful proliferation of brain images sets
Psychiatry in the Journal.” New England Journal in motion the idea that the mind and its workings
of Medicine, v.367/1 (2012). have finally been made transparent. However, a
Rowland, Lewis P. The Legacy of Tracy J. Putnam further step remains to be taken before such bold
and H. Houston Merritt. Oxford: Oxford hypotheses can give rise to real discoveries, with
University Press, 2008. possible applications in daily clinical practice. On
 Psychiatry and Neuroscience 701

the other hand, the rhetoric of progress and of the suspicion of arbitrariness because treatment is
“neurorevolution” harks back to a 19th-century always rooted in the expression of a mental ill-
dream considered finally attainable: the idea that ness, as opposed to in identifying the location of
psychiatry has been provided with the scientific a disease.
grounding that it lacked during its many years While the idea of locating mental illness in the
astray in the realm of psychoanalysis. brain is age-old, the development of instruments
revealing and visualizing how the brain works is
Imaging as Clinical Authority relatively recent, as is the massive investment in
Although the idea of neurology dates back to the this field of research. This has even produced a
17th century and developed particularly in the new way of seeing the brain, which Nikolas Rose
19th century, it was only in 1945 that the first and Joelle M. Abi-Rached call a “neuromolecular
professional association was founded in biologi- gaze.” And this is how, in 1990, President George
cal psychiatry and only in 1962 that the term neu- H. W. Bush was able to herald “the decade of
roscience emerged. At the end of the 1970s in the the brain.” By providing and circulating more
United States, the hegemony of psychoanalysis images of the depressed or schizophrenic brain,
progressively waned in the field of psychiatry, and imaging tools for the neurobiology of the brain
in 1980, the Diagnostic and Statistical Manual (e.g., the positron emission tomography, or PET
of Mental Disorders (DSM) abandoned any etio- scan) have given the impression that they provide
logical theorization of disorders. Nonetheless, the proof of the biological existence of mental illness
absence of diagnostic biomarkers (e.g., a protein) in the brain: the regional abnormalities that act
stains the clinical authority of psychiatry with the as biomarkers.
This is the reason for the shift that Brent Gar-
lant notes in the field of psychiatric expertise.
From an evaluation tool for the victims of trau-
matic brain injury, brain imaging became over a
few short years a tool to reinforce criminology
within a new field of interdisciplinary research
called “neurolaw.” Common understanding
is now imbued with these facts. And it was the
“effective and affective power” of these images,
as visual fact, that anthropologist Joseph Dumit
studied, particularly in the case of depression.
However, beyond this cultural success and some
applications of deep brain stimulation (DBS) and
transcranial magnetic stimulation (TMS) in neu-
rological cases, the scientific results have so far
proven somewhat disappointing. The clinical
reality of psychiatry remains unchanged: diag-
nosis and treatment remain just as empirical and
eclectic.

Respectability as Moral Economy

Based on images of the brain, the sudden value
placed on neurobiology within research policies is
more a sign of the promise of scientific revolution
than of a revolution that is already under way. In
A technician observes brain imagery results from a positron the age of evidence-based policy, where there is
emission tomography scan. Imaging tools for the neurobiology a desire to make informed decisions and reduce
of the brain have given the impression that they provide proof the uncertainties of contemporary political life,
of the biological existence of mental illness in the brain. neurosciences became rapidly included in public
702 Psychiatry and Sexual Orientation

policy because of the forms of external objectivity Littlefield, Melissa and Jenell Johnson, eds. The
that they provide. This discourse, structured by a Neuroscientific Turn: Transdisciplinary in the Age
moral economy of respectability, has given rise to of the Brain. Ann Arbor: University of Michigan
two avenues of hope in psychiatry. Press, 2012.
First, it led to the belief that the scientific Rose, Nikolas and Joelle M. Abi-Rached. Neuro: The
respectability of psychiatry is now within reach. New Brain Sciences and the Management of the
It is a matter of finally including psychiatry in Mind. Princeton, NJ: Princeton University Press,
biomedicine and the clinical neuroscience disci- 2013.
plines in the context of research “from bench to
bedside” that is emphasized by the development
of “translational platforms.” The issue at stake
is returning to an older dream of a perfect and
definitive equivalence between neurology and Psychiatry and
psychiatry, as well as between mental and neu-
rological disorders. Consequently, it is a question Sexual Orientation
of finally making psychiatry scientific in order to
achieve undeniable success in terms of diagnosis Sexual orientation structures important aspects
and treatment. of people’s lives because whether someone is
The second hope, also linked to the slogan “con- attracted to individuals of the same sex, differ-
quer brain disease,” is that of the moral respect- ent sex, or both plays an essential role in sexual
ability of families and patients regarding their and social behavior. The norms governing sexual
disorder. Neurobiology can be used on a moral orientation dramatically vary among different
level as the foundation for an ethics of removing cultural groups, although this may not be fully
responsibility from patients and families. On the recognized by Americans or psychiatrists practic-
one hand, the idea is to reduce stigma, blame, and ing in the United States. The American Psychiatric
the risks of discrimination against people affected Association (APA) has exercised ethnocentrism,
by mental illness by improving the general pub- or privileging of American perceived norms in
lic’s scientific awareness of the matter, but this regard to its diagnosis history with sexual orien-
has not proven conclusive in the evaluations that tation. The APA grants its membership the power
have been carried out. On the other hand, patient to determine whether individuals are experienc-
and family organizations see this as a tool to free ing a diagnosable mental illness, and while the
themselves from the guilt present in systemic and organization reflects social norms, it also influ-
psychoanalytical theories. However, the con- ences them. For this reason, the history of how
cept of the brain’s plasticity, the fact it develops psychiatry has dealt with, and continues to deal
throughout life according to the environmental with, sexual orientation is important.
factors affecting an individual brain, may well Sexual orientation may be understood as physi-
render this social use of biology obsolete. cal attraction to potential sexual partners, but it is
deeper than this for most people because it is also
Samuel Lézé connected to emotional and romantic feelings.
Ecole Normale Superieure de Lyon There may also be cultural, economic, religious,
or other implications, depending on the social
See Also: Anthropology; Biological Psychiatry; environment. Typically, in the contemporary
Mental Illness Defined: Psychiatric Perspectives; United States, people categorize themselves or are
Psychiatry and Neurology. typed by others as heterosexual (attraction to the
opposite sex), bisexual (interest in both men and
Further Readings women), and homosexual (same sex attraction),
Choudhury, Suparna and Jan Slaby, eds. Critical although more recent research demonstrates the
Neuroscience: A Handbook of the Social and fluidity of these categories, and individuals’ abili-
Cultural Contexts of Neuroscience. Chichester, ties to change their orientation as they mature
UK: Wiley-Blackwell, 2012. and their life circumstances alter. However, this
 Psychiatry and Sexual Orientation 703

should not be taken to imply that humans have ways was not yet a politically aware entity. For
the ability to determine their sexual orientation example, during World War II, despite increased
because despite heroic efforts, when individuals military enlistment needs, the U.S. armed forces
truly wish to change, they are seldom able to con- were actively purged of “unfit” soldiers and sail-
sciously achieve this. ors, identified by their sexual orientation.
This type of repression continued into the
History of American Sexual 1950s, despite Dr. Alfred Charles Kinsey’s (1894–
Orientation and Psychiatry 1956) pioneering research. He expanded public
Contemporary Americans are not very open to a understanding of sexuality, with his popular Sex-
homosexual attraction and lifestyle, but in many ual Behavior in the Human Male (1948), and Sex-
other times and places in the world, there has been ual Behavior in the Human Female (1953). His
little stigma attached to lesbian, gay, and bisexual research showed that sexual orientation consisted
(LGB) orientation. When American explorers and of many gradations between socially acceptable
colonists arrived in the New World, they encoun- heterosexuality and socially unacceptable homo-
tered aboriginal people with dissimilar lifestyles sexuality, rather than two separate categories, as
from those practiced in Europe. Many Native was commonly believed. Perhaps even more chal-
American groups had different ideas about gen- lenging for public understanding, his research also
der, recognizing three or four gender roles, and demonstrated that for many men, sexual encoun-
Europeans were occasionally puzzled when dis- ters with other men were not unusual.
covering that someone assumed to be a woman Despite Kinsey’s publications, when the devel-
was a biological male, or vice versa. Indigenous oping APA needed to standardize psychiatric diag-
people also had accepted and honored roles for noses, psychiatrists chose to medicalize homosex-
people practicing nonheterosexual behaviors, uality, and it was included in the Diagnostic and
well documented in early historic records. With Statistical Manual of Mental Disorders (DSM,
time, America became colonized, Native Ameri- 1952). This decision helped to support systemic
cans were confined to reservations, and foreign repression in the United States. For example,
religious instruction ensured some erasure of Executive Order 10450 (1953) expanded the mil-
these early histories. U.S. religious and social itary purge of homosexuals into other branches
orthodoxy guaranteed that heterosexual behavior of government, and public figures such as Senator
became the publicly sanctioned norm, although Joseph Raymond McCarthy (Republican, 1908–
many individuals behaved differently in private, 57) vocally and negatively targeted lesbians and
and there were documented gay subcultures in the homosexuals.
late 1800s and early 1900s. Although some politicians and the APA sup-
While American standardization of social ported homosexual repression, some mental
norms continued, the disciplines of psychiatry health specialists had different ideas. Evelyn
and psychology also became formalized with the Hooker (1907–96), a psychologist, showed that
creation of the APA in 1844 (originally known homosexual research participants were as men-
as the Association of Medical Superintendents of tally healthy as her nonhomosexual sample, for-
American Institutions for the Insane, renamed in mally challenging APA-endorsed stereotypes in
1921) and the founding of the American Psycho- 1957. In addition to professional journal pub-
logical Association (also the APA) approximately lication, these results were also circulated to an
50 years later. These mental health practitioners, increasingly connected homophile population (as
especially psychiatrists, became more influential, the gay and lesbian community called itself at that
with the power to confine those deemed mentally time) through the Mattachine Review, published
ill to asylums. Increasingly, psychiatrists became by the Mattachine Society (founded in 1950), and
involved in policing sexual norms, with concerns The Ladder, published by the Daughters of Bilitis
about homosexual behavior. (created in 1955).
This growing psychiatric attention fueled atten- Despite developing social activism, and Hook-
dant social concern, and both resulted in discrimi- er’s and Kinsey’s research, the 1968 DSM-II also
nation against the LGB community, which in many included homosexuality among its list of mental
704 Psychiatry and Sexual Orientation

illnesses. However, a year later, the Task Force on groups, who sponsored conversion therapy, also
Homosexuality, which had been established by known as reparative or reorientation therapy.
the National Institute of Mental Health in 1967, The goal of these unorthodox treatments was to
issued its final report, opposing the APA decision. create heterosexuals, using a variety of therapeu-
Evelyn Hooker, the chair of the task force, and the tic techniques, none of them successful. Instead,
other members recommended that homosexual- many program enrollees experienced harm, and
ity receive recognition as a normal form of sexual both the American Psychological Association (in
expression. This report was suppressed by Presi- 1997) and the American Psychiatric Association
dent Richard Milhous Nixon’s (1913–94) admin- (in 2000) passed resolutions against these inap-
istration, although once again, the final report propriate therapies.
was distributed through dissenting networks. In While the nonheterosexual community receives
the same year, the Stonewall Riots in New York no benefit from conversion therapy, other treat-
City further motivated gay and lesbian activism. ment programs are valuable for this group
Based on political activism and ongoing sci- because people often need assistance in dealing
entific research, the APA finally removed homo- with negative stereotypes and discriminatory acts
sexuality from its list of mental illnesses with that may adversely affect mental well-being. For
publication of the DSM-III in 1980. This allowed example, many gay youth encounter homopho-
many psychiatrists to be more open about their bia and violence in their families, schools, and
personal sexual orientation and also encouraged communities, resulting in stress, depression, and
social change. risky behavior such as alcohol consumption,
drug use, and unsafe sexual practices. Some-
Post-DSM-III Sexual Orientation times, these issues result in suicide. To assist
The APA and other legal and political entities adolescents, many schools have LGB community
shifted their positions about sexual orientation in support groups, and this is also the case at col-
tandem. For example, in 1982, Wisconsin was the leges. As these students develop confidence, some
first state to outlaw discrimination on the basis take on activist roles at their educational insti-
of sexual orientation. Other states followed, and tutions and also in their communities. Similar
11 years later, the national “don’t ask, don’t tell” desire for social change may also encourage LGB
policy lifted the ban on gay people in the military, individuals to enroll in psychiatry, psychology,
although still restricting their behavior, until its and other health programs to improve mental
repeal in 2011. health outreach to community members and to
While the military has now relaxed its prohibi- revolutionize these disciplines. The current field
tions, the new battleground is same-sex marriage, of psychiatry and the APA are far more conscious
with many states still upholding the Defense of of LGB rights and the need to decrease prejudice
Marriage Act, endorsing marriage of one man to and discrimination against this community than
one woman. The lesbian and gay community is at any time in the past.
small, estimated to number 2 to 6 percent of the
adult American population, so it is unlikely to Susan J. Wurtzburg
encourage change alone, despite powerful allies. Jamie L. Owens
However, this situation will almost certainly alter University of Hawai‘i, Manoa
with time, even if the Supreme Court does not
invalidate the act, because research demonstrates See Also: Adolescence; Gender; Marital Status; Sex;
that young American people are far more support- Sex Differences; Sexual Surgery.
ive of gay and lesbian rights than their parents.
Young people are also more likely to envisage Further Readings
sexuality as a continuum and are more tolerant American Psychiatric Association (APA). Diagnostic
of the fact that its expression is often quite fluid and Statistical Manual of Mental Disorders.
through an individual’s lifetime. Washington, DC: APA, 1952.
This fluidity has been exploited by psychologists Kidd, Sean A., Albina Veltman, Cole Gately, Jacky
and psychiatrists linked to conservative religious Chan, and Jacqueline N. Cohen. “Lesbian, Gay,
 Psychoanalysis, History and Sociology of 705

and Transgender Persons With Severe Mental The theory behind mesmerism was that the move-
Illness: Negotiating Wellness in the Context of ment of the planets, as well as other mysterious
Multiple Sources of Stigma.” American Journal of forces such as magnets and electricity, could cure
Psychiatric Rehabilitation, v.14 (2011). everything from mild ailments to serious disease.
Valelly, Richard M. “LGBT Politics and American Treatments would often cause patients to fall
Political Development.” Annual Review of Political into trance state, leading to the use of the term
Science, v.15 (2012). mesmerized.
Mesmer’s methods were not accepted by many
medical practitioners of his time, and he demon-
strated his treatments in popular venues, gain-
ing a large following that included members of
Psychoanalysis, History the French royal family. When treating patients
in large groups, Mesmer would use a baquet, a
and Sociology of device with various protuberances that allowed
everyone in a room to make contact with it and
Psychoanalysis is a theory of behavior and mental through which healing forces were channeled.
processes that focuses on the role of the uncon- Mesmerism spread to England through Mesmer’s
scious. The term psychoanalysis is also used to follower, John Elliotson (1791–1868), before its
refer to the practice of psychotherapeutic inter- popularity waned. Mesmerism was successfully
vention in a clinical setting. Sigmund Freud employed to calm patients undergoing surgery.
(1856–1939) is the founder of psychoanalysis. James Braid (1795–1860) used the term hyp-
Throughout its history, the study and practice of notism to describe the deep, sleep-like state often
psychoanalysis has developed into a range of dif- experienced by patients undergoing treatment by
ferent schools, including ego psychology, object a mesmerist. Braid rejected the influence of mag-
relations, relational psychoanalysis, and self-psy- nets and believed that the trance state was from
chology. suggestion and focused attention under the direc-
Psychoanalysis takes into account interper- tion of a practitioner. In Paris, French neurolo-
sonal, social, cultural, environmental, physical, gist Jean-Martin Charcot (1825–93) employed
and psychological influences on the trajectory hypnosis to treat patients in the large Salpêtrière
of human development. A major contribution of teaching hospital, treating patients diagnosed
psychoanalysis is its focus on the importance of with hysteria, a disease marked by unexplained
sexual drives and experiences in the development physical symptoms with no apparent underlying
of unconscious conflict. Psychoanalysis generally medical cause.
places mental health into the context of a contin- While mesmerism and hypnotism developed
uum, so that mental illness is seen as an expression in Europe, the spiritualist movement was devel-
of fears, desires, drives, and conflicts that are also oping steam in America. In 1848, in Hydesville,
present in mental illness and in mentally healthy New York, the Fox sisters, Maggie and Kate,
individuals. Psychoanalysis has made important reported hearing mysterious noises in the night.
contributions to psychology, psychiatry, philoso- The young sisters interpreted the noises as “spirit
phy, sociology, feminist studies, science studies, rappings,” coded messages from a murdered
medicine, and popular culture. peddler seeking to communicate from beyond
The medical and spiritual interventions of mes- the grave. Maggie and Kate became celebrities of
merism, hypnotism, and spiritualism are impor- the new movement and performed some of the
tant to the development of psychoanalysis in large first public exhibitions of spirit communication
part for the way in which they drew connections as “mediums,” reporting contact with the spirit
between the mind and the body, taking mental world, including celebrated historical figures, in
phenomena as objects suitable for measurement, front of audiences. Popular interest in spirit con-
research, and treatment. tact and spirit realms, and the related phenomena
Physician Franz-Anton Mesmer (1734–1815) of hypnotism and trance states, grew throughout
developed mesmerism in France in the 1760s. the next half century.
706 Psychoanalysis, History and Sociology of

Sigmund Freud and the Origins definable universe. Psychoanalysis is one reac-
of Psychoanalysis tion to the scientific theories of the day, providing
In 1885, Sigmund Freud trained in Paris with objective measures and structures for the subjec-
Charcot, observing hysterical patients. Freud was tive processes of the human mind.
already familiar with hysteria, having trained In 1900, Freud published The Interpretation
with Theodor Meynert (1833–92) at the Vienna of Dreams, describing a method of dream inter-
General Hospital. He encountered a particularly pretation that focused on what dream symbols
startling case of hysteria through the work of could reveal about conflicts and desires in every-
his colleague, Josef Breuer (1859–1936). Breuer day life. Freud argued that all dreams provide
worked with Anna O., a young woman who a form of wish fulfillment. Central aspects of
experienced unexplained physical symptoms, dream analysis were condensation and displace-
including involuntary movement of her limbs, ment. In condensation, a single dream symbol or
fatigue, and spontaneous mutism. Breuer found set of symbols might stand for a broad range of
that allowing Anna to speak about her thoughts issues. Displacement referred to the way in which
under hypnosis helped to alleviate the symptoms, dreams appear to oscillate around trivial con-
and that uncovering the events surrounding the cerns that work to conceal more important latent
earliest appearance of the symptoms could do dream elements.
away with them entirely. Anna referred to this Freud considered The Interpretation of
process as “chimney sweeping.“ Dreams the most important of his works and said
Freud employed the same techniques with his that dreams are the “royal road” to the uncon-
hysterical patients and was encouraged by the scious. Interpretation of Dreams is important
results. He developed Breuer’s method of allowing from a cultural perspective because it incorpo-
Anna to talk freely into the practice of “free asso- rates a wide range of dream symbols and expla-
ciation,” encouraging his patients to say whatever nations, indicating how the specific context of
came to mind. If patients appeared unwilling or an individual’s daily life affects the expression of
unable to recall early memories surrounding their their unconscious conflicts and desires. Carl Jung
symptoms, Freud would press on their forehead (1875–1961), a psychiatrist who worked closely
while they were under hypnosis, telling them that with Freud prior to their falling out, would later
when he released the pressure of his hand, they emphasize the role of a collective unconscious,
would remember the events he was asking about. drawing on archetypal images and icons as seen
Later, Freud altered his method so that this pres- in dreams. According to Jung, the collective
sure and even hypnosis were not always neces- unconscious plays a role in the development and
sary. Unlike Breuer, Freud emphasized the rela- transmission of cultural artifacts and myths and
tionship between doctor and patient, alongside helps to explain unconscious influences shared
the cathartic effect of recalling the events precipi- between individuals linked by community, cul-
tating symptoms. ture, religion, and shared biological origins.
Historian George Makari has critiqued the use In 1896, Freud delivered a paper to the Vienna
of Freud as the central figure to which the genesis Society of Psychiatry and Neurology called “The
of psychoanalysis is traced by practitioners and Aetiology of Hysteria,“ in which he described his
theorists alike. Makari points out that Freud’s work with 18 hysterical patients, 12 women and
followers and detractors share a focus on Freud six men. Freud reported that he had uncovered
as the central figure in the discipline. He argues evidence of childhood sexual abuse by a parent or
that the cultural context of 19th-century Europe caregiver in the personal histories of each of these
gave rise to the conditions that made a science of patients. He suggested that this early experience
the unconscious mind possible and identifies the acted as a “presexual shock,” causing his patients
most important years for the development of psy- to display neurotic symptoms later in life. Many
choanalysis historically as 1870 to 1945. Makari of the patients did not report any memories of the
argues that the dominance of Newtonian phys- abuse until Freud uncovered them during treat-
ics and Darwinian evolutionary theory demanded ment. Freud’s paper was controversial. He was
an increasingly mechanistic and scientifically accused of overstating the problem, and perhaps
 Psychoanalysis, History and Sociology of 707

to sexual desires experienced in childhood, such

as masturbation. Critics of Freud have suggested
that Freud revised his theory in response to public
censure, obscuring real incidents of abuse. How-
ever, other scholars have defended Freud, not-
ing that he constantly revised his theories as he
learned from patients and considered the limits of
existing theories.
Psychoanalysis underwent many changes dur-
ing its development, but the role of the uncon-
scious and the primacy of sexual life in uncon-
scious conflict were always at the center of Freud’s
theory. Over time, Freud found that the “talking
cure” had limits, with symptoms that appeared
to have been eradicated reappearing, sometimes
in altered and exaggerated forms. He proposed
his topographical model, comprised of the uncon-
scious—the site of hidden memories and desires,
and the genesis of the strange symptoms of hys-
teria and images of dreams—as well as conscious
and preconscious content. Freud observed that
his patients did not appear to have any awareness
of the many defenses that they employed to avoid
confronting troubling memories.
Freud proposed the structural model, yet again
revising his system to account for the extent to
which unconscious conflict affected everyday
life. The structural model does not involve literal
structures within the mind. Rather, it describes
an integrated structure of mental contents that
influence one another. They are the ego, the id,
and the superego. In 1923’s The Ego and the Id,
Freud describes the relation between these struc-
tures. The largely conscious ego involves the
control exhibited in everyday life, managing the
unchecked impulses, drives, and desires of the id.
The superego is comprised of moral and societal
In the large Salpêtrière teaching hospital in Paris in the late values and mores, including the influence of par-
1800s, Jean-Martin Charcot employed hypnosis to treat patients ents and caregivers, and is the origin of self-cen-
diagnosed with hysteria and other abnormal mental conditions. soring behaviors and guilt.
He had a profound influence on Sigmund Freud. Freud described the interaction of these struc-
tures in early childhood in his development of the
Oedipus complex. He hypothesized that children
experienced sexual desires for the opposite-sex
eliciting reports of seduction in his patients parent, wishing to displace the same-sex parent
through improper suggestion. in their affections. Forced to resolve this con-
Freud later revised his seduction theory. In flict because of societal norms and the need for
1905, he published Three Essays on the Theory belonging within the family unit, the child trans-
of Sexuality, in which he suggested that memories fers their affections to the same-sex parent, desir-
of sexual abuse might actually be fantasies related ing a relationship both to avoid persecution for
708 Psychoanalysis, History and Sociology of

their id-centered drives and to overcome guilt traditions beyond Freudian “ego psychology” are
generated by the superego. The Oedipus complex referred to as psychoanalytic schools.
is named for the Greco-Roman myth of Oedipus, Many of these schools are associated with the
an orphan who ended up killing his father and figures who founded them. For example, the work
marrying his mother. Freud pointed to the long of Melanie Klein (1882–1960), who emphasized
history of versions of this myth as evidence of the the volatile nature of infantile experience, is often
universal nature of the childhood conflict of the referred to as Kleinian analysis. Klein is also asso-
“family romance.” ciated with the object relations school of psycho-
Psychoanalysis continued to develop through- analysis, in which “object” refers to people in
out the early 20th century. In 1909, Freud trav- the physical and psychological life of individuals.
eled to American to give a series of lectures at Klein argued that a central task of development
Clark University at the invitation of G. Stanley was developing a sense of objects that could be
Hall (1844–1924). The journey was difficult both good and bad, loving and hating. Other
for Freud, but it marked the beginning of the notable figures associated with the object relations
rapid growth of psychoanalysis in America. The school include Donald Winnicott (1896–1971),
American Psychoanalytic Association (APA) was Sánder Ferenczi (1873–1933), Ronald Fairbairn
founded in 1911. Freud was accompanied on the (1889–1964), and Otto Rank (1884–1939).
trip by Carl Jung. Freud spoke of Jung being his Lacanian psychoanalysis is a school of psy-
successor at the head of psychoanalysis. How- choanalytic theory associated with Jacques
ever, the two would later have a falling out, partly Lacan (1901–81). Lacanian psychoanalysis
because of Jung’s interest in parapsychology. focuses on the role of language in psychoana-
Following World War I, Freud and other analysts lytic theory, emphasizing linguistic patterns and
were faced with patients suffering from shell shock meanings between the patient and analyst and
and other war-related traumas. Freud acknowl- within everyday life. A well-known component
edged that the anxiety dreams characteristic of of Lacanian accounts of development is the “mir-
these disorders appeared to disprove his theory of ror stage,” where children’s ability to recognize
dreams as wish fulfillment. Freud posited the exis- themselves in the mirror marks their movement
tence of a “death drive” that caused individuals to from an imaginary and fantastical relationship
seek earlier life states, to the point of destruction. with the world to a sense of a world outside the
This drive, balanced by the life instinct, influenced self. Experimental psychological studies have
traumatized patients so that they were not able to shown that this ability to recognize oneself in
maintain any kind of balance. the mirror is consistent across many cultures,
Theorists have used psychoanalytic theories of although children from some cultures that do not
trauma to explain the experiences of survivors of emphasize individuality may not appear to rec-
large-scale traumas such as the Holocaust, the ognize themselves in the mirror or may react dif-
Vietnam War, 9/11, and natural disasters. Psycho- ferently to their reflection. Experiments have also
analytic approaches emphasize the ways in which shown that certain animals, including primates
trauma may be inaccessible to the conscious and elephants, show an ability to recognize them-
mind. Psychoanalytic approaches emphasize selves in the mirror, although it is impossible to
both the universal nature of trauma—involving know whether this is evidence of other forms of
unconscious conflict—and the culturally and his- psychodynamics.
torically specific ways in which trauma manifests Other schools of psychoanalysis include rela-
in the psychological, personal, and interpersonal tional psychoanalysis, self-psychology, and the
health of individuals. psychoanalytic study of attachment. Across the
different schools of psychoanalysis, training at a
Psychoanalytic Schools psychoanalytic institute is required of individuals
As increasingly more people practiced psycho- wishing to practice psychoanalysis. Trainees are
analysis, different methods for interacting with required to learn about psychoanalytic concepts,
patients and different theories concerning the to complete a personal analysis called a “training
workings of the mind proliferated. Psychoanalytic analysis,” and to analyze their patients.
 Psychoanalysis and Literary Theory 709

Psychoanalysis and Culture Freud’s stages of psychosexual development—

Psychoanalysis is both a theory of mind and a oral, anal, phallic, latent, and genital—are
therapeutic intervention. Freud believed that recalled as descriptive markers based on char-
analysis could help patients to deal with psy- acteristic behaviors associated with these stages.
chic conflict and lead fuller lives. Additionally, Movies and books are more likely to depict ana-
he believed that psychoanalytic theory could be lytic sessions than any other kind of mental health
applied more broadly to cultural productions, treatment. Persistent apocryphal stories associ-
social movements, art, philosophy, literature, and ated with Freud include the quote “sometimes a
politics. Freud frequently wrote on aesthetics, cigar is just a cigar,” supposedly spoken by Freud
analyzing the work of artists such as Michelan- to describe the limits of psychoanalytic analysis
gelo and Shakespeare, as well as popular artists and his alleged likening of the mind to an iceberg,
of his day, such as the German author E. T. A. with the bulk of its contents “underwater.”
Hoffman. Freud made several comments suggest-
ing that the work of poets prefigured the work Kira Walsh
of psychoanalysis. He wrote that jokes contained Emory University
much of the same condensed content of dreams,
providing a socially acceptable avenue for the See Also: Freud, Sigmund; Hypnosis; Hysteria;
release of tension. Psychoanalytic Treatment; Trauma, Psychology of.
In Civilization and Its Discontents and The
Future of an Illusion, some of Freud’s later writ- Further Readings
ings, he expanded on the role of society in the Ellenberger, Henri F. The Discovery of Psychoanalysis:
development of the ego and the superego. He pos- The History and Evolution of Dynamic Psychiatry.
ited that individuals are driven by both a “plea- New York: Basic Books, 1970.
sure principle” and a “reality principle,” driven Laplanche, J., J. B. Pontalis, and Donald Nicholson-
by the id to seek their desires without thought to Smith, trans. The Language of Psycho-Analysis.
anything else, but subject to the reality of need- New York: Norton, 1967.
ing to live and function within family and society Makari, George. Revolution in Mind: The Creation of
throughout development. Psychoanalysis. New York: HarperCollins, 2008.
Today, psychoanalytic treatment for psycho- McWilliams, Nancy. Psychoanalytic Diagnosis:
logical distress is not as common as it was in Understanding Personality Structure in the Clinical
the late 20th century. Analysis is unique among Process. New York: Guilford Press, 1994.
many more recent mental health interventions Mitchell, Stephen A. and Margaret J. Black. Freud
in requiring a large time commitment. Multiple and Beyond: A History of Modern Psychoanalytic
sessions per week for several years are required Thought. New York: Basic Books, 1995.
to “complete” an analysis. In the United States,
analysis has in many cases been excluded from
health coverage because of the availability of
less-expensive and time-consuming treatments
and psychopharmacological drugs. In countries Psychoanalysis and
such as France and Argentina, psychoanalysis has
maintained its popularity as a treatment, partly Literary Theory
because of infrastructure to support the cost and
the time commitment. Analysis is also sometimes Psychoanalysis is seen by some as a type of literary
more accessible in countries with socialized medi- theory, or even its archetype. The theory of psy-
cine. Recently, there has been increased interest choanalysis, as developed by Sigmund Freud in
in analytic therapy in China because of the grow- fin-de-siècle Vienna, constituted a form of textual
ing middle class and related demands on mental interpretation of signs, symbols, and signifiers.
health infrastructure. And Freud specifically treats the interpretation of
Psychoanalytic ideas permeate many aspects texts (Sophocles’s Oedipus Rex and Shakespeare’s
of life outside the treatment room. Colloquially, Hamlet) within his groundbreaking 1899 text,
710 Psychoanalysis and Literary Theory

The Interpretation of Dreams. His student Carl which would motivate a child to sexually possess
Gustav Jung’s psychoanalytic thought formed the his or her mother and kill his or her father. Shake-
basis of the tradition that would become known speare’s Hamlet played an explicit role in Freud’s
as archetypal literary theory and criticism. Joseph explanation of the Oedipus complex and repre-
Conrad’s 1899 novella Heart of Darkness served sented one of psychoanalysis’s paradigm cases for
as a wellspring for the application of such Jung- the discipline of modern psychology.
ian psychoanalytic literary theories of the arche- From the psychoanalytic theories of Freud,
type. In addition to archetypes, Jungian literary Carl Gustav Jung developed the intellectual niche
theory employed notions of symbols and the sym- of archetypal literary criticism. The unconscious
bolic. In France, psychoanalytic theorist Jacques for Jung was an inaccessible part of the mind, and
Lacan conducted a well-documented seminar that he developed notions of both the personal and
focused on a close reading of Edgar Allen Poe’s collective unconscious. The implications for psy-
short story The Purloined Letter. choanalytic literary theory were that archetypes
Like Jung, the symbolic was a key theme transmitted through the collective unconscious
in Lacan’s psychoanalytic theories, although involved the conveyance of both symbols and
Lacanian theories of the literary represented a myths that held particular and general meanings
departure from the Jungian analysis popular to the personal and collective, respectively. Jung-
in the era that preceded it, marking a return to ian psychoanalytic readings were especially per-
Freud’s original theories of the mind. In another vasive in the underlying themes of Joseph Con-
of Lacan’s well-attended seminars, “The Ethics rad’s Heart of Darkness (1899).
of Psychoanalysis,” the psychoanalytic theorist
gave an influential reading of Sophocles’s Anti- Lacan and Žižek
gone, which was further developed in the work In Jacques Lacan’s reading of Edgar Allen Poe’s
of contemporary cultural critic Slavoj Žižek. The The Purloined Letter, a notion of the signifying
Lacanian psychoanalytic theory of jouissance, chain was developed, grounded in semiotic theory
or pleasure, was developed in this seminar and and representative of his intellectual era. In general,
was also influential in Žižek’s psychoanalytic the psychoanalytic theories of Lacan represented a
theories of literature, in the contexts of grander departure from notions of the symbolic in Jung-
social and political narratives most commonly ian psychoanalysis and a return to, and engage-
associated with the tradition of critical theory. ment with, Freud’s original theories of the mind.
Philosophers Gilles Deleuze and Félix Guattari’s Lacan was a major figure in the history of intel-
literary theory collaborations in their two vol- lectual thought known as French structuralism/
umes of Capitalism and Schizophrenia, as well poststructuralism, and his contributions to these
as in a work of scholarship dedicated to a read- fields represent the psychoanalytic consequences of
ing of Franz Kafka’s literary thought, signified fragmenting the text, most notably in a poststruc-
the limits of traditional psychoanalytic theories turalist tradition of psychoanalytic literary studies.
and synthesized earlier forms of such a literary French cultural theorist Roland Barthes applied
theory with what was at the time a new genera- textual strategies similar to that of Lacan’s and
tion of critical theory. developed an entire corpus of literary theory from
the themes presupposed by them, streamlining his
Freud and Jung intellectual thought with the Lacanian-coined psy-
In The Interpretation of Dreams (1899), Sigmund choanalytic concept of jouissance and employing it
Freud gave influential readings of Sophocles’s Oedi- in the literary theory scholarship of his short book,
pus Rex and Shakespeare’s Hamlet. The readings The Pleasure of the Text (1973).
were intended to outline the organization of the Lacan’s poststructuralist theories of a frag-
unconscious mind. Freud’s reading of Sophocles’s mented self are applied to the understanding and
Oedipus Rex highlighted what he coined “the meaning of literary texts in a diagnostic sense,
Oedipus complex,” intended to denote the emo- one that links rather than separates literary mean-
tions and ideas that the mind held unconsciously ing. In the narcissism of the individual, psychosis
in the form of dynamically repressed thought, is intended to represent a self that is subsumed
 Psychoanalysis and Popular Culture 711

by the unconscious and its desires and impulsive Further Readings

drives in the classic Freudian definition of the term Deleuze, Gilles and Felix Guattari. Anti-Oedipus:
psychosis. Lacan witnessed linguistic discoveries Capitalism and Schizophrenia. Minneapolis:
in his career of psychoanalytic theory construc- University of Minnesota Press, 1983 [1972].
tion that were not available to Freud’s in his era, Harland, Richard. Literary Theory From Plato to
most notably the posthumously published schol- Barthes: An Introductory History. New York: St.
arship of Swiss structural linguistic Ferdinand de Martin’s Press, 1999.
Saussure. Representing an emergent generation Waugh, Patricia, ed. Literary Theory and Criticism:
of psychoanalytic structuralism/poststructuralism An Oxford Guide. New York: Oxford University
in France, Lacan employed such an approach to Press, 2006.
linguistics in his denoting that the unconscious is
structured like a language.
Žižek appropriated Lacan’s reading of Sopho-
cles’s Antigone given in his 1959 seminar titled
The Ethics of Psychoanalysis. In the seminar, Psychoanalysis and
Lacan developed his well-known and psychoana-
lytic theory of jouissance with the sexual conno- Popular Culture
tation of the term (stemming from the orgasmic)
lost in translation with the usage of the English Although they are often considered separately,
term enjoyment. Such concept forms a basis of there are two possible relationships between psy-
Žižek readings of Lacan’s formulas of sexuation choanalysis and popular culture and the media.
and is where he develops his philosophical stance On the one hand, psychoanalysis is a critical the-
on Lacanian psychoanalytic literary theory and ory that contributes to cultural studies by apply-
criticism, both in the context of contemporary ing a specific grid of interpretation to cultural
cultural studies and social and political thought. objects, from paintings to advertisements and
films. On the other hand, the cultural authority of
Deleuze and Guattari psychoanalysis is built through its popularization
Gilles Deleuze and Félix Guattari collaborated on in mass culture—in a positive form with Freud-
the two-volume Capitalism and Schizophrenia. ism, and in its opposing, but reciprocal form with
Guattari’s concept of “schizoanalysis” presup- anti-Freudism.
poses Freud’s original Oedipus complex in clini-
cal settings and then deviates from the presuppo- Beyond Clinical Practice
sition on grounds of the authoritarianism of the The application of psychoanalysis to art, litera-
psychoanalyst in favor of the subjected patient. ture, and popular culture is a movement that is
The subversive concept was originally developed inherent to the development of the science of the
by G. Deleuze and F. Guattari in their first vol- unconscious, as conceived by Sigmund Freud. This
ume of Capitalism and Schizophrenia, titled Anti- movement goes far beyond clinical practice, even
Oedipus (1972). The second volume, A Thousand though Freud constantly illustrated his approach
Plateaus (1980), involved Deleuze and Guattari’s through the pathography (or medical biography)
poststructuralist approaches to interpreting liter- of famous artists such as Leonardo da Vinci and
ary texts such as novellas and continued the theme Fyodor Dostoyevsky. The aim was to study the
of “schizoanalysis,” for which they had gained a creative process, in other words, the link that
reputation in cultural and literary theory. existed between the creator’s affectivity and his or
her creative aesthetics. As well as these limited case
Dustin Bradley Garlitz studies, which were strongly criticized by special-
University of South Florida ists in art history, Freud also used psychoanalysis
as a tool for the cultural critique of war, religion,
See Also: Critical Theory; Freud, Sigmund; Jung, and the discontents of civilization. This more gen-
Carl Gustav; Lacan, Jacques; Psychoanalysis, History eral expansion of psychoanalytic theory accounts
and Sociology of. for its subsequent integration into cultural studies.
712 Psychoanalysis and the Social Sciences

In this field, psychoanalysis is used today in an of its conflicts of interest. By attempting to tarnish
attempt to reveal the emotional, imaginary, and or reverse the image of psychoanalysis and Freud
symbolic aspects of cultural objects such as films, in popular culture, anti-Freudism shows the rela-
novels, magazines, and advertisements. Gender tionship between psychoanalysis and culture.
relations offer a classic and paradigmatic example
of this approach, developed by feminist research- Samuel Lézé
ers. Studies in this tradition try to show, for exam- École Normale Superieure de Lyon
ple, how the image of women in the cinema is
constructed through the male gaze. The aim is See Also: Art and Artists; Creativity; Freud,
to reveal and denounce the impact of patriarchal Sigmund; Mass Media.
society’s unconscious and of its cultural author-
ity, which makes women into objects of desire, Further Readings
in the very content and narrative structure of Bainbridge, C. Radstone, M. S. Rustin, and C. Yates,
films, which become a means for reproducing the eds. Culture and the Unconscious. Basingstoke,
dominant ideology regarding the social relations UK: Palgrave Macmillan, 2007.
between the sexes. Roth, Michael. Freud: Conflict and Culture. New
The dissemination of psychoanalysis and the York: Knopf, 1998.
construction of its cultural authority depend upon Voela, Angie. “In the Name of the Father—or
the popularization of its theory of the unconscious Not: Individual and Society in Popular Culture,
and its impact on popular culture. From the very Deleuzian Theory and Lacanian Psychoanalysis.”
early stages, this inspired cultural productions Psychoanalysis, Culture & Society (2011).
(e.g., theater, literature, cinema, and comic book Winter, Sarah. Freud and the Institution of
series) that sometimes included either the figure of Psychoanalytic Knowledge. Palo Alto, CA:
the psychoanalyst, or even Freud himself, with his Stanford University Press, 1999.
couch and his cigar as cultural icons. The HBO
drama In Treatment is a recent example of this
phenomenon (2008–11). Moreover, psychoanal-
ysis has more generally transformed the moral
language used to speak of ourselves and our rela- Psychoanalysis and
tionships to others, making the great majority of
people aware of the “secrets” of demonstrations the Social Sciences
of the unconscious, such as slips of the tongue,
the Oedipus complex, and phallic symbols. The The contribution of psychoanalysis to the social sci-
radio and magazines have been important means ences is threefold. It has encouraged the emergence
for the dissemination of this language, around of interdisciplinary research with fields such as his-
media figures such as Donald Winnicott in the tory and anthropology, introduced new theoretical
United Kingdom and Françoise Dolto in France, issues (e.g., the question of subjectivity, sexuality,
who both addressed questions of education. and emotions), and contributed to the develop-
This popularization involves substantial distor- ment of important social theories such as structur-
tions of the theory. Certain psychoanalysts even alism, the Frankfurt school’s critical theory, and
consider this generalized fascination to be a sophis- postmodernism, which gives an important role to
ticated form of resistance to psychoanalysis and analyzing the symbolic. Conversely, the contribu-
therefore suspect. Nonetheless, culture at-large is tion made by the social sciences to psychoanalysis
the locus for evaluating the legacy of psychoanaly- is often ignored or minimized. Psychoanalysts now
sis today. The very existence of the “Freud Wars” pay little if no attention to this reciprocal influence.
in the United States in the 1990s and in France at Yet, both Sigmund Freud and Jacques Lacan were
the turn of the 21st century, taking as their tar- inspired by the social theories of their time, such
get the cultural icon now represented by Freud, is as social evolutionism and structuralism. In both
particularly revelatory of the ambivalent role that cases, the element encouraged not only dialogue,
Freudism still plays today in popular culture and but also misunderstanding.
 Psychoanalysis and the Social Sciences 713

Sigmund Freud and Jacques Lacan The contribution of psychoanalysis is essential

The writings of Sigmund Freud and Jacques Lacan to understanding the dynamics between individual
reveal constant references to the historians and and society and therefore to considering schools
anthropologists of their time. First, in founding his of thought such as culture and personality, fol-
theories on the prohibition of incest or the murder lowing Franz Boas, who had attended Freud’s
of the father, Freud borrowed from works by social famous lectures at Clark University in 1909, and
evolutionists such as Lewis H. Morgan and Sir the intellectual figures of the Frankfurt school,
James Frazer. The claim about the universal nature who constructed the Marx-Freud couple. This
of the Oedipus complex depended upon these continues to be the case today in the example of
sources. Freud then imported anthropological con- Axel Honneth’s theory of social pathologies. On a
cepts, such as ambivalence or taboo, in order to more subtle level, the theme of subjectivity, which
enrich his theory of neuroses, in which he postu- is central in today’s theoretical debates, initially
lated the equivalence between child, savage, and entered the social sciences on a methodological
neurotic. Finally, he contributed to the cultural crit- level with the works of Norbert Elias, Georges
icism of his time by denouncing religion and war, Devereux, and Jeanne Favret-Saada, according to
and by formulating a diagnosis of civilization and whom affects play a role in producing knowledge
its discontents. This last point is often underplayed in the social sciences.
but is of paramount importance to understanding
the very institutionalization of psychoanalysis and Misunderstandings
its cultural authority in France and in the United This interdisciplinary crossover and the impres-
States, particularly during the 1960s. sion of speaking the same language or addressing
These three aspects can also be found in the the same theoretical problems have led to many
work of Jacques Lacan in France. His intellectual profound misunderstandings. In part because of
rise can only be understood within the framework this, researchers in the social sciences have been
of the intellectual debates that were taking place in highly critical of psychoanalysis’ claims at for-
the social sciences and humanities during his time. mulating a general social theory. Anthropolo-
His initial writings on the decline of the father gists such as Branislaw Malinowski and Marga-
and his theory of the superego, between 1938 and ret Mead attempted to relativize the theory of
1953, were marked by his readings of sociologist the Oedipus complex on the basis of research on
Émile Durkheim and the latter’s conception of the kinship, even if they did accept the legitimacy of
family. His “Rome Speech” (1953) was a turning the debate with Freud or psychoanalysts in other
point in his work, and henceforth Claude Lévi- respects. More generally, one should be wary of
Strauss’s structural anthropology was a determin- what may be only superficial agreements. While
ing influence. His effort to provide a new reading Claude Lévi-Strauss and Pierre Bourdieu may fre-
of the basics of psychoanalysis, which he referred quently use the word unconscious, the concept is
to as a “return to Freud,” led him to bring in a not understood in a Freudian way.
new language that gave precedence to the sym- In the name of biology, the former is harsh in
bolic over the imaginary and the real. his criticism of the reductionism, pansexualism,
The concepts of psychoanalysis were easily dis- and mythological dimension of Freudian psycho-
seminated among the first generation of American analysis. The latter is even more ambiguous and
sociologists. However, the antipsychologism of refers more often than not to the analysis of his-
the French school of sociology centered on social torical elements that remain untheorized. Thus, in
facts and rejected what appeared as mass psychol- the postwar intellectual language that was heavily
ogy centered on collectives. Mainly in an applied tinged with Marxism, psychoanalysis was some-
form, which often took the shape of a defense times a tool for critical unveiling—understand-
and illustration of Freud’s works, psychoanalysis ing social determinisms was considered to be a
found a certain echo in the margins of the major way of escaping them. Yet, this definition could
disciplines by developing hybrid forms such as easily enter into conflict with Freudian theory,
psychohistory, psychoanalytical anthropology, which social, feminist, and homosexual move-
and ethnopsychoanalysis. ments might view as not as subversive or radical
714 Psychoanalytic Treatment

as might be surmised from its position within the Western notions of the psyche and self and left
same intellectual field. an indelible mark on the practice of talk therapy.
While psychoanalysis is no longer prominent
Samuel Lézé in American psychiatry—psychoanalytic treat-
École Normale Superieure de Lyon ment is more common today in Europe—it is
still crucial to psychologists’ and social workers’
See Also: Freud, Sigmund; Lacan, Jacques; treatment approaches. Previously, few institutes
Psychoanalysis, History and Sociology of. allowed psychologists to train in psychoanaly-
sis. Traditional psychoanalytic treatment, which
Further Readings requires four to five sessions per week for 45 to
Devereux, Georges. From Anxiety to Method in the 60 minutes each time, is rare given financial and
Behavioral Sciences. The Hague, Netherlands: time constraints but endures in certain (largely
Mouton, 1967. wealthy) populations; some practitioners now
Favret-Saada, Jeanne. Deadly Words: Witchcraft in the consider thrice-weekly sessions to be analysis.
Bocage. New York: Cambridge University Press, Although Freud conceptualized psychoanaly-
1980. sis as a treatment paradigm, the influence of
Leupin, Alexandre, ed. Lacan and the Human Sciences. psychodynamic principles is clearest today in
Lincoln: University of Nebraska Press, 1991. the humanities and social sciences, films (in the
Manning, Philippe. Freud and American Sociology. manner of Woody Allen), songs (such as those by
Malden, UK: Polity, 2005. Simon and Garfunkel), and everyday language,
Stannard, David E. Shrinking History: On Freud where Freudian concepts such as slips of the
and the Failure of Psychohistory. Oxford: Oxford tongue abound.
University Press, 1980.
Winter, Sarah. Freud and the Institution of Basic Principles of Psychoanalysis
Psychoanalytic Knowledge. Palo Alto, CA: Though Freud published The Interpretation of
Stanford University Press, 1999. Dreams in 1900 and made his only trip to the
Zafiropoulos, Markos. Lacan et les Sciences Sociales: United States to deliver a keynote speech at Clark
Le Déclin du Père (1938–1953). Paris: Puf, 2003. University in 1909, his work had little influence
on American psychiatry until the 1920s. He was
more widely read posthumously in the 1940s,
partly because post–World War II America was
increasingly secular and socially liberal (espe-
Psychoanalytic cially surrounding sexuality) and thus open to
a theory of the psyche that centered on psycho-
Treatment sexual development. A culture friendly to psycho-
therapy emerged in the United States, one that
This article presents a description of the goals depended on individuals who were well educated,
and theories that underlie classic psychoanalytic had ample incomes, and often belonged to perse-
treatment, with a focus on the American cultural cuted groups. After the Depression subsided, art-
context. Founded by the Austrian neurologist ists, gays and lesbians, and Jews were especially
Sigmund Freud in the late 1800s, psychoanalysis interested in the idea of psychological explora-
became the most influential paradigm of in-depth tion. People engaged in psychoanalysis were
talk therapy. Other notable figures in the founda- mostly upper and upper-middle class, white, and
tion of psychoanalysis were Freud’s former stu- professional. Young intellectuals—artists, writers,
dents: Carl Jung, Alfred Adler, and Wilhelm Reich. and social theorists—espoused a need to radically
Psychoanalytic theory offers a model of the alter Americans’ puritanical perspective on sexu-
psyche, and psychoanalytic treatment offers a ality. Psychoanalysis offered freedom from repres-
therapeutic method to relieve troubling, even sion, particularly sexual repression.
debilitating symptoms. Freudian and neo- Psychoanalysis offered a new language for
Freudian theories forever altered psychiatry and understanding psychiatric conditions. Freud
 Psychoanalytic Treatment 715

conceptualized most of his patients’ troubles as brain-focused explanations that abounded in asy-
neurosis, generally some manifestation of inhibi- lum-era psychiatry.
tion or anxiety, which was the central concern Under Freud’s theory, at the heart of the dynamic
of psychoanalysis. Though there is not one clear mind are the id, ego, and superego, forces of the
definition of the concept, neuroses were presumed mind in constant dynamic interplay. The innate,
to be the result of psychic conflict rather than bio- instinctual id consists of drives and instincts and
logical malfunctioning, which had been the pre- is governed by the pleasure principle. The ego is
vailing etiological theory through the early 1900s. governed by the reality principle, and its capaci-
Freud suggested that psychiatric symptoms were ties involve reality testing, judgment, and intel-
instead rooted in psychological mechanisms and lect. The superego is the moral part of the psyche.
early life experiences. He believed that certain For Freud, good mental health was dependent
parts of the personality were deeply entrenched, on successful navigation of childhood psycho-
but the psychoanalytic focus on the influence sexual stages, particularly the Oedipal phase.
of the past on the present and the assump- Problems emerged from stumbles or atypical
tion that the mind is active and in motion—in movement through these stages. For instance,
short, dynamic—challenged the prior body- and one could become fixated, or stuck, in a stage
(such as the oral stage) and later develop a neu-
rotic tendency in that vein (such as biting one’s
nails). This could happen to anyone; everyone
experiences neurosis, which was conceptualized
as the natural result of struggling through child-
hood development. For instance, the Oedipus
complex for boys (Electra complex for girls) is
one of Freud’s most famous and widely debated
theories of childhood psychosexual development.
Between the ages of 3 and 6, he argued, chil-
dren desire their opposite-sex parent and learn
to identify with same-sex parents. The result of
successful navigation of this subconscious pro-
cess is that children develop the gender roles that
will solidify as they grow into adulthood, and
the superego is formed. While most people navi-
gate this stage of life successfully, others cannot
for a variety of reasons; this explains neurotic
symptoms that develop later in life that would be
treated with psychoanalysis.
The structure of psychoanalysis is intensive and
extensive talk therapy. In order to relieve their
symptoms (both neurotic and debilitating condi-
tions), patients lie on an analytic couch while a rel-
atively quiet analyst sits behind them and encour-
ages free association. The potential to assuage
symptoms is thought to lie in uncovering sub-
conscious fears and repressed memories through
guided exploration of the psyche. Therapists are
crucial to the treatment; they become a vessel for
the patient’s past experiences, eliciting reactions
Carl Gustav Jung in front of the Burghölzli clinic, Zurich, from the analysand called transference, wherein
Switzerland, circa 1909. As Sigmund Freud’s former student, he patients redirect feelings about important past fig-
was a notable figure in the foundation of psychoanalysis. ures (especially parents) toward the therapist.
716 Psychoanalytic Treatment

Also key is countertransference, in which the belonged to Emil Kraepelin, who is both credited
psychoanalyst uses her reactions to the patient to and criticized for his conceptualization and mea-
understand responses the patient is likely eliciting surement of mental illnesses as specific categories
in interactions outside the treatment. Along with with particular symptoms. Many lauded Kraepe-
transference, dream analysis is used to access the lin for categorizing difficult and murky symptoms.
unconscious mind, or the parts of the psyche that Sullivan became critical of Kraepelinian classifica-
are inaccessible in everyday life, unknown to the tion and even accused him of mistaking behavior
patient, repressed, and seemingly forgotten. The that resulted from hospitalization for symptoms
therapist assumes that the analysand has defenses of schizophrenia; rather than identifying anything
in place to keep thoughts from the conscious mind truly characteristic of illness, Sullivan claimed that
and therefore experiences resistance to treatment, Kraepelin inaccurately captured behavior born of
the goal of which is to uncover the very thoughts the institutional environment. Sullivan accused
and fantasies causing problematic symptoms. The researchers of objectifying patients instead of
overarching goal of psychoanalysis is to soften trying to understand or make sense of behavior.
overly harsh (self-condemnatory) superego atti- Similar critiques are levied against the contempo-
tudes, relieve guilt, and restructure rigid defenses rary psychiatric model for which the Kraepelinian
so the patient has greater freedom. In order for system laid the groundwork.
this to occur, the patient and therapist must suc- Sullivan argued that schizophrenia is socially
cessfully work together through the patient’s con- and culturally emergent rather than the result of
flicts, resistances, and defensive reactions. a biological trait (today it is largely undisputed
Dynamic psychiatry was meant to identify for that the etiology of schizophrenia is biological).
patients a biographical context in which various He later expanded his theories to include other
conditions emerged, with the idea that recognition illnesses and became a prominent founding theo-
of past—especially repressed experiences—could rist and practitioner of American psychoanalysis.
over an extended period of time free people from Freud and his predecessors opened the door for a
their neurotic tendencies, whether they involved a more complete understanding of both problem-
phobia of certain objects or a tendency to experi- atic and “normal” neurotic behavior. Since every-
ence intense sadness. one had the potential to be symptomatic, psycho-
analysis shifted the attention of psychiatrists and
Freudian Contemporaries laypeople alike to milder conditions and away
Freud’s contemporaries were divided over the from psychosis, which had been the focus of psy-
extent to which psychoanalysts should take cul- chiatry through the early 20th century. It became
ture into consideration in understanding person- less necessary to isolate or stigmatize symptomatic
ality and when treating patients. Harry Stack individuals, as was the case in asylum psychiatry;
Sullivan advanced psychoanalytic techniques for talk therapy was largely an outpatient treatment.
use in America but also fervently disagreed with
the lack of context in Freud’s psychoanalysis. He What Happened to Psychoanalysis?
and other prominent neo-Freudian theorists of During the psychoanalytic heyday, medicine
the time—Erich Fromm, Karen Horney, Clara was oriented toward in-depth relationships with
Thompson, and Freida Fromm-Reichmann— patients. In bodily medicine, patients often had
are responsible for the most prominent rework- one doctor who would treat them (and likely the
ings of Freudian psychoanalysis. There was a rest of their family) from childhood through adult-
deeply social bent to Sullivan’s work, especially hood (perhaps even until death). In the psychody-
in his focus on how interaction and relationships namic tradition of psychiatry, which emerged dur-
affected psychological function and troubles. ing this era, symptoms were a starting point but
Sullivan studied in the 1920s during the peak were located in the context of patients’ complex
of American asylums, when the severe symptoms lives. The goal was to know how past conditions
of schizophrenia (namely, hallucinations and affected present thinking and experience. The goal
delusions) generally led to institutionalization. of psychoanalysts was to understand the mind
The most prominent theory of schizophrenia then through individual cases, as in Freud’s “Ratman,”
 Psychopharmacological Research 717

“Wolfman,” and “Little Hans.” Longitudinal case development. The psychoanalytic heyday was
studies provided detailed information about indi- the birth of outpatient treatment and established
viduals and insight into each patient’s character. psychiatry as a true field. On one hand, psycho-
This legacy is alive in psychodynamic treatments analytic theory has expanded; its principles are
today and is in fact one of the distinguishing char- now central in the humanities and are still an
acteristics of in-depth talking treatments. anchor in many clinical psychology programs. As
Starting around 1980, the prevailing politi- a treatment paradigm, however, psychoanalysis is
cal, social, and medical epistemologies shifted, rare, though recent studies show that even short-
and dynamic psychiatry lost its foothold as the term, in-depth talk therapy is effective (sometimes
dominant means for dealing with psychological equally to medicines) for reducing symptoms and
distress. “Hard science,” “facts,” and “proof” increasing quality of life.
became increasingly important to all scientific dis-
ciplines. Psychoanalysis was ill equipped to defend Dena T. Smith
against accusations that it was “unscientific.” Goucher College
Statistical studies and double-blind placebo medi-
cine trials gained prominence in evidence-based See Also: Antipsychiatry; Biological Psychiatry;
research. The medical professions evolved to meet Freud, Sigmund; Imperial Psychiatry; “Normal”:
new standards of scientific rigor that involved an Definitions and Controversies; Psychiatric
abandonment of all things uncertain or immea- Training; Psychoanalysis, History and Sociology of;
surable. Psychiatry shifted lenses to focus on diag- Schizophrenia Therapy, Individual.
nostic measures, modeling itself on the natural
sciences and medicine of the body. By 1980 there Further Readings
were new medications, especially those aimed at Freud, Sigmund. The Wolfman and Other Cases.
treating depression. New antipsychotic medicines New York: Penguin Books, 1940.
were considered relatively safe and effective for Greenson, Ralph R. The Technique and Practice
treating severe illness. By the 1990s, the practice of Psychoanalysis. Madison, WI: International
of psychiatry was characterized by shorter office Universities Press, 1995.
visits, increased medication therapy, a reliance on Hale, Nathan. The Rise and Crisis of Psychoanalysis
discrete diagnostic categories, and an etiological in the United States: Freud and the Americans,
focus on biology and neurochemistry. Managed 1917–1985. New York: Oxford University Press,
care and advances in brain scanning technologies 1995.
and pharmaceuticals fueled these changes. McWilliams, Nancy. “Some Thoughts on the Survival
Psychiatry floundered in the face of deinstitu- of Psychoanalytic Practice.” Clinical Social Work
tionalization; America’s most severely mentally Forum, v.37 (2009).
ill moved into community settings and psycho- Shorter, Edward. A History of Psychiatry: From the
analysts could not effectively treat psychotic Era of the Asylum to the Age of Prozac. New
symptoms. Managed care was also unfriendly York: John Wiley & Sons, 1998.
to the long-term, in-depth approach of psycho-
analysis. Many classically trained psychoanalysts
adamantly opposed quantifying their patients’
progress, which was counterintuitive to their con-
ceptualization of treatment, but their resistance Psychopharmacological
to medications was seen as a marker of psycho-
analytic dogmatism. Because of its basis in a set Research
of strict diagnostic criteria, biological psychiatry
offered a strategy for measuring progress. The global pharmaceutical research and develop-
ment apparatus of the 21st century has its roots in
Conclusion European and American contexts, and in 2009, 18
Psychoanalysis revolutionized the way peo- of the 20 largest firms were headquartered in the
ple view psychiatric conditions and “normal” European Union (EU) or the United States. In the
718 Psychopharmacological Research

European case, a tradition of medical education resulted in practices and regulatory frameworks
and a relatively stable pharmacopeia had existed that would define the construction of the Ameri-
in Italy since early in the Middle Ages. In the late can as well as global pharmaceutical industry.
18th and early 20th centuries, England, France, The practice of medicine and pharmacy in the
and Germany became centers of new pharmaceu- United States had been connected throughout the
tical industries as distinct from pharmacy prac- colonial period and well into the 19th century,
tice, and these efforts often relied on techniques, with pharmacists often providing medical advice
processes, and equipment developed for industrial and physicians selling and compounding drugs.
uses, especially the development of dyes from coal These professions were separated by the increas-
tar. The early transnational nature of the phar- ingly powerful American Medical Association in
maceutical industry is also evidenced by the 1849 1877, a separation reflected in state laws regulat-
founding of Pfizer in Philadelphia, at first as a ing both pharmacy and medical practice, although
chemical concern, by German immigrants. A few physicians remained actively involved in drug
decades later, in London, two graduates of the research. The development of bacteriology and
Philadelphia College of Pharmacy, Silas M. Bur- its importance in public health, as well as rapidly
roughs and Henry Solomon Wellcome, formed expanding U.S. markets, drove the next expan-
Burroughs, Wellcome and Co. in 1882. sion of the industry. In the last years of the 19th
century and the first years of the 20th, the ability
Emergence of the Pharmaceutical Industry of private companies to marshal the manpower
The U.S. pharmaceutical industry emerged by and capital necessary to mass-produce diphthe-
1830 in New York as well as in Philadelphia, ria antitoxin—in contrast to the failure of public
which was, at the time, the center of American health laboratories— helped generate significant
medical education and home of a nascent chemical credibility for the pharmaceutical industry and
industry. These firms were often started as drug its scientific claims in the United States. However,
distributors for London-based, and, later Ger- the first significant government regulation of the
man and French enterprises. The American Civil industry was in response to legal conflicts over the
War provided significant growth for the American practices used to create safe vaccines and antitox-
pharmaceutical industry. Colonel Eli Lilly was ins using cows, including not only concerns about
both an infantry officer and an industrial chemist safety and effectiveness but conflicts over related
who organized his firm along military lines. patents and company stock.
After the Civil War, manufacture and distri- The Federal Act of July 1, 1902, provided for
bution of so-called patent medicines increased the licensing and inspection of biological agents
significantly, and at the same time, medical and including viruses, serums, toxins, and analogous
pharmacy care was all but unregulated. Toward products—helping to both define and create a
the end of the 19th century, however, pharma- new market, one safe for consumers to enter. Five
ceutical companies began investing in medical years later, and widely credited to Upton Sinclair
research, and scientific credibility was claimed in and his best-selling indictment of the food-pro-
marketing efforts to both doctors and patients. cessing industry, The Jungle, the 1906 Pure Food
The use of cocaine and opium products was legal and Drugs Act created the U.S. Food and Drug
and widespread, constituting a significant part of Administration (FDA) and was also vigorously
over-the-counter pharmacy sales, and heroin was endorsed by Mahlon N. Kline, vice president of
famously introduced by Bayer as a nonaddictive Smith, Kline, and French as well as the industry’s
form of morphine in 1895. Nonetheless, con- chief lobbyist as head of the National Wholesale
cerns about problems with cocaine and morphine Druggists Association. Support was also provided
use—as well as emerging professionalization in by progressive administrators of the U.S. Agricul-
the medical and pharmaceutical industries at the ture Department and a crusading chemist, Har-
end of the 19th century, including several notable vey Wiley, who became the first commissioner of
successes and scandals—would serve to provide the FDA. The 1906 act spurred the industry to
increasing partnership among the medical profes- develop the American Pharmaceutical Manufac-
sion, government, and industry. This partnership turer’s Association as an organization to develop
 Psychopharmacological Research 719

industry guidelines and standards and work with led these efforts. Other pharmaceutical compa-
government to create related legislation. In addi- nies worked on government-sponsored research
tion, staff from leading companies often moved, projects seeking cures or treatments for typhus,
creating both competition and common practices malaria, and myriad additional medical and sur-
among the larger firms. gical applications.
In 1914, the Harrison Narcotics Tax Act was In contrast to the end of World War I, when
passed by Congress in the United States, crimi- funding shrank, after World War II, government
nalizing cocaine and opium products used in any funding for pharmaceutical research continued to
but the strictest medical settings and increas- grow dramatically. This support took the form
ing limits set on nonmedical use of morphine in of direct grants to research institutions as well as
1905. The 1914 act was a result of international various forms of market support, including the
action led by the United States to appease China direct and indirect undertaking of pharmaceutical
by suppressing the opium trade and to help the costs by the welfare state in forms as diverse as
United States manage its colonial outpost in Great Britain’s National Health Service and the
the Philippines, where opium use was rampant. United States’ Medicare, Medicaid, and corporate
In the United States, the Harrison Act was pro- health insurance tax subsidy programs.
moted with racialized political rhetoric aimed at In 1950, the synthesis of the first effective anti-
black and Chinese populations and passed with psychotic drug, chlorpromazine, heralded the
the support of the pharmaceutical industry. This beginning of a psychopharmaceutical bonanza.
marked the beginning of an international treaty Diazepam and Valium were introduced by Roche
regime controlling drugs and defining some drugs in 1963, and the monoamine oxidizer inhibitor
as illicit, a regime still enforced vigorously in the (MAOI) and tricyclic classes of antidepressants
21st century. also emerged in the late 1950s and early 1960s.
Also in the 1950s, the American Medical Asso-
Increasing Specialization ciation discontinued its practice of sponsoring
After a period of growth during World War I, U.S. drug tests and independent surveys in favor of
pharmaceutical companies focused increasingly increasing partnership with industry by physi-
on drug development and manufacture of pro- cian researchers in both academic and corporate
prietary pharmaceuticals and much less on offer- settings. These findings were reviewed in increas-
ing distribution for European firms or the manu- ingly commercialized journals, often sponsored
facture of commodity products. This resulted in directly through advertising by the pharmaceuti-
increasing specialization, reduced numbers of cal companies.
products in any given company’s product line, In 1960, the introduction of affordable phar-
and an increasing emphasis on scientific practice maceutical contraception for women unleashed
and technical expertise in both product devel- significant cultural and social forces, the effects
opment and marketing. The defining success of of which are still emerging around the world.
the pharmaceutical industry during this period The thalidomide tragedy of 1961, in which an
is perhaps the development of insulin as a puri- antinausea drug intended for pregnant women
fied, marketable product by Eli Lilly based on produced profound birth defects, resulted in the
the insight of Frederick Banting, an independent strengthening of the FDA, including a require-
medical researcher who won the Nobel Prize in ment that safety and efficacy be proven. These
Medicine and Physiology for his contributions. drug trials created a statistically driven, market-
Although first isolated by Alexander Fleming focused drug-testing regime, often relying on
in 1928, it was not until World War II that the industry-sponsored research.
mass-scale production of penicillin was made pos- A number of other significant pharmaceuti-
sible, sponsored by an international consortium cal products or categories were developed in
of governments that provided funding for the the postwar period through the 1970s, defined
scientific and laboratory resources necessary for by either market or medical success. These suc-
the development of large-scale, industrial phar- cesses included chemotherapies for cancer, often
maceutical production. Merck, Pfizer, and Squibb developed through national funding of research,
720 Psychopharmacological Research

and angiotensin converting enzyme (ACE) inhibi- EU- and U.S.-patented pharmaceutical products
tors to treat hypertension and heart failure. In without sanction in developing countries. Further,
1977, Tagamet, an antiulcer medication, became tensions present for decades in the market-driven,
the first of what are termed blockbuster drugs— yet state-regulated and state-sponsored global
that is, drugs with $1 billion or more in annual pharmaceutical industry have created a number
sales—and won its discoverers a Nobel Prize. of ongoing controversies.
Blockbuster drugs became critical to the success
of pharmaceutical companies in the 1980s, under Controversies
pressure from global markets to maximize sales The global health care market of the early 21st
and quarterly earnings. In the 1980s, blockbust- century is, in many ways, driven by the pharma-
ers included statins for the control of cholesterol, ceutical industry. In particular, the pharmaceuti-
with Merck first marketing lovastatin as Mevacor cal industry largely created the late 20th-century
in 1987, and the latest in psychopharmaceuticals, trend toward market-driven commodification of
selective serotonin reuptake inhibitors (SSRIs), health care, not only through the development
first famously marketed by Eli Lilly as Prozac, of new products promoted aggressively through
also in 1987. Such blockbuster drugs were usually advertising and sales efforts to physicians—and,
followed to market by a group of “me too” drugs, even in the United States, patients—but through
each carefully developed and marketed to empha- data-driven or so-called evidence-based valida-
size some advantage for some patients, resulting tion of new practices and procedures. This has
in significant parallel research and market frag- led to a health care market based on the dispen-
mentation among leading companies. sation of pharmaceutical products and medical
The 1980s also saw the emergence of so-called services according to statistically driven, stan-
biotech pharmaceutical producers, including dardized care practices. In the case of the phar-
Amgen and Genentech. Relying on genetic engi- maceutical industry, these practices and products
neering to produce drugs using genetically repro- have become captive to industry-sponsored stud-
grammed bacteria, this is claimed as the leading ies, mandated by both European and U.S. law
edge of pharmaceutical technology. This indus- and supervised by the FDA and other regulatory
try trend has also created large-scale centers of agencies. In short, company trials have come to
development for not only genetic technologies dictate clinical practice.
but also advances in computer analysis of pro- Nonetheless, the data-driven model of devel-
tein structure and synthesis. Several products oping new treatments has demonstrated serious
have emerged from this approach, perhaps most flaws in the government–industry partnership that
notably Amgen’s Epoetin alfa, Epogen, itself a currently creates, defines, and regulates pharma-
blockbuster drug introduced in 1989 and used ceutical markets. These problems include and go
to increase red blood cell and oxygen-carrying well beyond conventional public policy concerns
capacity—most notably by cancer patients under- over simple regulatory capture in which pharma-
going chemotherapy and world-class endurance ceutical executives operate through a metaphori-
athletes, particularly cyclists. cal revolving door, serving both government and
By the late 20th century, the pharmaceutical industry. More significantly, careful construction
industry had consolidated to a few dozen global by pharmaceutical companies of medical studies
firms. Government regulations, often interna- to define new markets, not just new treatments,
tionally coordinated by both government and as well as outright fraud, most often through the
industry groups, set high barriers to market entry. concealment of hazards and side effects, have
Small, innovative firms were, and continue to be, created a number of serious problems. Two of
purchased by larger companies, repeating pat- the most successful drugs the pharmaceutical
terns driven by market forces and venture capital- industry produced in the 1990s illustrate some of
ists since the 1870s. This global dominance has these concerns: Rofecoxib and Vioxx, nonsteroi-
been challenged, however, by emerging trends dal anti-inflammatory drugs (NSAID) similar in
including generic drugs, the always escalating many ways to some currently available over-the-
cost of drug development, and manufacturing of counter medication, and Paroxetine and Paxil,
 Psychopharmacology 721

part of a flood of SSRIs introduced in the 1980s Conclusion

and 1990s and now produced in many generic In the last two centuries, the pharmaceutical
variants. industry has emerged as a powerful and often pro-
Vioxx was developed and marketed by Merck ductive force in the creation of widespread public
& Co. as a specific treatment for not only pain health and the welfare state. However, regulation
but acute osteoarthritis, a condition suffered by at created with the participation of the pharmaceu-
least 10s of millions all over the world. Five years tical industry’s company-sponsored trials, as well
after its introduction, Vioxx was withdrawn from as public funding of both research and consump-
the market after having gained widespread accep- tion, has unleashed powerful market forces with
tance among physicians and patients and generat- little restraint and sometimes unfortunate results.
ing sales of some $2.5 billion per year. Vioxx had
been released in the face of serious side effects, Rob Schraff
which were hidden from government regulators University of California, Los Angeles
for years, and has since been blamed for on the
order of 100,000 cases of serious heart disease. See Also: Clinical Trials; Pharmaceutical Industry;
In the case of Vioxx, market incentives made Placebo Effect; Prozac; Psychopharmacology.
fraud an attractive option. However, the omis-
sion of results as anomalies and the suppression Further Readings
of negative data, and even complete studies with Boussel, Patrice, Henri Bonneman, and Patrice Bové.
unfavorable results, is standard in the industry, as History of Pharmacy and the Pharmaceutical
is the practice of ghostwriting reports by phar- Industry. Paris: Asklepios, 1983.
maceutical companies on behalf of well-paid and Epstein, Steven. Inclusion: The Politics of Difference
ostensibly independent research physicians. in Medical Research. Chicago: University of
Such was the case of Paxil, first marketed in Chicago Press, 2007.
1992 by SmithKline Beecham, now GlaxoSmith- Healy, David. Pharmageddon. Chicago: University of
Kline, as part of the race to develop new SSRIs Chicago Press, 2012.
in the wake of the success of Prozac. In a 1997 Liebenau, Jonathan. Medical Science and Medical
trial, Study 329, Paxil was shown to be no more Industry: The Formation of the American
effective than a placebo, yet young people were Pharmaceutical Industry. Baltimore, MD: Johns
six times more likely to become suicidal and twice Hopkins University Press, 1987.
as likely to actually commit suicide. These results Musto, David F. The American Disease: Origins of
were simply omitted from the ghostwritten arti- Narcotic Control. New York: Oxford University
cle, which appeared in one of the most prestigious Press, 1999.
journals in the field. Porter, Roy and Mikukás Teich, eds. Drugs and
In addition, identification of research subjects Narcotics in History. Cambridge: Cambridge
by age, race, and gender, intended by policy mak- University Press, 1995.
ers to provide safe, effective treatments for all,
has instead often obscured socioeconomic factors
in health and disease and constructed powerful
new categories sanctioned by the state. Defining
and recruiting research subjects across both class Psychopharmacology
and racial lines has proven highly problematic,
making results defined by race alone impossible The field of psychopharmacology began to coalesce
to resolve against the background of cultural and during the 1950s as psychiatrists were observing
economic effects. In much the same way, stud- unexpected and dramatic improvements in mental
ies across gender lines, other than those strictly disorders with drugs like chlorpromazine, imipra-
related to reproductive systems, has been prob- mine, and lithium. In 1954, Nathan Kline orga-
lematized because the sources of nonreproductive nized Symposia on Psychopharmacology at both
biological gender distinction are very difficult to the American Association for the Advancement
pinpoint. of Science (AAAS) and the American Psychiatric
722 Psychopharmacology

Association (APA) meetings; and in the five years standard procedures for the investigation of new
that followed, the Josiah Macy Foundation drugs in animals and humans.
brought pharmacologists like Bernard Brodie and In November 1960, the Conference for the
Joel Elkes together with other scientists interested Advancement of Neuropsychopharmacology
in the brain at a series of annual meetings. In 1956 met at the Hotel Barbizon–Plaza in New York
was a Conference on the Evaluation of Pharma- to establish a new organization on the model of
cotherapy in Mental Illness, jointly sponsored by the American College of Physicians (ACP). Paul
the APA, the U.S. Public Health Service (USPHS), H. Hoch, the New York State commissioner for
the National Institute of Mental Health (NIMH), mental illness, then serving as president of the
and the National Academy of Sciences/National CINP, chaired the meeting, two exciting days in
Research Council (NAS/NRC). Soon after, Kline which the congregants discussed the problems of
and fellow psychiatrists Frank Ayd and Henry drug evaluation and regulation, the structure and
Brill appealed to Congress to form an NIH Psy- activities of the new organization, and its prospec-
chopharmacology Division; the NIMH’s Psycho- tive relationship to the Food and Drug Adminis-
pharmacology Service Center/Research Branch tration (FDA) and to pharmaceutical companies.
(PSC/PRB) was established in 1956 and organized The result, in 1961, was the American College of
the first large federal drug trials in state hospi- Neuropsychopharmacology (ACNP), an affiliate
tals. The following year, 1957, an International of the CINP, with 123 founding fellows. Joel Elkes
Symposium on Psychotropic Drugs, organized by became the first president, and the first annual
pharmacologist Silvio Garattini at the University meeting was held in January 1963, in Washing-
of Milan, led to the founding of the Collegium ton, D.C.
Internationale Neuro-Psychopharmacologicum The ACNP and CINP have promoted research
(CINP); Swiss pharmacologist Ernst Rothlin of the in the field and interdisciplinary collaboration
Sandoz pharmaceutical company became the first through annual (ACNP) and biennial (CINP)
president. The first international congress took meetings and through their respective journals,
place in Rome in 1958. Neuropsychopharmacology (founded in 1987)
The promise of the nascent field was not only and the International Journal of Neuropsycho-
the development of better treatments for the men- pharmacology (founded in 1998). The ACNP
tally ill but also the realization that psychoac- has also, beginning in 1968, published reviews of
tive compounds could help to elucidate the neu- research in psychopharmacology at 7- to 10-year
rochemical activity of the brain, yet researchers intervals, which in addition to disseminating cur-
realized the complexity of the problem and of rent knowledge, have also contributed to defining
observing, measuring, and assessing behaviors as the scope and parameters of the field. Both major
outcome measurements in the clinical setting. As organizations have grown, maintaining rigorous
psychiatrist Abraham Wikler wrote in The Rela- standards for fellowship but creating lower-level
tion of Psychiatry to Pharmacology in 1957: categories of membership as well. (As of 2012,
the ACNP rolls included 1,004 fellows, members,
What are called “behavioral effects” are not associate members, and emeriti; 35 members were
isolated, elementary changes in “conscious- promoted to fellow status that year.)
ness,” “perception,” “emotion,” “ideation,” The ACNP has also sought to play a major
or “learning” . . . but complex patterns of public and government advisory role on issues
change, proceeding in time, involving all of such as human subjects protection, animal experi-
these aspects of behavior to varying degrees, mentation, research ethics, psychopharmacology
and dependent not only on the drug adminis- education, abuse of psychoactive drugs, sero-
tered, but also on biographical and environ- tonin reuptake inhibitors (SSRIs) and suicidality,
mental factors as well as on the activities of and standards for clinical investigation. In the
the observer. late 1960s, for example, the organization col-
laborated with NIMH to establish principles for
Therefore, a key goal of Wikler, Elkes, and other evaluating psychotropic drugs and, in the early
leaders in pharmacology was the development of 1970s, created task forces on Drug Safety and on
 Psychosocial Adaptation 723

Guidelines for the Evaluation of Anti-Anxiety and Further Readings

Anti-Depressant Drugs, the latter under contract Efron, D. H., ed. Psychopharmacology: A Review
from the FDA. Both the FDA and ACNP saw of Progress, 1957–1967. Washington, DC: U.S.
these projects as essential in the rapidly expand- Government Printing Office, 1968.
ing psychoactive drug market, a situation that Elkes, J. “Psychopharmacology: Finding One’s Way,”
Task Force Chair J. N. Wittenborn described as Neuropsychopharmacology, v.12/2 (1995).
“a therapeutic cacophony.” Healy, D. The Creation of Psychopharmacology.
The latter task force chose to address these four Cambridge, MA: Harvard University Press, 2002.
problems: (1) definition and selection of a trial Lipton, M. A., A. DiMascio, and K. F. Killam, eds.
patient population, (2) methods for the assess- Psychopharmacology: The Second Generation of
ment of change, (3) criteria for defining clinically Progress. New York: Raven Press, 1978.
meaningful change as distinct from statistically
meaningful change, (4) training of observational
raters and improvement of inter-rater reliabil-
ity. The work of these task forces illustrates the
ACNP’s self-proclaimed role as an honest broker Psychosocial Adaptation
among industry, academia, and government, as
well as the ongoing difficulty of assessing drug Psychosocial adaptation is a process whereby a
effectiveness in mental illness through observa- persons make the necessary adjustments in their
tion of behavioral changes. behavior, cognition, physiology, and emotions as
Some ACNP members have seen the honest bro- they interact with other people, environmental
ker role as difficult to maintain, as from the early circumstances, and/or intrapersonal conditions.
days, pharmaceutical companies held corporate Additionally, adaptation is critical to a person’s
membership, and their researchers played active continued existence relative to intelligence and/or
roles at annual meetings. The ACNP adopted its innate ability.
first Conflict of Interest Policy Statement in 1982, Psychosocial adaption is used in every aspect
asking that members advise the secretary of any of an individual’s life. Even at the time of concep-
conflicts. A few years later, however, when new tion, the zygote began its adaptation process by
drug development seemed to have slowed, the attaching to the uterine wall in its mother. This is
leadership created the Task Force on Coordinat- its natural form of adapting and interacting with
ing Academic–Industrial–Government Efforts in the environment hosted by the mother, and is vital
Psychopharmacology, which later became known to its survival. This evolution continues through-
as the Liaison Committee. The committee’s some- out a prenatal period until its birthday.
what ambiguous role has been to monitor govern-
ment and industry drug development and ACNP Psychosocial Adaptation to People
involvement but also to promote collaborations In 1950, German-born behavioral scientist Erik
to keep the field moving forward. Erikson (1902–94) theorized psychosocial adap-
Through the ACNP and CINP, psychophar- tation in the form of a psychosocial crisis. Erikson
macologists have played major roles in fostering postulates the significance of interaction among
interdisciplinary collaboration and translational people for healthy psychosocial adaptive growth.
research and have also contributed to the shaping He describes psychosocial adaptation as a life span
of the discourse on the research enterprise and its developmental process. The theory is divided into
complex ethical and social role within psychiatry. eight stages. Each stage involves a crisis occurring
at different ages during the life span. As the per-
Marcia Meldrum son is able to successfully overcome each crisis,
University of California, Los Angeles they develop the strength to adapt psychosocially.
In stage one, from birth to 18 months of age,
See Also: Antidepressants; Lithium; the crisis is trust versus mistrust. The psychosocial
Psychopharmacological Research; Serotonin adaptive strength is motivation and hope. Stage
Reuptake Inhibitors. two lasts from 18 months to 3 years of age. The
724 Psychosocial Adaptation

crisis is autonomy versus shame. The psychosocial good for an individual. Although such stimuli are
adaptive strength is self-control, courage, and will. stressful, they are perceived as less harmful on the
Stage three is from 3 to 5 years of age, the crisis body, and in many respects are considered “good
is initiative versus guilt. The psychosocial adap- stress.” This kind of stress is called eustress. The
tive strength is purpose. Stage four occurs from term was coined by Hans Selye in 1956, and it
6 to 12 years of age, the crisis is industry versus also requires the individual to make changes in
inferiority. The psychosocial adaptive strength is their lifestyle, all of which requires some form of
competence. Stage four is from 12 to 18 years of adjustment to maintain a degree of mental equi-
age, the crisis is identity versus role confusion. librium, hence psychosocial adaptation.
The psychosocial adaptive strength is devotion Scientist Hans Selye (1907–82) introduced the
and fidelity. general adaptation syndrome in 1936. This model
From 18 years to 35 years of age, the crisis is explains the body’s stress response process in three
intimacy versus isolation. The psychosocial adap- stages. First, the alarm reaction is when an indi-
tive strength is affiliation and love. From 35 to vidual recognizes the existence of a threat. This
65 years of age, the crisis is generativity versus is where the decision to fight or flight becomes a
stagnation. The psychosocial adaptive strength is psychosocial adaptation mechanism. The fight or
productivity and care. From 65 years of age to flight concept is primarily a physiological stress
death, the crisis is integrity versus despair. The reaction to a threat that prepares an individual
psychosocial adaptive strength is wisdom. to attack (fight) or flee (flight). The autonomic
The strength and ability to adapt psychoso- nervous system of the human body automatically
cially helps an individual make adjustments to liv- shifts from the parasympathetic nervous system
ing with other people. An individual’s behavior is to the sympathetic nervous system at the time of
subject to change as they think differently about stress stimulation.
their relationship with a person. As a result of The second is the resistance stage. Throughout
this change, the individual may experience mixed the resistance stage, prolonged exposure to the
emotions and physiological reactions. For exam- stressful stimuli causes the physiological reactions
ple, there are countless stories reported where an to remain activated by the sympathetic nervous
individual has preconceived notions about a per- system. This is a form of psychosocial adapta-
son’s ethnicity based largely on stereotypes. After tion, and although it may level off at a rate higher
repeated interactions and continual exposure to than normal, it is more likely to become a serious
the person, the individual comes to the realization problem.
that each of their ethnic backgrounds has more Finally, there is the exhaustion stage. This stage
similarities than differences. is the serious problem because the body’s abil-
ity and resources for this demand of psychoso-
Psychosocial Adaptation to the Environment cial adaption are limited. The body’s resources
Psychosocial adaption is necessary to adjust to are subject to depletion, and normal physiologi-
environmental situations. Environmental situa- cal arousal will decrease. There is a failure to
tions can present external stimuli that affect an replenish or overtax those resources. Eventually,
individual. At times, the stimuli may even be per- the individual’s psychosocial adaptation system is
ceived as a threat to the well-being of an individ- subject to failure from exhaustion. Consequently,
ual. Adapting to external stimuli from the envi- psychosocial adaption to the environment as a
ronment can result in stress. result of distress becomes ineffective.
Stress is a nonspecific response of the body that
originates from a situation or event in an individ- Psychosocial Adaptation to Self
ual’s life. It is considered harmful because of the Psychosocial adaptation occurs as an adjustment
impact it has on a person’s body. Distress comes to intrapersonal conditions. Intrapersonal con-
when an individual experiences frustration, pres- ditions can include an infinite array of circum-
sure, conflict, or change in their environment. stances impacting an individual. Moreover, such
Conversely, there are external stimuli that circumstances may last for an extended period—
stem from something that is generally considered or a lifetime. Regardless, psychosocial adaptation
 Psychosomatic Illness, Cultural Comparisons of 725

to intrapersonal conditions involves a process Psychosomatic Illness,

that only the individual may experience.
One example of psychosocial adaptation to Cultural Comparisons of
an intrapersonal condition is that of adjusting to
chronic illness. A chronic illness is defined as a Psychosomatic illness is a phenomenon that
physical and/or mental disorder that affects the attempts to identify the relationship between
daily functioning of an individual for longer than mind and body. It was first acknowledged by Ali
three months during a 12-month period, or for ibn Abbas al-Majusi (ca. 925–94), who was born
duration of one month or longer of hospitalization. in Ahvaz City, Iran, and worked as a physician
Chronic illness is a difficult challenge for an and psychologist. His 10th-century book about
individual. A person may experience symptoms medicine stressed the significance of the connec-
of anxiety or depression from both the illness and tion between psychological and physical health.
the treatment process. The manner in which a Since that era, the concept of psychosomatic ill-
person adapts to a chronic illness varies depend- ness has maintained its presence and definition in
ing on personality traits, age, social attitudes, and the behavioral sciences and medicine. This was
their relationships with other significant people in the birth of the evolution of psychosomatic medi-
their lives. cine. Franz Alexander (1891–1964), a Hungary
A less immediately threatening circumstance native, led the development of psychosomatic
may involve good fortune. For example, a person medicine during the 20th century. Psychosomatic
wins a sweepstakes or becomes a gold medal win- medicine is a branch of medicine that examines
ner at the Olympics. While these kinds of events the relationship between the social, psychologi-
are favorable, they still require intrapersonal life- cal, and behavioral factors affecting human body
style adjustments. Events such as these require processes. Moreover, it is a specialized area of
psychosocial adaptation. psychiatry that treats psychosomatic illnesses.
Any change in life, regardless of whether the A psychosomatic illness is a psychiatric
outcome is positive or negative, requires some somatoform disorder in which the physical symp-
degree of psychosocial adaptation. Psychosocial toms are the result of a mental-emotional fac-
adaptation is a means by which a living organism tor. In other words, the physical symptoms that
is able to exist. a person experiences are related to psychological
factors, rather than medical causes. Moreover,
Dashiel Geyen the exact etiology of psychosomatic-somatoform
Texas Southern University disorder is relative. It may stem from nature, a
genetic factor passed from one generation to
See Also: Acculturation; Business and Workplace another. Conversely, psychosomatic-somatoform
Issues; Children; Critical Theory; Employment; disorders may originate as an emotional-mental
Family Support; Life Skills; Psychiatric Social Work; circumstance such as chronic stress, depression,
Self-Help; Social Support; Stress; Veterans. anxiety, or stress, contributing to the onset of an
organic disorder that requires medical attention.
Further Readings Examples of psychosomatic-somatoform symp-
Caserta, Mary T., et. al. “The Associations Between toms may include digestive problems, headaches,
Psychosocial Stress and the Frequency of Illness, body pain, and fatigue. More serious concerns
and Innate and Adaptive Immune Function in that warrant a psychiatric diagnosis are body dys-
Children.” Brain, Behavior, and Immunity, v.22/6 morphic disorder, conversion disorder, somatiza-
(2008). tion disorder, and hypochondriasis. A person who
Erickson, Erik H. Childhood and Society. New York: suffers from somatoform disorder will generally
Norton, 1950. not recognize the significance that psychological
Erickson, Erik H. Identity: Youth and Crisis. New factors play in their physical symptoms.
York: Norton, 1968. The concept of psychosomatic-somatoform
Selye, Hans. The Stress of Life. New York: McGraw- symptoms is common across all cultural groups.
Hill, 1956. However, the perception and interpretation of
726 Psychosomatic Illness, History and Sociology of

the symptoms may vary as it relates to cultural See Also: Mind–Body Relationship; Psychosomatic
norms. Depending on the circumstances, psycho- Illness, History and Sociology of; Somatization of
somatic-somatoform symptoms may be perceived Distress.
as an index of diseases or disorders. The symptoms
could be seen as an indication of mental illness, a Further Readings
symbolic consideration of an intrapsychic conflict. Edwards, R. R., D. M. Doleys, R. B. Fillingim,
It may also be a culturally coded expression of dis- and D. Lowery. “Ethnic Differences in Pain
tress or a medium for expressing social discontent. Tolerance Clinical Implications in a Chronic
Psychosomatic-somatoform symptoms may be a Pain Population.” Psychosomatic Medicine, v.63
mechanism through which a person attempts to (2001).
reposition themselves within their local environ- Kirmayer, L. J. and A. Young. “Culture and
ment. The fourth edition, text revision of the Diag- Somatization: Clinical, Epidemiological, and
nostic and Statistical Manual of Mental Disorder Ethnographic Perspectives.” Psychosomatic
(DSM-IV-TR) has identified an outline for cul- Medicine, v.60 (1998).
tural formulation and a glossary of cultural-bound Koh, K. “Culture and Somatization.” Journal of
syndromes. This segment of the DSM-IV-TR is Psychosomatic Research, v.55/2 (2003).
designed to help professional clinicians to system- National Institutes of Health. “Psychosomatic
atically evaluate the significance of a person’s cul- Medicine: ‘The Puzzling Leap.’” http://www.nlm
ture as it relates to their psychiatric diagnosis. .nih.gov/exhibition/emotions/psychosomatic.html
Regarding psychosomatic-somatoform symp- (Accessed April 2013).
toms, first there is a concept called root work.
It is a set of cultural interpretations that ascribe
that an illness is the result of hexing, witchcraft,
sorcery, or the evil influence of another person.
The symptoms stemming from root work can Psychosomatic Illness,
include generalized anxiety and gastrointestinal
complaints. There is also the presence of weak- History and Sociology of
ness, dizziness, and paranoid feelings of being
poisoned or even killed. Root work has been a Views on the relationship between organic disease
more traditional and common practice in south- and psychological illness have varied greatly over
ern United States among both African Ameri- time and are based on cultural beliefs. Cultural
cans and Caucasians. It has also been observed and religious beliefs, in contrast to medical knowl-
in Caribbean and Latino societies. Another is edge and science, influence societal understanding
sangue dormido (sleeping blood). This disorder of the strength and directionality of this compli-
is most commonly found among the Portuguese cated relationship. In the contemporary health
Cape Verde Islanders. Its symptoms include care paradigm, psychosomatic illness is generally
pain, numbness, tremors, paralysis, convulsions, defined as a physical illness in which psychologi-
stroke, blindness, heart attacks, infections, and cal factors impact the susceptibility, prevention,
miscarriage. Finally, there is a culturally bound development, presentation, maintenance, or reso-
syndrome from Asian society. Shen-k’uei is from lution of the condition. This modern medical defi-
Taiwan, and shenkui is from China. Moreover, it nition is in contrast to the history of this concept.
is a Chinese folk label describing marked anxiety Ali ibn Abbas al-Majusi (ca. 925–994), a Per-
or panic symptoms with accompanying somatic sian physician and psychologist, published The
complaints for which no physical cause may be Complete Book of the Medical Art, in which he
found. Associated symptoms include dizziness, described his views on the link between medi-
back pain, fatigue, weakness, insomnia, and sex- cine and psychology. In his work, he prescribed
ual dysfunctions. patients’ healthy diets and other natural healing
methods as part of their treatments—a belief that
Dashiel Geyen physiological and psychological factors were inter-
Texas Southern University related (e.g., hypochondriasis, mental disorders,
 Psychosomatic Illness, History and Sociology of 727

and love sickness). His writings were unique to illness can have emotional and mental processes
the extent that he focused on the patient–provider as their primary underlying etiology. Specifically,
relationship; he wrote that a positive relationship the presenting physical symptom was viewed as a
between doctor and patient was needed to heal function of repressed fantasies, memories of trau-
the psychological and physiological bases of ill- matic experiences, or internal conflict. Treatment
ness, and that medical ethics was a critical com- through psychoanalysis would bring these uncon-
ponent to professional medical care. scious dynamics to the surface, leading to allevia-
In the 1700s, physicians began to conceptual- tion of the organic symptom.
ize unity between the mind and body. In 1733,
George Cheyne’s The English Malady suggested Research During the 1900s
that mental illness came from the body. Specifi- In the early 1900s, Hungarian psychoanalyst
cally, he proposed that madness stemmed from Sandor Ferenczi examined the link between
disturbances of the humors (or bodily fluids), emotional-mental processing and organic dis-
physiological process, or the nerves. In subse- ease states. He believed that actual illness or tis-
quent years, German physician Franz Anton Mes- sue injury could precipitate pathoneuroses in the
mer (1734–1815) used mysticism and magnets affected organ (e.g., fainting, headaches, seasick-
to treat organic disease in Vienna and Paris. He ness, gastrointestinal issues, and nervous asthma).
believed that magnets could unblock the flow of He proposed that after an organic disease healed,
natural electromagnetic energy. there may be a residual neurosis that remains
behind, possibly because of secondary gain or
Theories From the 1800s psychological advantage conveyed by the physi-
In the early 1800s, Johann C. A. Heinroth, a Ger- cal symptom that has since resolved.
man psychiatrist, developed the naturalist and After World War I, there was significant atten-
“vitalist” approach to medicine. He first used the tion paid to the syndromes of returning soldiers,
term psychosomatic and highlighted the connec- collectively termed shell shock. Treatment provid-
tion between the body and the soul. He conceptu- ers began to attribute their clinical presentations
alized madness as a disease of the entire being. In (e.g., tics, stuttering, shaking, and mutism) to
the 1830s, German psychiatrist Christian Fried- anxiety and cognitive disorders, rather than sim-
rich Nasse described a system of mental illness ply organic illness. However, successful treatment
assessment and treatment that included the study of these conditions remained elusive.
of patients’ organic processes. He believed that In the 1920s, physician and writer Georg
medical disease could create an imbalance in the Groddeck (1866–1934) began to use psycho-
link between the psyche and the body that may analysis in the treatment of organic disease. He
lead to a mental disturbance. Thus, to treat the suggested that “morbid afflictions” can be pur-
condition, the clinician must address both the poseful conditions that may provide some benefit
psychic and somatic components. to the patient. For example, colds were to avoid
By the late 1800s and early 1900s, medicine gave smells. His treatments for chronic illness stressed
rise to psychodynamic theories and an emphasis the role of obedience, healthy dietary choices,
on the role of the unconscious in physical symp- and physical activity, earning him the designation
toms. Josef Breuer (1842–1925) employed psy- of founder of psychosomatic medicine. Grod-
chodynamic approaches to treat organic medical deck also introduced the concept of “Es” as an
diseases, believing that they had underlying emo- unknown force in control of physical disease.
tional or psychological etiologies. He coauthored Freud later modified this concept into the “Id,”
a book in 1895 with Sigmund Freud titled Studies the unconscious source of all impulses.
on Hysteria. He is also well known for his famous In the 1930s the field of psychosomatics was
case study of Anna O., in which he treated her greatly impacted by W. B. Cannon’s work on
paralysis and anesthesias with hypnosis. Freud homeostasis. His theory proposed that living sys-
(1856–1939) went on to focus on the “conver- tems are designed to maintain a stable and consis-
sion” of pathological notions into hysterical tent level of functioning. Later, in the 1950s, Har-
physical symptoms. He emphasized that physical old Wolf extended this notion by suggesting that
728 Psychosomatic Illness, History and Sociology of

psychiatrist and psychoanalyst Henri Ey devel-

oped organodynamic psychology. In this view, the
psychic lives of patients are divided into a struc-
tured hierarchy that includes both organic and
psychodynamic factors. Also, in the mid-1900s,
American researcher Helen Flanders Dunbar pro-
posed that various personality profiles specifically
predispose individuals to certain symptoms and
diseases. In following this “neovitalist approach,”
she asserted that organic disease resulted from the
destruction of vital energy.
In the mid-1960s, physicians at the Psychoso-
matic School of Paris developed a more detailed
model of the somatization process. Specifically,
Pierre Marty developed a conceptualization of
the relation between early trauma and later psy-
chosomatic presentations. He proposed that early
trauma led to disorganization and regression/fix-
ation that promoted the onset of psychosomatic
symptoms.
Throughout the 1960s, treatment options for
psychosomatic conditions remained primarily
in the Freudian tradition. French psychoanalyst
Jean-Paul Valabrega suggested that psychoso-
matic symptoms stem from fantasy and can actu-
ally function as a physical barrier. In his treatment
model, the psychosomatic condition is addressed
by crossing this barrier into the hidden fantasy
region of the psyche. Felix Deutsch (1884–1964)
also emphasized that because psychosomatic
symptoms are the result of long-standing psy-
chodynamic processes, their treatment requires
resolution of the underlying unconscious psychic
In the 19th century, patients suffering from “neuroses” with
no organic cause were often thought to be suffering from conflict.
imaginary diseases, as depicted by Honoré Daumier’s 1833 Over time, the connection between psycho-
lithograph “Le Malade Imaginaire” (top). Later, in the 1940s logical process and organic illness became more
and 1950s, illustrated tomes such as Franz Alexander’s refined. Franz Alexander (1891–1964) developed
Psychosomatic Medicine in 1950 (bottom) were created to meet the specificity hypothesis, in which he asserted
the public’s growing fascination with psychosomatic medicine. that organic illnesses (e.g., peptic ulcers, ulcer-
ative colitis, bronchial asthma, neurodermati-
tis, hypertension, rheumatoid arthritis, and thy-
rotoxicosis) arise as a result of a temporal link
organic disease arose when an organism’s attempts with specific emotional upsets. In this model, pat-
to return the body to homeostasis were thwarted. terns of psychological turmoil precipitate specific
In 1945, the term psychosomatic was for- organic illness. In the treatment of patients with
mally established by British psychologist James these conditions, he used the concept of a “cor-
L. Halliday. In his work, he focused on several rectional emotional experience” in an attempt to
organic conditions that he believed had a psy- repair past traumatic experiences.
chological component (e.g., goiters, diabetes, and In 1964, the World Health Organization pub-
peptic ulcers). In the 1950s and 1960s, French lished a report on psychosomatic disorders. Their
 Public Education Campaigns 729

conceptualization of psychosomatic conditions 2nd ed., William A. Darity, ed. Detroit, MI:
included considerations for a constitutional pre- Macmillan Reference USA, 2008.
disposition based on heredity, childhood experi- Fava, G. A. and N. Sonino. “The Clinical Domains
ence, and/or development; personality changes of of Psychosomatic Medicine.” Journal of Clinical
later life that affected the organ systems; weaken- Psychiatry, v.66 (2005).
ing of an organ by injury or infection; and the Wells, K. “Psychosomatic Medicine.” In Gale
symbolic meaning of the organ in the personality Encyclopedia of Alternative Medicine, Jacqueline
system of the patient. L. Longe, ed. Detroit, MI: Thomas Gale, 2005.

Contemporary Definition
Currently, the term psychosomatic is used to
describe a process, an approach, and a group
of illnesses. The psychosomatic process empha- Public Education
sizes the temporal nature of psychological stress-
ors relative to the presenting organic symptoms. Campaigns
The psychosomatic approach incorporates a
broad sociocultural perspective associated with Public education campaigns within mental illness
the whole patient rather than a narrow view of and health resulted from the massive deinstitu-
individual symptoms. Pathology, or psychoso- tionalization movement in the 1960s and 1970s.
matic illnesses, can result from the psychosomatic Because of the number of asylums closed and the
process. Psychological interventions may be indi- increased number of patients placed back into the
cated for psychosomatic disorders when patients community, the public was fearful of this popula-
exhibit nonadherence with recommended treat- tion. There was ample evidence found by research-
ment plans, psychological disorders exacerbate ers that the public had not changed in their percep-
physical illness, illness behaviors are uncharacter- tions of the mentally ill from the 1950s through
istic of the disease, and symptom severity/level of to the 1990s. Most believed that the population
disability are inconsistent with objective clinical was dangerous and criminal. Jo Phelan and her
findings. Treatment can also be indicated when colleagues discovered that individuals with psy-
the nature of the illness appears as a direct exten- chiatric illnesses were perceived as dangerous and
sion of a psychological process (e.g., chronic pain, were consistently socially rejected throughout the
headache, or gastrointestinal distress). 1950s and 1960s. The concern with these findings
lies in the discrimination not only felt socially but
Christopher L. Edwards also the implications that this has on the economic
Duke University and social outcomes of individuals with mental ill-
Katherine L. Applegate nesses. As a result, the call for public education
Duke University Medical Center initiatives to reduce stigma was sought, and these
public education campaigns came to full inter-
See Also: Mind–Body Relationship; Psychosomatic national implementation in combating stigma by
Illness, Cultural Comparisons of; Somatization of 1996. Numerous campaigns have spawned from
Distress. this grassroots initiative and can be subcatego-
rized into international, global, and North Ameri-
Further Readings can initiatives. The perceived effectiveness of
Blakemore, C. and S. Jennett. “Psychosomatic such campaigns and policy initiatives is still being
Illness.” In The Oxford Companion to the Body, assessed; however, some studies have pointed out
New York: Oxford University Press, 2001. that their effectiveness lies in the aims of such pro-
Deuraseh, N. and M. Abu Talib. “Mental Health in grams and ensuing implementation.
Islamic Medical Tradition.” International Medical
Journal, v.4/2 (2005). International and Global Initiatives
Edwards, C. L. and C. McDougald. “Psychosomatics.” The World Federation for Mental Health was one
In International Encyclopedia of the Social Sciences, of the first organizations to rally around the issue
730 Public Education Campaigns

of mental health and public awareness. Founded within the World Health Organization, where
in 1948, the organization currently collaborates child and youth mental health has become of
with a number of governments and nongovern- recent concern; consequently, WHO has orga-
mental agencies in advancing the cause of mental nized a child and youth mental awareness day,
health services and policy on a global scale. This partnering with World Mental Health Day. These
includes a number of policy initiatives aimed at awareness days are accompanied by various
demystifying the public perception of mental ill- themes such as autism and depression, but aware-
ness and the creation of a World Mental Health ness campaigns work with youth, celebrity, and
Day. In an effort to reach a global population, the local talent to bring more awareness to the issues.
organization works with various local agencies
to disseminate literature in different languages to North American Educational Campaigns
educate the public. The World Psychiatric Asso- Initiatives in the United States and Canada began
ciation was the first to initiate a global campaign with a much different focus than that of interna-
with its Open the Doors campaign. This cam- tional initiatives. A report from the Royal Col-
paign encouraged those with schizophrenia to lege of Psychiatrists concluded that instead of
return home and integrate back into the commu- targeting one specific diagnosis, much like the
nity, while initiating mass education campaigns Open the Doors campaign, or dispelling mental
to increase awareness of schizophrenia and its illness generally, the college would focus on the
symptoms and to dispel the myths associated differences in public attitudes toward a variety
with it. This initiative was deployed in various of mental illnesses, including anxiety, depres-
countries, including Canada, the United King- sion, schizophrenia, eating disorders, dementias,
dom, Germany, Italy, Austria, Egypt, and India. It and drug and alcohol addiction. This campaign
also involved collaboration with other local and began in 1998, and has since developed into a
regional campaigns in these various areas, and it national initiative named Mind Out for Men-
resulted in numerous conferences and media edu- tal Health and Changing Minds. This campaign
cational opportunities. had an extensive educational kit and even a film,
Building off the Open the Doors campaign, adapted for World Mental Health Day, which
Germany founded its German Alliance for Men- was shown in 2000.
tal Health, which targeted not only specific men- One other large American venture was set
tal illnesses but also partnered with regional orga- forth by the National Alliance on Mental Illness
nizations and individuals in its implementation. (NAMI); it began as a grassroots organization
One other regional initiative that focused on men- with its inception in 1979, but grew to a national
tal health literacy was the Australian National organization that funds research and programs
Mental Health Promotion and Prevention Action that claim to be aimed at creating a better life
Plan. As a result, a number of smaller initiatives for individuals with mental illness. It attempts to
focused on combating stigma of mental illness in accomplish this by creating awareness and sup-
several capacities: through education, a media port, education, and advocacy for those with
blitz, empowerment, and awareness. New Zea- mental illness. One such initiative put forward by
land also collaborated on this effort using vari- NAMI was its program StigmaBusters, wherein
ous programs developed in tandem with the New the organization presents an antistigma agenda by
Zealand Mental Health Commission. Both Aus- organizing a network of advocates both nation-
tralia and New Zealand worked together in host- ally and globally. This program sends out its Stig-
ing a media awards event recognizing the positive maBuster Alerts to the network disseminating
attitudes portrayed by media. agendas, media, and public messages of mental
New Zealand also put forward a Like Minds, illness. It also relies on the public to report images
Like Mine campaign, which aims at reducing and messages of mental illness in various media
stigma and discrimination of those with mental outlets to the program.
illness by educating the general public through a In Canada, Calgary led the way with the Mental
number of campaign videos and radio messages. Health Commission of Canada’s (MHCC) Open-
These global initiatives have also found roots ing Minds campaign. This campaign focused on
 Public Education Campaigns 731

four different segments of the population: health employers, politicians, and the general public.
care providers, youth ages 12 to 18, the workforce, It is not enough to target just the general public
and the media. The MHCC has recently launched but to penetrate specific groups who can prompt
an antistigma campaign, asking the public to read change in the perceptions of those with mental
through the consensus statement, sign, and join illness. More importantly, some researchers have
the agreement. More recently, telecommunications found that targeting the general public with mere
company Bell Canada launched the Let’s Talk cam- media campaigns can result in no change toward
paign, partnering with local and regional athletes, experienced stigma; the suggestion is to target
the Kids Help Line, and the Canadian Mental specific audiences and educate not only the pub-
Health Association to demystify mental illness. This lic, but also the media in this capacity. Corrigan,
campaign includes a large-scale media initiative to in a more recent publication, states that effective
promote the antistigma message, but then partners publication education campaigns are not only
with schools and other institutions to promote its specific and targeted but also local.
message, even going so far as to create educational Current campaigns have ventured into other
and curricular materials for classrooms. populations with the awareness of children’s men-
Bell Canada has also dedicated funds toward tal health issues. As a result, a number of cam-
research, providing many partners within Can- paigns have launched in schools with the focus
ada, including institutions and private agencies on breaking down barriers to communication of
with the means to discover and disseminate the children’s mental health problems and daily strug-
experiences of individuals with mental illnesses. gles, while combating the issue of bullying. As a
More recently, the Canadian Mental Health Asso- result of the grassroots organizations as well as
ciation has launched a social networking media the pervasiveness of global education initiatives,
campaign on Facebook, while the Kids Help Line a number of smaller, more local education cam-
has worked with popular youth television net- paigns can be found. These education campaigns
works and radio stations to spread their message. have filtered into not only schools but also the
workplace, higher education institutions, and
Effectiveness and Future Work community organizations.
The potential effectiveness of such campaigns is A number of associations have also partnered
great, given that many media outlets and the gen- with teacher and senior organizations as well as
eral public tend to be misinformed about mental patient advocacy groups. The growing aware-
illness. However, one early Canadian study by ness of mental illness, coupled with the increased
John and Elaine Cumming found that educational numbers of public education campaigns, has
campaigns may sometimes have perverse effects, begun to diversify campaigning by specifying
increasing—rather than reducing—public hostil- various disorders and targeted audiences for
ity toward the mentally ill. Some researchers have each. More attention, however, needs to be paid
found that by providing media outlets, specifi- to the evaluation of efficacy of such campaigning
cally, with the appropriate information prior to and implementation, and, as Corrigan states in
reporting, stigma could be reduced while foster- his latest publication, there needs to be a more
ing a more positive image of mental illness. These thorough understanding of the media utilized by
sorts of initiatives have also created a new context the general public. This is why many education
for stigma discussion; they have created a new dis- campaigns have resorted to using mass texting
cursive space open for discussion and sympathy. and social media Web sites, while others have
Some researchers have measured the effectiveness become more precise in their measurement of
of public campaigning programs on the perceived intended outcomes.
attitudes toward those with mental illness.
For example, Patrick Corrigan and Jen- Christina DeRoche
essa Shapiro have stated that effectiveness of McMaster University
such campaigns depends on the targeted audi-
ence; the goals of any antistigma program must See Also: Australia; Canada; Consumer-Survivor
adapt to the type of audience it targets, such as Movement; Legislation; Mass Media; National
732 Public Education Campaigns

Alliance on Mental Illness; Patient Activism; Stigma; Crisp, Arthur, Liz Cowan, and Deborah Hart. “The
United States. College’s Anti-Stigma Campaign, 1998–2003: A
Shortened Version of the Concluding Report.”
Further Readings Psychiatric Bulletin, v.28 (2004).
Corrigan, Patrick W. “Where Is the Evidence Rosen, Alan, Gary Walter, Dermot Casey, and
Supporting Public Service Announcements to Barbara Hocking. “Combating Psychiatric Stigma:
Eliminate Mental Illness Stigma?” Psychiatric An Overview of Contemporary Initiatives.”
Services, v.63/1 (2012). Australasian Psychiatry, v.8/1 (2000).
Corrigan, Patrick W. and Jenessa R. Shapiro. Rüsch, Nicolas, Matthias C. Angermeyer, and Patrick
“Measuring the Impact of Programs That W. Corrigan. “Mental Illness Stigma: Concepts,
Challenge the Public Stigma of Mental Illness.” Consequences, and Initiatives to Reduce Stigma.”
Clinical Psychology Review, v.30/8 (2010). European Psychiatry, v.20 (2005).
 R
Race times more likely to be admitted to psychiatric
hospitals (if male) and twice as likely (if female)
In order to discuss the epidemiology of mental ill- than male and female white groups. African
ness in the context of race or race culture, it is Americans are 20 percent more likely than non-
first important to consider whether the data from Hispanic white groups to report serious psycho-
which conclusions are drawn provide an accurate logical distress.
representation of prevalence. At first glance, avail- In research from 1973, J. H. Shore suggests
able data depict a good representation of different the prevalence of depression within select Indian
race cultures; there are also statistics available for communities is four to six times higher than the
different pathologies such as mood disorders, psy- general American population. In the UK, accord-
chotic episodes, and suicide rates. However, when ing to interviews by the mental health charity
the data are analyzed further and the way differ- Mind, 4.9 percent of the UK Pakistani population
ent race cultures view mental distress or mental reported depressive symptoms in the week lead-
health is considered, questions begin to arise about ing up to the interviews, compared to 2.9 percent
whether the complete picture is being captured. of the UK white population.
What do the patterns in diagnosis reveal about According to the National Institute of Mental
the way different race cultures experience mental Health, 5 percent of the general American popu-
health services? Are symptoms pathologized in the lation has a gambling disorder, compared to 20
same way across different groups? How easy is it percent of the American Chinese population.
for people to come forward and seek help when The World Health Organization states that the
the stigma of a mental illness may impact not just highest rates of male suicide in the world occur
the individual but the whole family? in Lithuania, Russia, and Belarus; for women,
the highest rates are recorded in the Republic of
The Epidemiology of Mental Illness Korea, Sri Lanka, and China.
The following are some commonly available sta-
tistics that consider trends and patterns in the epi- How Helpful Are Statistics on Race
demiology of mental illness. and Mental Illness?
For example, figures from the 2009 Count Me Do statistics on race and mental illness alone
In Census in the United Kingdom (UK) suggest enable one to draw conclusions about mental
that black and black mixed-race groups are three well-being across race cultures, or are there other

733
734 Race

factors surrounding the diagnosis of illness when people from minority ethnic backgrounds are more
it comes to working cross-culturally? likely to be “misdiagnosed . . . more likely to be
For example, in the UK, black men and women prescribed drugs.” He goes on to say that “institu-
are more likely to be admitted to psychiatric hospi- tional racism exists within mental health services.”
tals than their white counterparts. The main route However, the Mental Health Foundation sug-
to mental health services in the UK is primary gests that the number of black people actually
care; however, the majority of African Caribbean seeking help for common mental disorders is
people become known to services through courts lower than other groups; therefore, it is possible
or the police, and they are also more likely to be that individuals from this group may be hesitant
treated under the Mental Health Act. People from to seek help at an early stage because of a lack of
black or African Caribbean groups are more likely awareness of mental health services and stigma,
to receive medication than be offered a talking coming to the attention of services only when the
therapy and are overrepresented in medium- and illness is at a more severe stage.
high-security units and prisons. As S. P. Sashid- The higher prevalence of depression among
haran states in his 2003 report “Inside Outside,” select Indian communities is explained in a social
context by the U.S. Centers for Disease Control
and Prevention, linking depression to community
groups residing in areas characterized by “high
rates of alcoholism, crime, youth suicide, poverty
and other factors.” Native American groups con-
sider health in a holistic way that includes mental
well-being as a complex yet seamless interaction
between the physical world, mental processes, the
environment, and spiritual forces. Symptoms are
also viewed as not arising solely from the physi-
cal body but from other areas such as personal
misconduct or sin, a result of supernatural experi-
ences, or a feeling of unhappiness or heartbreak.
As the “problem” is seen to have stemmed from
a misalignment of the different “realms,” so the
solution is often viewed as wider than medical.
Help-seeking behavior often determines how a
problem is primarily perceived. A significant num-
ber of people seek the help of a spiritual healer
and only come to the attention of medical services
after all other methods have proven unsuccessful.
In this case, race statistics would capture only the
most severe symptoms or those that have per-
sisted for a long time.
Researcher Tanya Jukkala asserts that the high
prevalence of suicide in Russia is a result of Rus-
sia’s modernization, drawing the parallel to a
higher prevalence recorded in Western countries
during the latter half of the 20th century. Jukkala
A worshipper with a small spear in her tongue carries a pot on explains the link between modernization and sui-
her head and flowers in her hand during a Hindu Thaipusam cide as placing pressure on people to live in an
festival celebration in Malaysia, February 26, 2006. Racial “increasing number of social contexts” and hav-
expressions that are considered normal in one’s race or culture, ing to “meet a variety of social expectations.”
such as “possession” by a revered spirit in Hindu cultures, might Suicide in this context is seen as a way to escape
appear pathological to other races and cultures. all kinds of social participation.
 Race 735

High rates of gambling addiction among the dance, during which the affected individual seems
American Chinese population is explained not to go into a trance-like state; the ceremony comes
by social factors such as socioeconomic status to an end when the jinn leaves the body or agrees
but because gambling has been an intrinsic part to stay, but in a way that is harmonious with the
of the Chinese social culture for centuries. People individual’s well-being.
migrating from China to the United States find There are several other reasons why statistics
gambling sanctioned by the government and just are not very reliable in representing actual preva-
as easy to access as in their home country. lence of mental illness in different race cultures.
First, there are themes of institutionalized racism
Beyond Statistics within services with a lower threshold for diagno-
Statistics provide an incomplete picture of the prev- sis. Higher rates of admission and a tendency to
alence of mental illness in different race cultures; a prescribe medication compared to other holistic
more in-depth understanding is gained only when forms of treatment may cause statistics to over-
the statistics are viewed in a social and cultural represent prevalence within a particular race cul-
context. This is not dissimilar to the biopsycho- ture. Second, there is a trend to underreport by
social model of mental illness, which stresses the individuals and the wider family or clan because
importance of using a holistic view when treating of the stigma and shame associated with mental
mental illness—considering the psychological and illness. Third, if symptoms are interpreted dif-
social as well as biological and physical factors. ferently across race cultures, for example, if they
This model can be an asset during studies and are viewed as becoming more spirituality con-
research, ultimately feeding into statistics in the nected, then statistical data may fail to capture a
area of race cultures and mental illness. whole set of symptoms in a group, as they are not
As cultural beliefs impact the rates of illness, pathologized.
this leads to questions about how heavily a diag- Because of these factors and their varying
nosis is based on perceptions of illness, the belief degrees of influence on data capture, it is diffi-
system of the individual, and misunderstandings cult to draw conclusions about the epidemiology
about the race culture. How effective, then, are of mental illness across races. However, whether
statistics on prevalence of mental illness across understood as socially constructed, biologically
different race cultures if mental distress—or any ordained, or pathologically or spiritually under-
mental episode—is not pathologized? stood, mental experiences are very much prevalent
There are countless examples from many dif- across different race cultures around the world.
ferent race cultures in which mental experiences
are not always pathologized and viewed as an Shama K. Kanwar
unwelcome or untimely experience, as in the case National Health Service
of Hindu communities and deity possession. In
this case, a possession by a revered deity may See Also: Cross-National Prevalence Estimates;
occur by chance or be planned and anticipated to Cultural Prevalence; Psychosomatic Illness, Cultural
fulfill a vow to the deity in exchange for the fulfill- Comparisons of; Race and Ethnic Groups, American;
ment of a special request. While the “possessed” Racial Categorization.
person may outwardly display all the symptoms
of having a psychotic episode, no medical inter- Further Readings
vention would be sought as trance possession is Baldridge, D. “Diabetes and Depression Among
not considered an illness. American Indian and Alaska Native Elders”
In many Middle Eastern and North African (2012). National Association for Chronic Disease.
countries, certain symptoms that a medic may http://www.cdc.gov/aging/pdf/hap-issue-brief-aian
interpret as depression may be viewed as jinn .pdf (Accessed June 2013).
(spirit) possession, particularly when experienced Care Quality Commission. “Count Me In Census
by females. In this case, a zar ceremony is per- 2010.” http://www.cqc.org.uk/sites/default/files/me
formed instead of seeking medical help. During dia/documents/count_me_in_2010_final_tagged
the zar ceremony, a group of women perform a .pdf (Accessed June 2013).
736 Race and Ethnic Groups, American

Cross, T. “Spirituality and Mental Health: A Native These persist, despite decades of focused effort
American Perspective.” Portland State University to remedy past injustices and improve the lot of
(2002). http://www.rtc.pdx.edu/PDF/fpS0211.pdf minorities. As American society becomes increas-
(Accessed June 2013). ingly diverse, treatment philosophies and meth-
Jukkala, T. “Suicide in Russia: A Macro-Sociological ods are adapting to allow health care providers
Study.” Uppsala, Sweden: Acta Universitatis and social work professionals to address the per-
Upsaliensis, 2013. sonal goals and individual life circumstances of
Kleinman, A. and B. Good. Culture and Depression. each person they serve, with due regard for the
Berkeley: University of California Press, 1985. complexities of culture as each person experi-
Liao, M. “Asian Americans and Problem Gambling.” ences it. Approaches to diversity are increasingly
NICOS Chinese Health Coalition (2010). http:// important as the racial and ethnic characteristics
www.napafasa.org/pgp/.Asian%20Americans%20 of the American population change.
and%20Problem%20Gambling%20Rev.11.0321 American society today is profoundly influ-
.pdf (Accessed June 2013). enced by the political, social, economic, and
Mind. “Mental Health Facts and Statistics.” http:// cultural choices that have surfaced as Ameri-
www.mind.org.uk/mental_health_a-z/8105_men cans encountered people who were different in
tal_health_facts_and_statistics (Accessed June terms of race, ethnicity, or culture. What needs
2013). to happen today to address the effects of the
Sashidharan, S. P. “Inside Outside: Improving country’s history of slavery and racial discrimi-
Mental Health Services for Black and Minority nation? What obligations are owed to the coun-
Ethnic Communities in England” (2003). http:// try’s native people, who were conquered and
webarchive.nationalarchives.gov.uk/+/www.dh.gov displaced? Other questions come from changes
.uk/en/Publicationsandstatistics/Publications/Pub in the country’s ethnic and cultural mix that are
licationsPolicyAndGuidance/DH_4084558 becoming evident today. Should cultural differ-
(Accessed June 2013). ences be lauded, assimilated into the dominant
Shore, J. H., J. Kinzie, and E. M. Pattison. culture, or disapproved of? What role should
“Psychiatry Epidemiology of an Indian Village” race and ethnicity have in mental health, justice,
(1973). http://www.ncbi.nlm.nih.gov/pubmed/46 and education contexts?
87288 (Accessed June 2013).
World Health Organization. “Suicide Rates Per Social Distance
100,000 by Country, Year, and Sex” (2011). http:// American health care and social work practices
www.who.int/mental_health/prevention/suicide have largely mirrored broader social patterns.
_rates/en (Accessed June 2013). Among individuals within dominant ethnic or cul-
tural groups, issues of race, culture, and diversity
rarely surface. On the other hand, encounters with
someone from a different group are more compli-
cated. Human encounters are affected by social
Race and Ethnic distance, a measure of relatedness, and a bundle
of concepts ranging from familiar, approved,
Groups, American trustworthy, and safe to strange, different, suspi-
cious, and unsafe. People are said to be closest
Issues surrounding race, culture, and ethnicity to those they trust and know best, typically those
remain highly relevant and controversial within who are most like them. Social distance can be
American life. The American Dream and the pop- seen playing out in a benign fashion in school caf-
ular notion of the United States as a melting pot eterias, stadiums, and other public spaces. More
coexist with laws, social practices, and individual people gather in same-group clusters than in more
actions discriminating against and causing harm diverse clusters, even when everyone in the larger
to newcomers and people of various racial and setting peacefully abides and might even share
ethnic groups. Differences among people generate interests, attitudes, educational background, and
disparities in health and mental health outcomes. motivations for gathering.
 Race and Ethnic Groups, American 737

The notion of relative safety connected with theory and training is cultural positivism, the
one’s family and tribe and higher perceived risk notion that a single reference culture (typically
when encountering strangers is an artifact of white European or Christian) is universally opti-
human evolution, built into DNA and human mal, and a goal to aspire to. Other cultures are
nature. From the earliest moments, humans put into catalogs of standardized cultural char-
construct mental models, learning who is safe, acteristics, a kind of zoological approach. Prac-
whom to avoid, and how to obtain what is titioners become experts in characteristics of
needed. Humans develop and rely on patterns, various cultures. This intensifies the process of
lumping similar things (or similar types of peo- differentiation and social distancing. Cultures
ple) together. Mental models are working theo- are treated as “less developed,” “troubled,” or
ries of the world, approximations of what we “unhealthy,” and may even be ranked in terms
have learned that incorporate what is seen and of their deviance from “optimal.” As social dis-
heard from others, as well as what is personally tance increases, people are increasingly treated
experienced. Mental models connected to social as less entitled to the full range of human rights.
distance can be useful and accurate—or dead Poor outcomes pile up. Mental health stigma
wrong. Fortunately, mental models are subject to tacks on more social distance and creates even
revision as one gets to know others and as one worse outcomes.
learns and navigates the world. Social workers face the difficult task of taking
Measures of social distance track three main account of cultural effects, yet genuinely caring
factors: (1) affective distance, or sympathy for oth- for people in terms of human sameness. Several
ers; (2) normative distance, which involves who approaches have developed to help the profession
may be considered like or unlike us; and (3) inter- navigate this dichotomy. However, even these
active social distance, meaning how frequently or approaches can perpetuate certain effects related
intensely people interact. Social distance becomes to differentiation and distancing. The additive
embodied in social policies and plays out in indi- approach brings feasts, celebrations, and cata-
vidual actions. Service providers are not immune logs of typical cultural reactions to social work
to its effects, and so throughout American history, settings. This approach tends to be stereotypical
professionals have actually delivered many of the or superficial, emphasizing facts about a typical
harmful discriminatory effects of reprehensible culture rather than a person’s actual lived experi-
social attitudes and policies. Teachers and social ence of culture.
workers separated thousands of children from Integrative approaches fit selective aspects
African American, Native American, and immi- of a person’s reference culture into ecosystems,
grant families in the name of social betterment. empowerment frameworks, and strength-based
Forced sterilizations during the ascendancy of perspectives. Integrative approaches are nomi-
the eugenics movement disproportionaly affected nally universalist but tend to create artificial com-
members of minority groups. African Americans bination reference cultures that exist only within
were victimized in notorious medical experiments. the therapeutic framework and do not carry for-
Access to mental illness treatment affects the ward to support clients as they experience the
disproportionate criminalization of African world that they actually inhabit. Expansionary
Americans, the school-to-prison pipeline. Within approaches consider multiple reference categories
many cultures, there is a distrust of the medi- at once. Race, ethnicity, gender, religion, disabil-
cal community, expressed as stereotypes includ- ity, and even majority Western culture are fac-
ing one that men should be tough and reluctant tored into assessments and treatment protocols.
to seek medical care unless symptoms become However, even these approaches cannot avoid the
unbearable or truly life-threatening. distortions implicit in any use of catalogs of dif-
ferences. Transactions continue to be filled with
Cultural Diversity assumptions based on static ideas about cultures.
Today’s cultural diversity practices may be less Truly antidiscriminatory approaches involve
explicitly discriminatory in intent, but may still people relating to each other as people. They rec-
act oppressively. Implicit within social work ognize the complex, fluid nature of culture as it is
738 Racial Categorization

actually lived and start with techniques that have Further Readings
meaning within the world of the person served. Aguilar-Gaxiola, S., et al. “Community-Defined
People seeking help are recognized as experts in Solutions for Latino Mental Health Care
their culture and in what techniques might help Disparities: California Reducing Disparities
them. These techniques may differ considerably Project, Latino Strategic Planning Workgroup
from forms of practice favored by treatment sys- Population Report.” Sacramento, CA: University
tems or financed by claims payers. They may be of California, Davis, 2012.
difficult to audit for consistency with professional Brown, C. B. I Thought It Was Just Me: Women
or technical standards. The tension and poten- Reclaiming Power and Courage in a Culture of
tial for conflict within this “contextual fluidity” Shame. New York: Gotham, 2007.
model mirror the emergent features of life in a Cozolino, L. The Social Neuroscience of Education.
truly diverse, dynamic society. New York: W. W. Norton, 2013.
Race, culture, and ethnicity are important for Navarro, M. “For Many Latinos, Race Is More
every individual. People build these factors into Culture Than Color.” New York Times (January
their mental models and identity. They are part 14, 2012).
of the shame response, which, according to the
research of Dr. Brené Brown, “is experienced as
a complex web of layered, conflicting and com-
peting social-community expectations that dictate
who we should be, what we should be, and how Racial Categorization
we should be.”
The U.S. Surgeon General Office’s 2001 sup- Race is a highly controversial social concept that
plemental report on culture, race, ethnicity, and has been historically used to promote the inter-
mental health considered issues relating to men- ests of some populations and the exploitation and
tal health treatment for the four main minority abuse of others. It is used as a way of categoriz-
group classifications tracked by federal agencies: ing people into groups on the basis of biological
African Americans, American Indians and Alaska characteristics such as skin color and skeletal
Natives, Asian Americans and Pacific Islanders, structure. Ethnic classification is based on social
and Hispanic Americans. People within these and cultural behaviors attributed to individuals
classifications constituted 30 percent of the U.S. and groups, rather than merely physical charac-
population in 2000 and are expected to reach 40 teristics. The concepts of race and ethnicity are
percent of the population by 2023. different, but they overlap and may be treated
The four labels used in the Surgeon General as having the same meaning depending upon the
Office’s supplemental report are artificial group- context in which they are applied.
ings, extremely broad and imprecise. The Bureau The term race derives from words that refer to
of Indian Affairs recognizes 561 American Indian common descent, roots, or stock. The construc-
and Alaska Native tribes. People who are indig- tion and use of racial categories to differentiate
enous to the Americas may be called Hispanic if between people has taken a number of forms
they are from Mexico but American Indian if they throughout history. In ancient Greece, Hip-
are from the United States. pocrates referred to racial differences between
In 2012, the New York Times reported that the Asiatic people and Europeans. In the 17th century,
U.S. Census Bureau was having difficulty devel- the push to describe nature through classification
oping classification questions that Latino Ameri- led to attempts to define race as a biological con-
cans would answer with consistency. cept based on categorization of all human beings
into a number of racial types. In the 18th and
Paul Komarek 19th centuries, racial categorization was linked
Independent Scholar with developments in physiology, anthropology,
and European colonialism. Popular and scien-
See Also: Ethnicity; Race; Racial Categorization; tific interest in such classification is reflected in
United States. the common familiarity with the typology derived
 Racial Categorization 739

but the idea that certain races are less intelligent

than others still has some potency, as has been
seen in recent controversial writings. The socially
constructed scientific model of race has been used
to justify unequal power relationships explicitly
and implicitly throughout history.
Recent developments in genetic research,
including the Human Genome Project, have led
to a re-emergence of discussion about racial sus-
ceptibility to disease. There are some diseases
where there is genetic susceptibility associated
with broad racial categories, such as sickle cell
disease. However, the genetic basis of most com-
mon diseases remains largely unknown, and all
human beings are remarkably genetically similar.
Human genetic variation in populations does not
match up in any reliable way with racial catego-
ries. There is little biological or genetic difference
between human races, and there is much greater
A Native American youth testifies during a U.S. Senate Indian genetic heterogeneity at the individual level. From
Affairs Committee oversight hearing on Native American youth an ethnic categorization perspective, there is also
suicides and the urgent need for tribal mental health care much social similarity across different human
resources, March 25, 2010. In 2012, The suicide rate among societies in terms of culture and behavior, in terms
American Indian/Alaska Native individuals ages 15 to 34 was of social and cultural practices and rituals.
2.5 times higher than the national average for that age group. A shift in the use of race as a way of classifying
people began to occur in the mid-20th century.
In part, the horrors of the Nazi system that was
underpinned by an ideology of racial classifica-
from the work of writers such as Linnaeus, and tion and purity led to a revised conceptualization
later Blumenbach, of human races that are linked of human difference. In many societies, ethnicity
to continents, as can be seen in the racial catego- is now used as the favored way of grouping indi-
ries that still crop up in common parlance today, viduals and populations, based on self-identifica-
such as Caucasian, Mongolian, Malayan, Negro, tion. However, the stamp of racial classification
and American Indian. remains in most contemporary societal structures,
to a larger or lesser extent. It can be seen in social
Genetic Variation and health inequalities and in experiences of indi-
The language of scientific classification has been vidual and institutional racial discrimination. As
used to support claims that racial difference a concept, race is generally seen today as a way of
is natural or genetic, and therefore predictive. considering relationships between ethnic groups
While early writings on race highlighted physi- or in terms of race relations.
cal difference, in the 19th century, these physical
differences were linked to intelligence, moral- Social Definition
ity, and temperament. The first stage of genetic There are significant differences between coun-
research was underpinned by eugenics, a scientific tries and societies in the use of racial and ethnic
model that had a strong moral agenda. Eugenics categorization systems. In the United States, the
was used to support policies based on theories of social imprint of relatively recent social segrega-
racial purity and levels of intelligence, linked to tion policies and slavery based on racial catego-
assumptions about power and supremacy. There rization remains prominent. Although there is a
is no evidence that there are differences in levels shift to using ethnicity as a form of categorization
of intelligence between purported racial groups, in areas such as health policy and research, racial
740 Racial Categorization

grouping is still formally applied in the United in general, the appropriateness of their applica-
States alongside ethnicity. In the United Kingdom, tion across cultural groups, and the differential
on the other hand, self-identified ethnicity is for- ways in which they have been applied in some
mally used as a way of grouping people. Although ethnic minority groups. Queries have also been
race is not used in official statistics or documenta- raised about the validity and reliability of data
tion, implicit racial categorization may occur, as collected.
has been found in inquiries into racial discrimi- A prime example is the relatively high level of
nation in state institutions with a role in social diagnosed psychotic illness in people from Afri-
control, especially psychiatric and criminal justice can Caribbean backgrounds in the United King-
systems. dom. This has been interpreted as black people
Race and ethnicity are acknowledged by many having greater susceptibility to psychotic illness,
as constructs that reflect the social and economic in particular, schizophrenia. However, when the
circumstances of populations, including migra- interplay with environmental and social factors
tion patterns. Given that racial and ethnic catego- such as education, gender, migration status, and
rization systems have been overtly and covertly social class is taken into account, the significance
used to support and promote social interests of of ethnicity as a predictive risk factor is much
particular, mainly white groups, systems in place reduced. Related to this, concerns have also been
to collect and report on ethnicity are not always raised about differences in treatment, such as
trusted by those in minority groups. However, much higher levels of compulsory admissions of
collection of such data is needed to identify and black patients compared to the general popula-
monitor social and health inequality and to pro- tion and less control over treatment options. Pub-
mote equity. Self-identification with racial and lic inquiries have identified institutional racism as
ethnic categories is also viewed by many from a significant factor in experiences of psychiatric
ethnic minority populations as a way of drawing care for some black patients.
attention to inequality and redressing the balance For many people from ethnic minority groups,
of power and representation in society. Catego- there is a strong distrust of psychiatric care,
rization systems need to be responsibly applied, linked to the perceived role of psychiatry as a
with race and ethnicity understood as complex form of social control and oppression and cul-
concepts, the construction, meanings, and use of tural concerns about the stigmatization of those
which depend upon context, which will change with mental illness. Research has shown that
over time. racial stereotyping may affect rates of diagnosis,
Social discourse about race and ethnicity across decisions about treatment, and care experience.
different media, including research and policy Recent research has also focused on the mental
agendas, is selective. It is important that research- health of migrants who have experienced major
ers and policy makers appreciate that their val- trauma from war, ecological disaster, or famine,
ues will influence what data is collected and how and the associated impact of adapting to life in a
it is interpreted. Racial and ethnic groupings are new society.
included in popular discourses about immigration, Race and ethnicity are ways of thinking about
with negative social stereotyping and social exclu- difference between human beings. While both are
sion of certain immigrant populations, including contentious in terms of meaning and application,
economic migrants, refugees, and asylum seekers. grouping people according to race is particularly
Experiences of racism and social exclusion are controversial because it is based on unsound, sci-
associated with experiences of mental illness. entifically invalid criteria and has been used to
provide support for a racial hierarchy. Grouping
Mental Illness according to ethnicity is generally accepted as a
Mental illness has a particularly complex rela- way of defining and investigating human differ-
tionship with race and ethnicity. Rates of men- ence and inequality, but it is also subject to criti-
tal illness have been found to vary between eth- cism over interpretation and application. The
nic groups. However, major questions have been mental health and well-being of different ethnic
raised about the validity of psychiatric constructs groups needs to be critically considered in relation
 Randomized Controlled Trial 741

to the interplay between multifactorial influences, developed for investigating the effects of drugs and
including recent and past history such as colonial- medical treatments and not complex interventions
ism and migration. such as behavioral treatments for mental illness.
High-quality RCTs have core characteristics
Moira J. Kelly that control for potential bias and help ensure
Queen Mary University of London study validity. RCTs also have limitations, espe-
cially as they relate to behavioral treatments for
See Also: Diagnosis in Cross-National Context; improving patient and community mental health.
Ethnicity; International Comparisons; Race; Race and The outcome variable should be observable,
Ethnic Groups, American. quantitative, and reliable; add minimum random
variability; be chosen prior to data collection and
Further Readings data analysis; and importantly, clinically relevant.
Centers for Disease Control and Prevention. “Suicide:
Facts at a Glance, 2012.” http://www.cdc.gov/vio Design Types and Considerations
lenceprevention/pdf/suicide-datasheet-a.PDF The parallel group (about 75 percent) and cross-
(Accessed July 2013). over design (about 15 percent) account for the
Cornell, S. and D. Hartmann. Ethnicity and Race: vast majority of RCT designs. In a parallel-group
Making Identities in a Changing World. 2nd ed. design, or what in the behavioral sciences is
Thousand Oaks, CA: Pine Forge Press, 2007. called an independent groups design, participants
Frank, R. “What to Make of It? The (Re)Emergence are randomly assigned to either the intervention
of a Biological Conceptualization of Race in treatment (IT) or comparison treatment (C). For
Health Disparities Research.” Social Science & most behavioral treatments or any treatment that
Medicine, v.64 (2007). produces long-lasting effects, this is the preferred
Rogers, A. and D. Pilgrim. A Sociology of Mental design. In a crossover design, each participant
Health and Illness. 4th ed. Maidenhead, UK: Open receives both the intervention treatment and the
University Press, 2010. control treatment in one of two sequences (such
as IT-C and C-IT) in order to evaluate the pres-
ence of carryover effects that would complicate
interpretation of the results.
For an RCT to be convincing, a number of pre-
Randomized randomization experimental design factors should
be specified. Three salient prerandomization fac-
Controlled Trial tors include (1) clearly outlining the study partici-
pant inclusion/exclusion criteria; (2) developing
A randomized controlled trial (RCT) is a planned clear guidelines for analyzing subgroups, including
experiment, conducted on human participants methods for handling simultaneous testing; and
assigned randomly to treatment conditions to (3) specifying the methods for handling dropouts
determine the clinical efficacy or effectiveness and missing data. The most conservative and rec-
of a therapeutic intervention. Randomized com- ommended approach is to analyze all participants
parative or randomized clinical trials are alterna- randomized to treatment. The phrase, “once ran-
tive terms. RCTs are common in medical, mental domized, always analyzed” captures the essence
health, educational, and social research situations. of the intention-to-treat (ITT) principle. Follow-
Major characteristics of an RCT include random- ing an ITT analysis protocol minimizes bias and is
ization to treatments, comparing a new treatment a characteristic of a high-quality RCT.
intervention with a standard or placebo treat-
ment, and various additional methods to ensure Blinding, Sample Size, Power,
study validity. and Randomization
RCTs are true experiments and frequently Blinding or masking participants (single), and
described as the “gold standard” for determin- investigators, clinicians, or data analysts (double
ing treatment effectiveness. Initially, they were or triple) to the treatment condition to which the
742 Randomized Controlled Trial

participant has been assigned is a characteristic and the baseline data are collected prior to ran-
of a high-quality RCT. Unblinded RCTs are espe- domization, baseline data can be used as a covari-
cially prone to bias, and, unfortunately, blinding ate or blocking variable in the analysis when
is especially challenging to design, implement, preplanned. Importantly, baseline data allows
and maintain with behavioral treatments. formation of subgroups, and a subgroups analy-
For both ethical and practical reasons, the sis can provide information about specific clinical
number of participants randomized to treatments differences in treatment efficacy or effectiveness.
should be kept as small as possible, yet large The focus of an RCT is the size and clinical
enough to detect a clinically important differ- importance of the treatment effect and not merely
ence. A minimally clinically important difference statistical significance. Reporting and interpreting
(MCID) is the smallest treatment difference held the magnitude and precision of the raw and stan-
by the investigator to be of clinical importance. dardized treatment effect should hold center stage.
Most trials with negative results fail because they Interpreting confidence intervals and effect sizes
do not use a large enough sample to detect a small provide a basis for determining the importance of
but important difference. Conducting a power the trial from a clinical perspective and for apply-
analysis to determine study sample size requires ing the results to individual patients. At a mini-
the investigator to specify power (usually 0.8 to mum, the reported results should include all sta-
0.9), effect size, trial variability, test directional- tistics required for conducting a meta-analysis of
ity (usually nondirectional), and acceptable type I the treatment effect. Special analytic approaches
error rate (usually 0.05). It is advisable to adjust are required for group or cluster RCTs.
sample size calculations in accordance with antic-
ipated attrition. Practical Limitations and
Randomizing participants to treatment has Ethical Considerations
three important benefits: (1) it eliminates assign- RCTs have a number of practical limitations
ment bias, (2) produces comparable or equivalent that reduce their deployability. Conducting an
groups in the long run, and (3) provides a basis RCT is time consuming, expensive, and resource
for valid statistical inference. Random assignment demanding. What is more, the results of a well-
to treatments distributes all factors and popula- designed RCT are artificial and are often difficult
tion characteristics uniformly across the treat- to apply directly to real-world patients. RCTs
ment conditions. The result is to provide an unbi- must meet strict ethical standards. Clinical trials
ased treatment comparison and form the basis for are conducted only when there is a clear body of
strong conclusions. prior research to suggest equivalence, noninferi-
Simple or unrestricted randomization has a ority, or superior effectiveness and safety of the
major limitation in small trials where unbal- intervention versus current methods in use. An
anced designs are likely to influence power. Many important limitation of a single RCT is that it is
restricted randomization methods are available to not powered to detect rare harmful effects (such
ensure balance throughout the trial. It is impor- as suicide). Thus, when a point estimate for a
tant to clearly define and report the randomiza- harmful treatment effect is reported, it is prudent
tion method. to examine the p-value function itself, given that
potential values for the parameter are more than
Baseline Data and Analyzing and six times likely at the estimate than are values at
Reporting Results the extremes of a 95 percent confidence interval.
Collecting baseline participant information adds
quality to any clinical trial. Baseline character- Ward Rodriguez
istics of the participants define the population California State University, East Bay
actually sampled, determine study eligibility, and
evaluate the effectiveness of the randomization See Also: Clinical Trials; Cognitive Behavioral
process itself, especially as it relates to disease sta- Therapy; Drug Development; Pharmaceutical
tus and prognostic variables. When the random- Industry; Placebo Effect; Psychopharmacological
ization process fails to produce equivalent groups Research.
 Rationality 743

Further Readings Max Weber

Barkham, Michael, Gillian Hardy, and John Mellor- In sociology, Max Weber was one of the first
Clark. eds. Developing and Delivering Practice- authors who conceptualized different sources,
Based Evidence: A Guide for the Psychological providing sense to social action. While Karl
Therapies. Hoboken, NJ: John Wiley, 2010. Marx, and especially Marxist thinking, idealized
Healy, David. “The Antidepressant Tale: Figures thought and consciousness as a kind of reflex of
Signifying Nothing?” Advances in Psychiatric material conditions in society, which is deter-
Treatment, v.12 (2006). mined as a one-to-one fit with the relations of
Healy, David. Pharmageddon. Berkeley: University of production, Max Weber was led by the idea that
California Press, 2012. consciousness is never right or wrong, but always
Marks, Harry M. The Progress of Experiment: has a (relative) autonomy from the status sig-
Science and Therapeutic Reform in the United naled by the regime of the material world. Cul-
States, 1900–1990. Cambridge University Press, tural factors, including religion and related dis-
1997. positions, are factors influencing the rationality
Murray, David, M. Design and Analysis of Group- of social behavior, according to Max Weber. He
Randomized Trials. New York: Oxford University came up with a typology of social action based
Press, 1998. upon different sources of legitimation, which are
National Institute of Mental Health. “Clinical Trials.” traditional social action (based on tradition and
http://www.nimh.nih.gov/health/trials/index.shtml cultural norms), affective social action (based
(Accessed May 2013). upon emotions), instrumental and purposeful
Piantadosi, Steven. Clinical Trials: A Methodological social action (zweckrationalität), and value ratio-
Perspective. 2nd ed. Hoboken NJ: John Wiley, nal action (wertrationalität), where the end justi-
2005. fies the means. According to that typology, there
is no single type of rationality, but four types can
be separated as an idealtypus; they practically
overlap each other, and behavior has different
compositions of elements of rationality.
Rationality Thinking of rationality as a driver of social
action, the implication is not that people can
Human action differs from processes in the physi- always decipher the individual elements of the
cal world in that action in the social world is forces by which they are driven. Sociology uses
driven by motivation. Motivation is embedded the term of habituation, which refers to deeply
in a social framework of social goals and related internalized routines of action, which help to
preferences. Phenomenology describes that social economize everyday life without repeatedly ask-
action is led by a cognitive structure of sense and ing for the argumentative legitimation of the self.
relevance, which guides people through their In that way, habituation acts as an economy mea-
biographies. Such cognitive structures of sense sure because people do not have to seek instruc-
and relevance serve as a kind of normative com- tions every time in order to come up with deci-
pass, indicating which aims are positive, neutral, sions, as discussed by Peter Berger and Thomas
or negative, and how specific social actions are Luckmann. In contrast to sociology, psychology
related to those aims. refers to subconsciousness as a separate sphere,
The term rationality has its origin in the Latin which influences people’s behavior without giving
ratio, which is another term for pure reason. full control to actors’ decisions, as Sigmund Freud
Statements of reason can differ according to dif- first explained.
ferent social logics within a single society and
between societies, in recent and historical times. Abraham Maslow and Gary Becker
Philosophy dealt with that question, and philoso- With respect to preferences in combination with
pher Karl Popper, in particular, discussed the rela- lifestyles, needs, and behavior, the social psy-
tivity of rationality in his critical rationalism in chologist Abraham Maslow developed a scheme
great depth. of steps that set goals for human behavior, which
744 Rationality

he ranked in the form of a pyramid. According but according to Becker all decisions are based
to Maslow, people try to meet the satisfaction of upon rational decisions of selfishness. Becker
basic needs first, and later they try to cope with put much effort into explaining his idea in many
more elaborate needs. Much earlier, Carl Menger, examples, such as choice of marriage, sports, res-
inventor of the marginal utility theory in econom- taurant visits, or decisions regarding the family or
ics, already operated with such a ladder of needs career, but finally an understanding of rationality
based upon assumptions about human nature, becomes self-referential, since all actions prove to
whereas neoclassical thought tended to reduce the be outcomes of a rational decision. If all emotion
economic man and a functionalized stereotype of tends to be part of rationality, the term becomes
social action corresponding to the homo oeco- obsolete, and the traditional meaning of ratio
nomicus, who is portrayed as driven by egoistic could be replaced by behavior.
and profit-seeking motivation. Although Weber A different way to foster an understanding of
had already argued that economics operated with rationality is the explicit addressing of emotions as
an unrealistic human being analogous to a math- a field of research. This method of analysis merges
ematical idealtypus, economics continued to use different disciplines and has gained considerable
the model as a kind of assumption and starting attention during the last two decades. However,
point for further reflections. talking about rationality (or nonrationality)
The homo oeconomicus was textbook knowl- always implies that one knows how people think.
edge for decades, until doubts were increasingly The brain usually serves as a black box. Sociol-
expressed, even in the field of economics. Her- ogy, psychology, or economics increasingly move
bert A. Simon had defined the term of bounded in new directions, in different integrations with
rationality as a type of behavior, which underlines neurosciences, by asking for neurophysiological
that rationality is much more complex than the and biological foundations of decisions. Diver-
abstraction tells. While Nobel laureate Simon had gent issues, such as happiness or trust capacity,
a background in psychology, other later psycholo- can also be analyzed in relation to the workings
gists succeeded in economics while pointing to the of the brain.
necessity of implementing more realistic features Cognitive neuroscience can deal with mem-
of human beings and their rationality. Psycholo- ory, speed of thinking, creativity, attention, and
gist and Nobel laureate in economics Daniel Kah- flexibility much more adequately than previous
neman extended that type of thought, referring to thinking, which has not tried to merge different
norms and further variables influencing behavior, insights. Future discussion should acknowledge
and accordingly, the definition of behavior. Nobel further developments in these fields in order to
laureates George Akerlof and Robert Shiller or avoid discussion on the basis of assumptions.
Douglass North also said that economics is too Also, it is important to arrive at a better under-
silent regarding an appropriate acknowledgement standing about the degree to which behavior is
of motivation and an analysis of its factors. socially learned and embedded in specific social
Given the fact that human behavior has proven contexts, and the degree to which behavior is gov-
more complex than can be expressed in mono- erned by neurotransmitters and neuromodulators.
causal and linear assumptions of a rational man
who has no social context and lives without being Dieter Bögenhold
captured by institutions and related norms, con- Alpen-Adria-University Klagenfurt
straints, and opportunities; without having social
attributes such as age, biography, life history, See Also: Cognitive Behavioral Therapy; Emotions
family, gender, occupation, and education; and and Rationality; Social Control.
without belonging to a specific concrete time or
space, the rationality concept remains a vague Further Readings
and empty term. Kahneman, Daniel. Thinking, Fast and Slow. London:
One way out of the dilemma was taken by Gary Penguin, 2012.
Becker when considering that “behavior is driven Lagueux, Maurice. Rationality and Explanation in
by a much richer set of values and preferences,” Economics. London: Routledge, 2010.
 Refrigerator Mother 745

Scherer, Klaus R. “On the Rationality of Emotions: hypothesized its role in the etiology of the dis-
Or, When Are Emotions Rational?” Social Science order. In subsequent papers, this hypothesis was
Information, v.50/3–4 (2011). worded more strongly, and a refrigerator analogy
was provided, whereby the child was described as
if they had been “left neatly in refrigerators which
did not defrost,” with their withdrawn state moti-
vated to seek solitude from this situation.
Refrigerator Mother The hypothesis was elaborated with reference
to psychoanalytic concepts and was popularized
The term refrigerator mother refers to the hypoth- by the works of Bruno Bettelheim in nonacademic
esis that emphasizes the role of parental factors in articles and the book The Empty Fortress: Infan-
the etiology of autistic disorders. This hypothesis tile Autism and the Birth of the Self in 1967. In
has been criticized for its lack of empirical support this book, Bettelheim paralleled the suffering of
and for placing blame and guilt on the parents of the child with autism in mother–child interac-
children with autism. Autism is a developmental tions with the experiences of deprivation in the
disorder initially described independently by Leo concentration camps of World War II. Such psy-
Kanner and Hans Asperger, with the current con- chogenic conceptualization had implications for
ceptualizations encompassing a triad of qualita- the treatments offered, including emphasis on the
tive impairments in social interaction and com- provision of empathy and emotional warmth, and
munication and restricted or repetitive behaviors the institutionalization of affected children away
or interests. from families labeled as causative.
The refrigerator mother hypothesis explained The refrigerator mother hypothesis faced
the infant’s development of autism as a defensive increasing dissent following publications by
response to inadequacies in parent–child interac- psychologist Bernard Rimland in 1964 and psy-
tion, considering the parenting as defective and chiatrists John and Lorna Wing in 1966. These
characterized by coldness and emotional unavail- authors critically examined limitations of the
ability. Furthermore, the pattern of parent–child explanatory power of the refrigerator mother
interaction was viewed as characterized by an hypothesis, suggesting that the evidence was
obsessional and mechanical attention to the more consistent with a biological etiology and
physical needs of the child. Dissent from this the- emphasized the need for further research. Prob-
ory served as a motivating force behind further lems with the refrigerator mother hypothesis
empirical research into the disorder and parental included both the presence of children unaffected
activism. There is limited evidence to support the by autism in families of autistic children with
etiological role of parenting in autistic disorders, parents who fit the refrigerator stereotype and
and the disorder is now most commonly explained the absence of increased risk of autism in studies
with reference to a complex interplay of poorly of children reared in highly emotionally deprived
understood biological factors. institutional settings. The refrigerator mother
hypothesis was also increasingly met with hos-
Rise of the Theory: 1950s to the early 1970s tility from parents who were frustrated at being
The theory of the refrigerator mother dominated blamed for their children’s difficulties and limita-
early academic and popular thinking about autism tions. This hostility provided the cultural climate
between the 1950s and early 1970s. While the within which the grassroots advocacy and sup-
origins of the term refrigerator mother are uncer- port organization the National Society for Autis-
tain, the etiological implication of parenting, and tic Children (now the Autism Society of America)
more specifically maternal factors, was evident in was established in 1965.
the earliest descriptions of the disorder by Kan- Over time, this dissent served to mobilize
ner. In his original case series-based description empirical research into autism. A body of research
of the syndrome in 1943, he made reference to examining children with autism and their parents,
parental obsessiveness and a relative absence of including the work of Michael Rutter and Mar-
“really warm-hearted mothers and fathers,” and ian DeMyer, emerged between the mid-1960s and
746 Religion

the 1970s, with findings not supporting the refrig- Religion

erator mother hypothesis. Such findings included
difficulties distinguishing between the parents The connection between religion and mental
of normal, autistic, and brain-damaged children health has deep historical roots; for thousands
on personality measures; the high prevalence of of years, many adherents of Christianity, Juda-
mental retardation and epilepsy in autistic chil- ism, Islam, and a variety of Asian and African
dren; similarities between children with autism religions viewed mental illness as at least partially
and brain damage on infant rating scales; and attributable to spiritual power or demonic pos-
the poor prognostic picture, despite treatment, in session. Events like the Salem witch trials, during
regard to independent functioning. which childhood mental illness was interpreted as
The refrigerator mother hypothesis has been the work of Satan and prayer was recommended
superseded by neurobiologically based theories. to cure it, underscored the extent to which beliefs
While the etiology of autism remains poorly about religion could penetrate secular under-
defined, a problem that may relate to the valid- standings of medical symptomatology.
ity of the core triad of symptoms as a unifying From a diagnostic perspective, while the Amer-
syndrome, the centrality of biological factors is ican Psychiatric Association’s Diagnostic and Sta-
emphasized and supported by the scientific litera- tistical Manual (DSM) refrained from explicitly
ture. However, themes relating to parental blame explaining mental illness via religion, examples
and maternal guilt continue to be acknowledged. of psychopathology routinely contained religious
This includes blame or guilt in relation to the content until the DSM-IV. Although debate con-
parent’s failure to protect the child from environ- tinues regarding the extent to which clinicians
mental factors such as vaccinations that continue should take religion into account in the diagnostic
to be a subject of popular debate, despite a lack and treatment processes, religion shapes experi-
of supporting empirical evidence. Additionally, ences of mental illness via a variety of pathways.
current Western cultural conceptualizations of Specifically, religious doctrine informs adherents’
the “good mother” involving intensive mother- views of mental illness; religious involvement is
ing can place a heavy burden of responsibility associated with variation in prevalence, inci-
on mothers to assertively advocate to maximize dence, and severity of a number of mental health
resources supporting their child or children with outcomes; and religious institutions provide sup-
autism. port for those who suffer from mental disorders.

Stephen D. Parker Religious Views of Mental Illness

University of Queensland Belief that religion may impact health is com-
mon. For example, a nationally representative
See Also: Autism; Pervasive Developmental study from the National Center for Health Sta-
Disorders; Psychoanalysis, History and Sociology of; tistics, National Center for Complementary and
Stereotypes. Alternative Medicine, and the Centers for Disease
Control and Prevention revealed that 43 percent
Further Readings of Americans pray for better health, while about
Bettelheim, Bruno. The Empty Fortress: Infantile 25 percent ask others to pray for them. Religious
Autism and the Birth of the Self. New York: Free doctrine across numerous religions provides a
Press, 1967. basis for belief in the efficacy of religious involve-
Silverman, Chloe. Understanding Autism: Parents, ment vis-à-vis mental health.
Doctors, and the History of the Disorder. Religious doctrines offer dramatic conceptual-
Princeton, NJ: Princeton University Press, 2012. izations of mental illness as a product of spiritual
Sousa, Amy C. “From Refrigerator Mothers forces. Biblical texts used by Jews and Christians
to Warrior-Heroes: The Cultural Identity alike, such as Deuteronomy, warn that disobe-
Transformation of Mothers Raising Children With dience to the Lord leads to mental confusion or
Intellectual Disabilities.” Symbolic Interaction, madness. In the gospels of Christianity, Jesus is
v.34 (2011). described as casting demons out of the sick (who
 Religion 747

could be described as mentally ill, according to In all of these cases, religion provides a frame-
modern conceptualizations). Consistent with the work for understanding mental illness, which
biblical principle of curing by casting out demons, may or may not conform to prevailing psychiatric
Roman Catholicism developed specific proce- definitions of particular diagnoses. Thus, religion
dures for ordained exorcism. has the potential to complicate and/or comple-
Islam similarly explains mental health as influ- ment patients’ understandings of their mental
enced by supernatural forces but depicts these health. Scholars have increasingly begun to sug-
forces as potentially beneficial; the Koran asso- gest that clinicians may be able to improve their
ciates psychosis with possession by supernatural communication with patients by framing their
jinn (spirits), which can assume benign or mali- treatment protocols in a manner consistent with
cious forms. Thus, schizotypal symptoms have explanations emanating from these patients’ faith
been described as indicative of closeness with traditions.
God, while similarly positive religious interpre-
tations have been made of paranoid, avoidant, Impact of Religion on Incidence
and obsessive-compulsive behaviors. Further, the and Severity of Mental Illness
Islamic perspective on stress is often focused on Religion often provides meaning, a sense of
its role as a test of endurance from God, from purpose, structure, and social support. It can
which God ultimately provides respite. serve as a useful coping mechanism in the face
The Tripitaka of Buddhism, a written account of stressors, providing, in many religious tradi-
of Buddha’s teachings, constructs mental illness tions, assurances that even if life is difficult, there
as the product of failing to be mindful and per- is a potentially better existence beyond it. Con-
ceptive of one’s thoughts. Spiritual shortcomings sistent with these benefits, the bulk of available
were equated with mental problems. However, evidence suggests that religion, whether assessed
modern Buddhists often distinguish between spir- via institutional factors such as church attendance
itual illness, which requires resort to the teachings or noninstitutional factors such as private prayer,
of Buddha, and mental illness, which is seen as is positively associated with mental health. Over
treatable by conventional medication and psycho- 250 studies articulate that some aspect of religios-
logical treatment. ity/spirituality is positively correlated with one or
In Hinduism, mental disorders within Ayurvedic more indicators of psychological well-being. Spe-
medicine are seen as resulting from excessive cifically, positive relationships between religion
grief, intoxication, poison, or the dosas (three and measures of well-being such as happiness,
humors), which include phlegm, bile, and wind. optimism, positive affect, hope, self-esteem, and
Ayurvedic texts such as the Carak Samhita and life satisfaction abound in the literature.
the Susruta Samhita also describe spirit posses- Studies linking religion to mental health tend to
sion in their description of conditions that closely focus on various aspects of well-being as opposed
resemble Western ideas of personality disorders to cut-point determinations of psychiatric disor-
and psychosis. Additionally, Ayurveda suggests der. However, over half of studies that go beyond
that insanity comes from unsettling in the mind, symptomatology and analyze the connection
which can arise when one commits evil, breaks between religion and psychiatrically diagnosable
a vow of celibacy, improperly conducts religious illness such as depression, anxiety disorders, and
ceremonies, insults a teacher or the gods, or com- schizophrenia and related psychoses demonstrate
mits one of a series of other acts. the protective capacity of religious involvement,
Like Judeo-Christian, Islamic, Buddhist, and and such protective effects are particularly appar-
Hindu traditions, certain African religions have ent in older adults. Still, psychiatric disorders may
also posited a religious origin for mental health still arise among the religious, necessitating con-
outcomes. For example, the Yoruba in precolo- sideration of not only whether religion is related
nial west Africa described malicious spirits that to differences in prevalence and incidence of men-
were responsible for mental illnesses. Divination tal illness but also whether religion is related to
formed an important part of treatment for mental changes in the severity of mental illness progres-
maladies. sion. Current research addresses these issues in
748 Religion

relation to depression, anxiety, and, to a lesser upon exposure to religious/spiritual interventions

extent, psychotic disorders. than those provided with secular interventions or
One of the most common psychiatric disorders, no intervention.
depression, is typically characterized by sadness, Religious attendance, volunteering, medita-
discouragement, and demotivation. At high levels, tion, viewing God as a source of strength, and a
depressive symptoms can signify a serious men- number of other manifestations of religiosity are
tal disorder, with the potential for complications inversely associated with mental illness. Analyses
in daily functioning and mortalities from suicide reveal that the impact of religion on depression
approaching a rate as high as 9 percent. Religion is robust in the face of numerous controls and is
may help individuals cope with stress that would consistent across a diverse range of samples, from
otherwise lead to the development of depression. young respondents in the National Longitudinal
Most observational, cross-sectional, prospec- Study of Adolescent Health (Add Health) in the
tive, and experimental studies of the connection United States to Palestinian participants in the
between religious involvement and depressive West Bank and Gaza Strip. Further, its effect size
symptoms or rates of depression report a positive approximates that of gender, a well-documented,
association, although some indicate that more reli- significant indicator of depression.
gious individuals have higher rates of depression, Anxiety is another common part of the human
and others find no significant association. Addi- experience that can become problematic at high
tionally, in a majority of clinical studies, patients levels, and it consists of emotional arousal in
with depression recovered significantly faster expectation of a potential threat. It catalyzes

A Hindu priest gives a blessing in Belur, Karnataka, India, October 11, 2008. In Hindu Ayurvedic medicine, mental disorders result from
excessive grief, intoxication, poison, or the dosas (the three humors of phlegm, bile, and wind). The description of spirit possession
in the Ayurvedic texts Carak Samhita and Susruta Samhita closely resemble Western ideas of personality disorders and psychosis.
Additionally, insanity comes from an unsettled mind, a result of sins such as committing evil or breaking a vow of celibacy.
 Religion 749

preparedness and typically does not interfere with Although the majority of studies connecting
normal functionality, unless severe or of signifi- religious involvement and mental illness suggest
cant duration. However, anxiety at the level of a an inverse relationship, several caveats should be
diagnosable condition, such as generalized anxi- noted. First, the relationship may differ signifi-
ety disorder or panic disorder, can manifest itself cantly according to faith tradition. For example,
from an overarching state of worry, detached from among religious individuals, Jews and Pentecos-
any specific major stressor. At least 299 studies tals appear to face a higher risk of depression
have examined the connection between religios- than Catholics and non-Pentecostal Protestants.
ity/spirituality and anxiety, utilizing quantitative, Additionally, even though the causal direction is
observational, experimental, and randomized typically presented with religion impacting men-
clinical methods. The results provide a compli- tal illness (e.g., those who attend religious services
cated account; although nearly half of studies on are less likely to develop depression), reverse cau-
this topic found a significant, inverse relation- sation is also possible; mentally ill persons may
ship between religion/spirituality and anxiety, 11 simply be less likely to involve themselves in reli-
percent found a positive relationship, and others gious activities. For example, depressed individu-
found no association. als may lack the motivation to participate in pray-
A number of religious activities are inversely ing, singing, or other forms of worship.
associated with anxiety, including reading reli- Further, although less common, studies that
gious texts (such as the Bible or Koran), praying, suggest a positive relationship (i.e., increases
and engaging in religious services and ceremo- in religious involvement are associated with
nies. Evidence also suggests that some religious increased likelihood or severity of mental illness)
and/or spiritual interventions might be used to deserve consideration. A number of religious doc-
actively treat patients with anxiety disorders. trines intentionally promote guilt for trespasses
Studies utilizing Eastern meditation, transcenden- as a way of motivating behavioral modification
tal meditation that draws on Hindu principles, in conformance with religious teachings. Addi-
and Buddhist mindfulness meditation generally tionally, while religion provides many positive
find that religious/spiritual intervention is asso- mechanisms for coping with difficult situations in
ciated with reduced anxiety. Religion appears to life, people can also use religion in mentally inju-
have an inverse relationship with anxiety in at rious ways in coping scenarios. When individu-
least some circumstances, although the evidence als respond to stressful events by viewing them
remains mixed. as a manifestation of a deity’s anger or punish-
Religion also has import for psychotic disor- ment, feel angry at a deity for their plight, or feel
ders. Research in this area is sparser, but some deserted by a deity or fellow religious adherents,
studies suggest an inverse relationship between these forms of negative religious coping are asso-
religiosity and the course of schizophrenia and ciated with psychological distress, anxiety, and
bipolar disorder (which includes depressive depression.
symptoms but is also frequently associated with These potential negative effects of religion on
psychotic symptoms). In one sample, if African mental health outcomes should also be critically
Americans with schizophrenia were encouraged examined. Research identifying such effects is
by family members to participate in religious wor- typically observational rather than clinical. Fur-
ship while in the hospital, they were less likely to ther, reverse causation may also explain the rela-
be rehospitalized. Several studies have also noted tionship in this case. For example, findings that
that religious coping is inversely related with church attendance is associated with greater inci-
schizophrenia symptom severity. Regarding those dence or severity of depression may simply indi-
living with bipolar disorder, data from a Cana- cate that mentally ill individuals increasingly turn
dian sample revealed that those who attended to religion to make sense of or cope with their ill-
church were less likely to report manic symptoms. ness. Finally, measurement error can distort find-
However, there are only a limited number of stud- ings; for example, negative religious coping may
ies available analyzing the potential relationship be picking up on broad feelings of anger or aban-
between religion and psychotic disorders. donment within an individual that are not specific
750 Religiously Based Therapies

to religious involvement. In fact, individuals with sometimes incorporate cognitive behavioral ther-
high levels of negative religious coping often do apy based on a Christian perspective. All of these
not self-identify as religious and draw on anger approaches are religiously centered but are still
toward God and related elements of negative reli- open to coordination with mental health profes-
gious coping to substantiate their nonparticipa- sionals for patient supervision and treatment.
tion in religion.
Steven L. Foy
Religious Institutional Support Duke University
for People With Mental Illnesses
Aside from access to religious experiences and See Also: Anxiety, Chronic; Depression; Mental
social support from fellow coreligionists that Illness Defined: Historical Perspectives; Mental Illness
may temper the onset or course of mental ill- Defined: Psychiatric Perspectives; Mental Illness
ness, religious institutions may also provide more Defined: Sociological Perspectives.
formalized institutional resources. Some reli-
gious institutions provide free health clinics or Further Readings
in-house faith-based health education programs DeHaven, Mark J., Irby B. Hunter, Laura Wilder,
that promote mental health. Studies suggest that James W. Walton, and Jarett Berry. “Health
participation in such programs is associated with Programs in Faith-Based Organizations: Are They
reduced mental illness symptomatology. Effective?” American Journal of Public Health,
Additionally, spiritual leaders may provide v.94/6 (2004).
assistance with mental health problems; in fact, Koenig, Harold, et al. Handbook of Religion and
more Americans turn to a clergy member than Health. 2nd ed. New York: Oxford University
to psychiatrists, psychologists, doctors, marriage Press, 2012.
counselors, or social workers for help with per- Levin, Jeff. “Religion and Mental Health: Theory
sonal problems, and many of these problems per- and Research.” International Journal of Applied
tain to psychological issues. Psychoanalytic Studies, v.7/2 (2010).
Although clergy can be a great source of com- Taylor, R. J., C. G. Ellison, L. M. Chatters, J. S.
fort and support for the mentally ill, their provi- Levin, and K. D. Lincoln. “Mental Health Services
sion of services may be subject to certain limita- in Faith Communities: The Role of Clergy in Black
tions. Clergy tend to underestimate the severity Churches.” Social Work, v.45/1 (2000).
of psychotic symptoms and may interpret medical Verhagen, Peter J., Herman M. van Praag, Juan J.
symptomatology in purely religious terms. For López-Ibor Jr., John L. Cox, and Driss Moussaoui,
example, ministers may explain hallucinations eds. Religion and Psychiatry: Beyond Boundaries.
as manifestations of religious conflict. Further- West Sussex, UK: John Wiley & Sons, 2010.
more, on average, lower-educated and more ideo-
logically conservative clergy members are more
likely to attempt to treat mental illness themselves
rather than refer congregants to secular mental
health providers. Religiously Based
Nevertheless, clergy-based counseling is not
necessarily antagonistic toward psychological or Therapies
psychiatric approaches. Theophostic prayer min-
istry (TPM) emphasizes how lies embedded in Although the science of psychological treatment
memories can result in psychological distress and and counseling represents a relatively modern
focuses on prayer to reveal the truth of previous domain within the activity of psychotherapy, the
experiences. Freedom in Christ Ministries (FICM) social role of the talk therapist has undergone
suggests that belief in unbiblical falsehoods leads multiple evolutions, both cross-culturally and
to psychological distress, requiring confession across time. Since antiquity, spiritual forms of
and denouncement of non-Christian involve- healing were the default method for alleviating
ment and repentance. Christian counselors also psychological distress, with charismatic clergical
 Religiously Based Therapies 751

authorities such as shamans, priest(esse)s, rabbis, demands from many of their patients, since 1999,
and other religious leaders their primary practi- the Joint Council of Accreditation of Health Care
tioners. In contrast, the social role of the scien- Organizations (JCAHO) has mandated that spiri-
tist was relegated to that of a technician, perhaps tual assessments be performed on every hospital-
most famously epitomized by ancient Greek phy- ized patient. Clergy, in contrast, often without spe-
sicians, who relied on naturalistic treatments and cific training, spend many hours delivering mental
their understanding of the bodily system in terms health counseling, perhaps even more than that
of the four humors to heal the body, rather than delivered by psychologists/psychiatrists.
depending on supernatural interventions such as The amount of time that clergy spend counseling
faith, charms, or prayer. In modern times, this their parishioners is substantial. Weaver reviewed
approach reasserted itself during the Middle Ages 10 studies showing that clergy spend 10–20 per-
and the Renaissance when, aided by the aggres- cent of their 40–60-hour workweek counseling
sive colonization by eastern European nations people. Koenig applies this percentage to a 1998
and the decline of the Catholic Church’s author- Department of Labor estimate of 353,000 clergy
ity, some version of scientific empiricism became a serving congregations in the United States, con-
ubiquitously championed Western cultural value. cluding that clergy spend approximately 138
With reason trumping revelation in the West, the million hours delivering mental health care each
sphere of psychological healing shifted to the phy- year. For the approximately 83,000 members of
sician and from there, in some instances, to the the American Psychological Association to reach
psychologist or social work therapist. such a figure would require each APA member
The usual method in the last two centuries of to offer 33.2 hours of mental health services per
addressing conflicts between science and religion week. Yet, Koenig questions the degree of knowl-
has been to attempt to avoid them by treating edge of mental illness of many clergy, even among
the two fields as having separate perspectives on those conducting pastoral counseling. J. E. Lafuze
the world. In the field of psychology in particu- and his associates report that 86 percent of 1,031
lar, mental health practitioners tend to disparage mainline Methodist ministers sampled agreed that
belief in a creator as delusional (a “mass delusion” medication helps people control symptoms and
as Sigmund Freud called it) or immature and to manage their relationships better. However, 47
avoid in therapy any reference to a patient’s reli- percent of these same pastors incorrectly believed
gious beliefs and their influence on them. Profes- that psychiatric patients are “more dangerous
sor Harold G. Koenig, codirector of the Center than an average citizen,” with only 24 percent in
for Spirituality, Theology, and Health at Duke disagreement.
University, cites surveys done in the 1980s and Most modern religious attempts at creating
1990s indicating that 57 to 74 percent of psy- a biblical psychology, from Franz Delitzsch (A
chologists and 24 to 75 percent of psychiatrists System of Biblical Psychology, 1885) forward,
did not profess a belief in God, in contrast to only are efforts at preserving theological orthodoxy
4 percent of the general American public. against the encroachments of the scientific and
Even so, since 1994, the special requirements secular world, rather than an attempt at generat-
for residence training for psychiatry of the Ameri- ing a new synthesis emerging out of constructive
can College of Medical Education have designated dialogue between fields.
that programs provide training of religious/spiri-
tual factors that influence psychological develop- Christian Faith-Based Interventions
ment. In an American context, unlike the more Far from representing a monolithic treatment
secular societies founding western Europe, the approach, a diverse range of Christian counseling
religious beliefs of many patients have produced options have been developed, spanning the spec-
a reaction against purely secular forms of mental trum of denominational affiliations and encom-
health counseling and the rise of supplementary or passing various types of education and training.
alternative forms of religiously based psychother- The popularity of Christian counseling has grown
apy, something largely confined, at least at pres- exponentially in recent years; for instance, the
ent, to the United States. Partially in response to American Association of Christian Counselors
752 Religiously Based Therapies

(AACC), the largest faith-based association for Rottenberg’s system derives inspiration from
professional, pastoral, and lay counselors, has the general Jewish tradition of mutual aid and the
grown from 15,000 members in 1999 to over rabbinic system of multiple interpretations of the
50,000 today. The common tendency to concep- Torah, the psychological principles that are found
tually conflate faith-based therapy approaches in postbiblical rabbinic writings, specifically
fails to capture the complexity and diversity of within the Kabbalistic-Hasidic Contraction, or
Christian-based therapies with the umbrella of tzimtzum paradigm. This paradigm is premised
Christian counseling encompassing several major on the mystical idea that God self-contracted in
interventional streams, the two most prominent the universe to create space for the world, which
being biblical counseling and pastoral counseling. serves as a prototypical interactional model for
Biblical counseling derives its epistemological humans to emulate. This tzimtzum model pro-
foundation solely based on revelatory knowledge motes an approach that orients around that value
contained within the biblical canon. Adherents of social responsibility, particularly emphasizing
to this counseling tradition strive to firmly resitu- duty and accountability for one’s fellow.
ate the role of counseling within the ministry of Kaplan has coined his variant of Jewish psy-
the church. In more extreme forms, psychology chology “biblical psychology,” which should
is viewed as a suspect competitor, and evidence- not be confused with biblical counseling, since
based treatments are dismissed out of hand. Bibli- Kaplan’s system de-situates biblical narratives
cal counselors complete their training in a variety from their theological context in the service of
of designated institutions that offer board certifi- inductively generating a biblically based, secular
cation in biblical counseling, such as Light Uni- metapsychology. The issue of revelation becomes
versity, with over 120,000 students enrolled in secondary, if not completely irrelevant, because
their online biblical counseling courses. the aim is to extrapolate from the Bible a viable
Although the type of counseling tradition- theory of normative and pathological behavior as
ally provided by clergy throughout the ages can well as actionable clinical interventions.
appropriately be considered pastoral counseling, Biblical psychology positions itself in opposi-
in the 20th century there has been a formalization tion to modern psychology, arguing that the latter
of this profession. Similar to biblical counselors, remains subtly based on assumptions and values
pastoral counselors aim to promote psychological emerging from a classical Greco-Roman view of
healing by utilizing interventions that draw from life. The treatment of the psyche, the emphasis
faith and spirituality, though these techniques on the Oedipus complex, and the fetishization of
tend to more completely incorporate mainstream freedom are but three examples. Many of these
psychological knowledge. In fact, many pastoral assumptions and values are encoded in primary
counselors have dual credentials in Christian min- Greek myths. Kaplan and his associates have
istry and clinical psychology or counseling. Even delineated 10 important contrasts with regard to
while pastoral counseling remains mainly asso- mental health between classical Greek and bibli-
ciated with conservative Protestant Christian- cal thinking: the primacy of God versus nature,
ity, in practice, pastoral counselors can be found the relationship between body and soul, cyclical
throughout various Christian denominations as versus linear conceptions of time, the relationship
well as altogether different faith traditions. between self and other, the relationship between
man and woman, the relationship between par-
Jewish Psychology ent and child, sibling rivalry and its resolution,
In contrast to biblical and pastoral counseling, the relationship between freedom and suicide, the
Jewish psychology is a young and relatively frac- question of rebelliousness versus obedience, and a
tured field that has not yet gained a broad num- tragic versus therapeutic outlook on life.
ber of followers. The two main figures promoting A recent interfaith declaration released by the
independently comprehensive systems of Jewish, AACC argues that the history of modern psychol-
or Hebraically, informed psychology have been ogy has progressed over five sequential waves:
Mordechai Rottenberg and Kalman J. Kaplan, first, psychodynamic; second, behavioral; third,
respectively. humanistic; fourth, multicultural; and now, fifth,
 Reserpine 753

spiritual/religious psychology. The last wave is pressure, as well as decreasing activity of dopa-
unique because it is prompted by patients/clients mine, serotonin, and norepinephrine. It was origi-
rather than professional psychologists. Spiritual- nally a primary choice medication for high blood
ity and the importance of faith-based counsel- pressure and schizophrenia but is now considered
ing have become the fifth force in mental health a second tier option as an antihypertensive and
care. When people seek mental health services, antipsychotic because of more available drug
they often start with a pastor, priest, or rabbi, options (in both of these categories) with fewer
and regardless of context, they usually want their and less severe side effects.
faith addressed as part of the therapeutic process. Reserpine is a type of rauwolfia alkaloid. It is a
naturally occurring drug from the root extract of
Paul Cantz Rauwolfia serpentina (Indian snakeroot), a plant
University of Illinois, Chicago College of Medicine found in India and Africa. It had long been used
in India, often as a tea to treat snakebites, cholera,
See Also: Psychoanalysis, History and Sociology of; and insanity. Mohandas Gandhi reportedly used
Religion; Spiritual Healing. it for its calming properties. It was first discov-
ered as a pharmaceutical in 1952. As a prescrip-
Further Readings tion medication, it is a white oral tablet available
Cantz, P. “Towards a Biblical Psychoanalysis: A in 0.1mg and 0.25 mg doses. It is usually taken
Second Look at the First Book.” Mental Health, once a day and is stored at room temperature in a
Religion, and Culture, v.15 (2011). tightly sealed container. For those taking it as an
Kaplan, K. J. and M. B. Schwartz. A Psychology antihypertensive, the dosage can range from 0.1
of Hope: A Biblical Response to Tragedy and to 0.5 mg, with lower doses for those taking it
Suicide. Grand Rapids, MI: William B. Eeerdmans
Publishing, 2008.
Koenig, H. G., E. G. Hooten, E. Lindsay-Calkins,
and K. G. Meador. “Spirituality in Medical School
Curricula: Findings From a National Survey.”
International Journal of Psychiatry in Medicine,
v.40 (2010).
Lafuze, J. E., D. V. Perkins, and G. A. Avirappattu.
“Pastor’s Perceptions of Mental Disorders.”
Psychiatric Services, v.53 (2002).
Weaver, A. J. “Has There Been a Failure to Prepare
and Support Parish-Based Clergy in Their Role
as Front-Line Community Mental Health
Workers? A Review.” Journal of Pastoral Care,
v.49 (1995).

Reserpine
Reserpine is an oral medication used to treat high
blood pressure and a variety of symptoms linked
to mental disorders. It is particularly useful as
an antipsychotic, reducing agitation and anxi-
ety, though it is not a cure for these symptoms. Mohandas Gandhi reportedly drank Indian snakeroot (reserpine)
It appears to act by slowing the activity of the tea regularly for its calming properties. References to Indian
nervous system, lowering heart rate and blood snakeroot were found in Hindu texts dating back to 600 b.c.e.
754 Reserpine

in combination with another drug. For those pre- One of the primary reasons for the decline of
scribed reserpine for its antipsychotic properties, reserpine’s use is the long list of side effects, some
the dosage typically ranges from 0.1 to 1.0 mg. that can be quite severe, especially for those pre-
While reserpine’s use as an antipsychotic had been scribed higher doses. Possible side effects include
declining, its use has been increasing as a drug dizziness, upset stomach, diarrhea, vomiting,
used in combination with other antipsychotics for loss of appetite, decreased sexual ability, erectile
an increased effect in lowering dopamine levels. impairment, nervousness, headache, dry mouth,
With the combination of drugs, lower levels of fatigue, and stuffy nose (most common side effect).
reserpine can be used, which minimizes the pos- More serious side effects are depression, fainting,
sibility of side effects. As a second-tier drug, up to slow heart beat, nightmares, chest pain, and swol-
0.25 mg is typically prescribed. In the past, some len feet or ankles. Patients with these symptoms
patients were prescribed up to 40 mg per day. should contact their doctor immediately. Parkin-
sonism can also be encountered in higher doses.
Effectiveness and Side Effects No deaths have been connected to overdoses of
Reserpine’s effectiveness as a medication is reserpine. Alcohol can exacerbate side effects and
because of its reduction of catecholamines and its use should be limited while taking reserpine.
other monoamine neurotransmitters in the syn- The medication can pass through the placenta
apses that impact mood and heart function. It and breast milk and care should be taken in pre-
acts in the nervous system by blocking the vesic- scribing reserpine to pregnant or nursing women.
ular monoamine transporter (VMAT), which is Patients may need to regularly check their heart
responsible for moving serotonin, norepineph- rate and blood pressure to ensure appropriate
rine, and dopamine. It transports these neu- dosing and response to the medication. It is not
rotransmitters from within a neuron’s terminal recommended for pediatric use.
button into the synaptic vesicles ready for release Some uncontrolled studies suggested a link
into the synapse. If not transported into the between reserpine and depression, leading to sui-
vesicles, they are prone to breakdown by mono- cide. Depression is a possible serious side effect
amine oxidase (MAO). Reserpine blocks uptake because of the reduction of monoamine neu-
and storage of norepinephrine, dopamine, and rotransmitters. This is the basis of the monoamine
serotonin into the vesicles, limiting the activity hypothesis of depression, on which there is some
of these neurotransmitters in the body. It takes disagreement. Some researchers do not believe this
effect in many parts of the body. The impact in has any effect, while others believe it works as an
the brain and adrenal medulla are of particular antidepressant. At first sign of depression, its use
interest in terms of its tranquilizing properties should be discontinued. The patient should remain
and general impact on mood. under medical care because the depressing effects
The drug is primarily metabolized by the body. can remain for a few months after withdrawal.
Only about 1 percent is excreted from the body Reserpine is not appropriate to use in patients
unchanged. Reserpine requires time to take effect with a number of conditions such as ulcers,
and, once in effect, can be long lasting because depression or history of depression, gallstones,
the body takes days to weeks to replenish the and those receiving electroconvulsive therapy.
depleted VMAT. Care should be taken if also prescribed a tricyclic
Because of its sedative nature and long-lasting antidepressant, MAOI, or other antihypertensive
effect, reserpine has been used as a treatment for medication.
schizophrenia. Beyond reserpine’s usefulness as
an antihypertensive and treatment for schizophre- Alishia Huntoon
nia, it can also be used to treat dyskinesia in those Oregon Institute of Technology
with Huntington’s disease. It is also used for seda-
tion of excitable horses that require rest. This has See Also: Atypical Antipsychotics; Dopamine; Drug
included tranquilizing horses for showing, though Treatments, Early; Monoamine Oxidase Inhibitor
this is a discouraged practice, and there is testing (MAOI) Antidepressants; Schizophrenia; Thorazine
that can detect reserpine in a horse’s system. and First-Generation Antipsychotics.
 Right to Refuse Treatment 755

Further Readings supposition that some people categorically lack

Stroup, T. Scott, Wayne M. Alves, Robert M. capacity. In the 19th century, it was widely believed
Hamer, and Jeffrey A. Lieberman. “Clinical Trials that certain classes of people, such as women,
for Antipsychotic Drugs: Design Conventions, children, natives of colonized lands, paupers, and
Dilemmas, and Innovations.” Nature Reviews, indigents had natural and immutable mental defi-
Drug Discovery, v.5 (2006). cits that rendered them incapable of moral rea-
Tone, Andrea. The Age of Anxiety: A History of soning. Although legal developments in the 20th
America’s Turbulent Affair With Tranquilizers. century extended the right to choose to all adults
New York: Basic Books, 2008. of sound mind, people with psychiatric diagnoses
Veselinovic, T., H. Schorn, I. Vernaleken, C. Hiemke, continued to be excluded until the 1970s, when
G. Zernig, R. Gur, and G. Grunder. “Effects of patient rights activists won enhanced protections
Antipsychotic Treatment on Psychopathology from state interference throughout the United
and Motor Symptoms in Healthy Volunteers.” States, United Kingdom, and Canada.
Pharmacopsychiatry, v.44/6 (2011). Since then, debates around the right to refuse
treatment have tended to revolve around the
question of how to evaluate capacity and what
recourse is available to those said to lack it.
Because people with psychiatric disabilities tend
Right to Refuse to face doubts about their mental capacity more
frequently than people with physical disabilities,
Treatment and because psychiatric patients are sometimes
believed to be irrational simply because they
The right to refuse treatment is the right of any have refused a recommended treatment, doctors
legally competent adult to refuse unwanted medi- have a duty to assess capacity soundly and sen-
cal intervention. In Western mental health care sitively so as not to deprive such patients of a
systems, a precondition for the right to refuse cardinal right. If a person is adjudged to possess
treatment is that criteria for legal competence the capacity and competence to refuse treatment,
and decision-making capacity be met at the time physicians are legally obligated to respect their
of refusal. Legal competence refers to a person’s refusal, even if the person’s reasons are unem-
capacity to reason, deliberate, and make sound pirical, idiosyncratic, unknown, or in defiance
decisions concerning their personal affairs, of conventional wisdom. As the World Medi-
including finances and health care. Determina- cal Association noted in its 2009 medical eth-
tions about a person’s legal competence—which ics manual, “Competent patients have the right
is conceived under the law as something that is to refuse treatment, even when the refusal will
either present or absent—rely on clinical evalua- result in disability or death.”
tions of the person’s functional decision-making
capacity, which can be situational and present to Evaluating Decision-Making Capacity
a greater or lesser extent at any given moment. Although parameters for defining capacity vary
When a person’s right to refuse treatment is by jurisdiction, there is general agreement that
in doubt, physicians, legal guardians, and courts assumptions about a patient’s capacity should
may decide whether his or her cognitive capac- not be made on the basis of his or her diagno-
ity meets the standards of legal competence and, sis—that is, a person who experiences debilitat-
therefore, whether their stated wishes should be ing hallucinations or delusions is not necessarily
respected. An individual may possess the cogni- globally impaired and may retain competence to
tive capacity to make health care decisions while make decisions concerning his or her health care.
still being incompetent to do so in the eyes of the Capacity is, instead, typically assessed in relation
law (such as a 17-year-old teenager). to the following four interrelated criteria:
The modern acknowledgment that capacity is
a fluctuating quality that should be evaluated on 1. Ability to understand: Understanding
an ongoing basis has supplanted the traditional refers to a patient’s ability to comprehend
756 Right to Refuse Treatment

the content of a statement, regardless of diagnoses account for a small portion of the vio-
whether he or she believes the statement. lence that afflicts society in general. Nonetheless,
2. Ability to appreciate: Appreciation refers when patients are deemed mentally incapable and,
to a patient’s ability to relate factual thus, legally incompetent to refuse treatment, it is
information to his or her own situation. commonly because they are believed to have mis-
3. Ability to reason: Reasoning refers to a judged the danger they represent to themselves or
patient’s ability to analyze information, others.
weigh costs and benefits, and draw
conclusions. Reasons for Refusing Treatment
4. Ability to express a choice: Expression There are many reasons why psychiatric patients
of choice refers to a patient’s ability may reject treatments that their doctors or fam-
to communicate his or her preferences ily members endorse. Some patients find that
and may require accommodations, such antipsychotic, antidepressant, and anxiolytic
as a language interpreter or written medications serve only to suppress their visible
instruments. symptoms and minimize the inconvenience they
represent to others rather than to heal them or
In addition to these elements of capacity address their underlying traumas and concerns.
appraisal, patients must be assumed to possess In many cases, patients find the adverse effects
capacity unless it has been established that they of psychotropic medications more distress-
do not, and patients may not be deemed unable ing than the original condition for which they
to make a decision unless all practicable measures entered treatment. In a departure from the best
to facilitate their doing so have been exhausted. practices of other medical specialties, it is com-
On the basis of these criteria, a patient may be mon for psychiatric drugs to incur side effects
adjudged cognitively incapable if he or she can- that are strongly deleterious to their recipients’
not meet the demands of a particular decision- physical health. However, because mentally ill
making exercise and apprehend its potential patients must work harder to establish credibil-
consequences. Patients who are deemed to lack ity with their clinical evaluators than physically
insight—that is, who do not agree that they have ill patients, their complaints of iatrogenic dis-
an illness—are frequently considered to lack deci- tress are sometimes trivialized.
sion-making capacity because acknowledgment In other cases, it is not the side effects but the
of illness is identified with the criterion of factual intended purpose of medications to which patients
appreciation. object. Many psychotropic drugs have an untar-
Some sociologists and anthropologists have geted suppressant effect, which can be a barrier to
pointed out that an intolerance for dissent may be recovery when patients require a full command of
latent in evaluations of patients’ abilities to under- their cognitive faculties to participate in activities
stand, appreciate, and reason. Because determina- that they value and are integral to their mental
tions of capacity are closely linked with determi- health (such as to engage in professional work,
nations of patients’ credibility, assessments can be study a subject, or express themselves creatively).
highly reliant on the life experiences, attitudes, For example, the Supreme Court of Canada ruled
and pretheoretical assumptions that diagnosti- in 2003 that a physicist who had been diagnosed
cians bring to the clinical encounter. By conflating with schizophrenia had the capacity and therefore
a patient’s refusal to accede to dominant inter- the right to refuse treatment, despite the severity
pretations of his or her condition with an inca- of his symptoms, because the intended function
pacity for inferential thinking, clinicians can run of his medications was to slow his thinking and
the risk of pathologizing healthy expressions of diminish the likelihood that he would be able to
skepticism. resume his scientific research.
Several important studies, such as the MacAr- Heightened insight has also been correlated
thur Violence Risk Assessment Study, have estab- with lowered self-esteem, demoralization, and a
lished that mental illness is not a reliable predic- loss of faith in one’s future and potential. Patients
tor of violence and that people with psychiatric who score highly in capacity evaluations because
 Right to Treatment 757

they strongly appreciate diagnostic facts relevant Right to Treatment

to their case have been known to rate themselves
less positively in self-assessments of personal The traditional view of medicine has supported
worth and even to see themselves as beyond hope. the paternalistic role of medical professionals to
Many researchers have accordingly discovered make decisions on the behalf of their patients,
that outcomes for people with serious mental ill- including treatment initiation, termination, and
nesses are worse in Western nations, where such modality. For many years, this practice was
illnesses are considered chronic and biologically accepted as a whole, without question, by both
durable, than in the developing world, where patients and medical professionals. Gradually,
they tend to be considered ephemeral. In short, with societal and cultural changes and the emer-
a patient’s refusal to accept attributions of men- gence of patient advocacy, the paternalistic view
tal illness and associated treatment options may of medicine shifted to one that encouraged patient
be grounded in considerations that are not ade- autonomy. Combined with the notion that medi-
quately assessable through conventional evalua- cal professionals have the education and experi-
tions of capacity. ence to guide patient care, and patients have the
right to make and approve of decisions that affect
Eugenia Tsao their health, the practice of medicine became
University of Toronto more of a collaborative endeavor, with respon-
sibility shared between both patient and physi-
See Also: Commitment Laws; Competency and cian. Although patient care has improved greatly
Credibility; Compulsory Treatment; Dangerousness; throughout the course of civilization, the change
Family Support; Iatrogenic Illness; Informed Consent; process is continual. The medical community
Patient Rights; Violence. continues to work to ethically and competently
serve its patients within an ever-changing social
Further Readings and cultural context.
Bassman, Ronald. “Mental Illness and the Freedom to In the field of mental health, patient advocacy
Refuse Treatment: Privilege or Right.” Professional and the support of a patient’s right to treatment
Psychology: Research and Practice, v.36/5 (2005). is particularly important. A patient’s right to
Deegan, Patricia E. “The Lived Experience of Using treatment, within the field of mental health, has
Psychiatric Medication in the Recovery Process and historically referred to the legal right of patients
a Shared Decision-Making Program to Support It.” who are institutionalized to receive adequate
Psychiatric Rehabilitation Journal, v.31/1 (2007). treatment. Historically, individuals with mental
Sklar, Ronald B. “The ‘Capable’ Mental Health illnesses, especially those who were severely men-
Patient’s Right to Refuse Treatment.” McGill tally ill, had limited resources for treatment, and
Journal of Law and Health, v.5/2 (2011). even fewer resources that were ethical, humane,
Supreme Court of Canada. Starson v. Swayze, 1 S.C.R. and left their dignity intact. In 1966, the District
722, 2003 SCC 32 (2003). http://scc.lexum.org/dec of Columbia Circuit Court of Appeals in Rouse
isia-scc-csc/scc-csc/scc-csc/en/item/2064/index.do v. Cameron upheld the right of civilly committed
(Accessed May 2013). individuals’ right to treatment, which prevented
Velpry, Livia. “The Patient’s View: Issues of Theory mental institutions from merely acting as holding
and Practice.” Culture, Medicine, and Psychiatry, cells for the mentally ill, with no hope or expecta-
v.32/2 (2008). tion of movement toward cure.
Weller, Penelope. New Law and Ethics in Mental
Health Advance Directives: The Convention on the Deinstitutionalization
Rights of Persons With Disabilities and the Right Deinstitutionalization, which began in the 1950s,
to Choose. New York: Routledge, 2013. was in part spurred by concerns over patients’
World Medical Association. “WMA Medical Ethics rights and the deplorable conditions in institu-
Manual.” 2nd ed. (2009). http://www.wma.net/en/ tions. Courts began to place limitations on when
30publications/30ethicsmanual/pdf/chap_2_en.pdf individuals could be institutionalized against
(Accessed May 2013). their will, and they began to set minimum
758 Right to Treatment

standards for their care when they were admit- the premature discharge of patients from hospitals
ted. The court rulings led to less emphasis on for economic reasons, despite the hospital’s abil-
institutionalization and instead emphasized the ity to treat the patient. In response to this practice,
current perspective that care must be provided in in 1986, Congress passed the Emergency Medical
the least restrictive setting. Treatment and Active Labor Act (EMTALA) (42
The onset of the deinstitutionalization of the U.S.C.A. § 1395dd).
mentally ill from state public mental hospitals gave
birth to a new problem regarding the placement of Emergency Medical Treatment
the released patients. In 1956, the 559,000 indi- and Active Labor Act
viduals housed in mental health facilities began EMTALA ensures the legal right of patients to
to move into the community; and by 1980, the receive treatment in emergency situations, regard-
number of residents in these facilities was reduced less of citizenship, legal status, or their ability to
to 154,000. Over the next quarter century, many pay for services rendered. A hospital cannot turn
institutions were closed, and there was increased a patient away on the basis of race, religion, or
reliance on community resources. The deinstitu- national origin, or refuse treatment to persons
tionalization of the mentally ill consisted of three with HIV/AIDS. An emergency situation is one in
intended components: individuals entered into which death, serious injury, or disability is likely
the community after release from hospitals, they to occur without swift and immediate treatment.
were diverted from hospital admission, and com- This statute also applies to mentally ill individuals
munity services were developed. However, there in acute psychotic states or who are in danger of
were insufficient resources to adequately attend harming themselves or someone else. Emergency
to the overwhelmingly complex needs of the mas- patients or women in active labor presenting any-
sive number of individuals released from hospi- where on a hospital’s campus or within 250 yards
tals. The manner in which deinstitutionalization of the hospital’s main buildings are entitled to
was carried out led to an influx of the mentally three levels of services: screening, emergency care,
ill into the criminal justice system and a rise in and appropriate transfers.
the homeless population. It is estimated that 20 Any patient requesting treatment must be
to 25 percent of the U.S. homeless population are given a medical screening and, if deemed to
severely mentally ill, which is in stark contrast to have an emergency medical condition, is entitled
the 6 percent of individuals in the general popula- to proper stabilizing treatment or appropriate
tion with a severe mental illness. transfer to another hospital. Any hospital, either
Access to health care is a major concern for private or public, that participates in Medicare is
many homeless and mentally ill individuals. Bar- federally mandated to provide stabilizing care for
riers to health care, specifically among the home- a patient presenting with a medical emergency.
less population, include a lack of health insurance, In most cases, the determination as to whether a
transportation, telephone, and access to primary patient is considered stabilized is decided by the
care; inner-city residence; minority status; chronic medical professional treating the patient. The
alcohol and drug abuse; and mental illness. Com- statute outlines strict guidelines for the transfer
pared to the general population, the homeless of a patient who cannot be stabilized. Termina-
are three times more likely to utilize emergency tion or suspension from Medicare can occur for
department services. With as much as a quarter of any hospital that negligently or intentionally vio-
the homeless population severely mentally ill, the lates any of these provisions. A penalty of up to
responsibility to provide adequate care to men- $50,000 for each intentional violation of the law
tally ill persons falls largely in the hands of emer- can be levied against the physician and hospital.
gency departments. In nonemergency situations, the statute places
In response to an increasing number of individ- no further obligation on behalf of the hospital.
uals unable to pay for services provided at health Nonemergency situations allow more flexibility
care facilities, many hospitals engaged in a now for individual hospitals in deciding whether to
illegal practice of patient dumping. Patient dump- admit a patient. However, when a hospital bases
ing is the denial of emergency medical services or admission on an individual’s ability to pay, there
 Ritalin 759

are statutory, regulatory, and judiciary limitations Display.cfm&ContentID=137545 (Accessed May

in place. Many hospitals that were recipients of 2013).
federal government financial assistance for con- Kushel, M., S. Perry, D. Bangsberg, R. Clark, and A.
struction are required to provide a minimum Moss. “Emergency Department Use Among the
amount of services to individuals who are unable Homeless and Marginally Housed: Results From
to pay. Also, individual states can and have pro- a Community-Based Study.” American Journal of
hibited hospitals from basing admission on abil- Public Health, v.92/5 (2002).
ity to pay. This is especially vital for the homeless Lehman, Jeffrey and Shirelle Phelps, eds. West’s
and mentally ill, who are heavily reliant on emer- Encyclopedia of American Law. 2nd ed. Eagan,
gency department services. MN: West Group Publishing, 2005.
After a patient has been admitted to a hospital, National Coalition for the Homeless. “Mental Illness
their right to treatment also includes the right to and Homelessness.” http://www.nationalhomeless
leave at any time, even if their bill has not been .org/factsheets/Mental_Illness.pdf (Accessed
paid or against medical advice. One exception to December 2012).
this includes cases of contagious diseases requir-
ing quarantine. Another exception is in the case
of the involuntary commitment of the mentally ill
in order to prevent persons deemed a danger to
themselves or others by a qualified mental health Ritalin
professional.
As in the case of determining stability, the Ritalin is the trade name for methylphenidate;
medical professional overseeing treatment makes today, it is used primarily to treat individuals,
the determination of when a patient is ready for mostly children, with attention deficit hyperactiv-
discharge. This decision can be disputed by the ity disorder (ADHD). However, Ritalin’s history
patient, and a second opinion can be granted. tells that it was marketed for a wide variety of
An ombudsman or patient representative in hos- uses other than for its most current one of treat-
pitals can advocate for patients’ rights. The deci- ing hyperactivity. CIBA, from 1961 to 1971,
sion to discharge a patient must be solely based CIBA–Geigy (CIBA merged with Geigy) from
on their medical condition, never on bill pay- 1971 to 1996, and Novartis (CIBA–Geigy merged
ment. Existing statutes have helped to empower with Sandoz) from 1996 to the present manufac-
and promote the rights of the general public tured Ritalin. While the pathway by which Rit-
and historically marginalized individuals such alin works is not entirely known, it is thought
as the mentally ill and minorities in obtaining that Ritalin changes ADHD behavior by binding
treatment. to dopamine transporters in presynaptic neurons
and, consequently, blocking dopamine reuptake.
Abigail Keys Ritalin also influences the neurotransmitters nor-
Jay Trambadia epinephrine and serotonin. Common side effects
Christopher Edwards of Ritalin include insomnia, anxiety, hyperten-
Duke University sion, headaches, anorexia, and tachycardia.
CIBA scientist Leandro Panizzon first synthe-
See Also: Deinstitutionalization; Emergency Rooms; sized Ritalin in 1944. The name Ritalin comes
Homelessness. from his wife Marguerite’s nickname, Rita. Paniz-
zon and Max Hartmann patented a process for
Further Readings synthesizing it in 1950, and CIBA obtained a pat-
Koyanagi, Chris. “Learning From History: ent for its use as an antidepressant in 1954. The
Deinstitutionalization of People With Mental Illness Food and Drug Administration (FDA) approved
as Precursor to Long-Term Care Reform.” (August it in 1955 for use in a broad spectrum of disor-
2007). National Alliance on Mental Illness. http:// ders: schizophrenia, depression, fatigue, obesity,
www.nami.org/Template.cfm?Section=About_the narcolepsy, and so on. It was also used in patients
_Issue&Template=/ContentManagement/Content suffering from drug-induced comas, such as after
760 Role Strains

anesthesia. Ritalin was used in both outpatient of Child Control, which argued that authoritar-
and inpatient mental institutions, and CIBA mar- ian teachers, school administrators, and teachers
keted it through prolific advertising for use in were using Ritalin as a chemical straitjacket. Soci-
institutionalized patients, depressed housewives, ologist Peter Conrad also argued that medicating
and cranky elderly persons. Ritalin had only mar- nonconforming children with amphetamines was
ginal success as a drug for these purposes. Conse- similar to silencing heretics. He laid the blame on
quently, for CIBA at that time, Ritalin was a drug both the pharmaceutical industry and the Asso-
in search of a patient. ciation for Children with Learning Disabilities.
When CIBA developed Ritalin, pharmaceutical These debates have not yet been resolved.
companies rarely financed research in the area of As Ritalin prescriptions increased, so too did
child psychopharmacology; between 1937 and the concerns about its potential for abuse. In 1971,
early 1950s, fewer than a dozen clinical research amid these growing worries, the Bureau of Nar-
papers had been published on the use of stimulant cotics and Dangerous Drugs placed Ritalin, along
drugs in children. In 1957, Maurice Laufer, Eric with all amphetamines, on Schedule II. Controver-
Denhoff, and Gerald Solomons created hyperki- sies aside, from 1990 to 2005, Ritalin’s produc-
netic impulse disorder as a behavior pattern con- tion increased by sixfold, reflecting the growing
sisting of symptoms such as hyperactivity, short importance of the psychostimulant drug market.
attention span, and poor powers of concentra- In 2004, for example, 29 million prescriptions
tion. Initially, psychostimulants were seen as had been written for psychostimulants. Of this,
adjuncts to the more important work of psycho- methylphenidate accounted for half.
therapy, consistent with the 1950s dominance of
psychodynamic psychiatry and the emphasis on Christine Tarleton
the psychological. University of California, Los Angeles

A Form of Social Control? See Also: Amphetamines; Attention Deficit

However, post–World War II America would Hyperactivity Disorder (ADHD); Children.
provide a fertile market for a new class of medi-
cations that could simultaneously enhance a Further Readings
child’s performance and control his (most often) Mayes, Rick and Adam Rafalovich. “Suffer the
or her behavior. Indeed, Ritalin’s 1961 FDA Restless Children: The Evolution of ADHD and
approval for use in children with behavioral Paediatric Stimulant Use, 1900–80.” History of
problems marked a growing reliance on medical Psychiatry, v.18 (2007).
solutions to problems of childhood. To this end, Myers, Richard L. “Methylphenidate (Ritalin).” In
CIBA marketed not only Ritalin as a drug but The 100 Most Important Chemical Compounds: A
also hyperactivity as a disorder. Not unexpect- Reference Guide. Westport, CT: Greenwood Press,
edly, as physicians increasingly prescribed Ritalin 2007.
for hyperactive children, normalized the use of Rasmussen, Nicolas. On Speed: The Many Lives of
psychoactive drugs in children and reinforced a Amphetamine. New York: New York University
belief in the biological nature of children’s behav- Press, 2008.
ioral problems. Smith, Matthew. Hyperactive: The Controversial
Despite its widespread use, Ritalin and its impli- History of ADHD. London: Reaktion Books,
cations have been divisive among mental health 2012.
professionals as well as the general public. While
some consider Ritalin to be a godsend in treat-
ing hyperactive children, others see it as a form
of social control, further medicalizing a particu-
lar child temperament (such as antiauthoritarian Role Strains
or hyperactive). In 1975, journalists Peter Schrag
and Diane Divoky wrote the widely read The The term role is used by sociologists to describe
Myth of the Hyperactive Child and Other Means an individual’s placement in the social universe,
 Role Strains 761

typically indicated by a named status such as available to people, and many people’s lives were
“mother,” “father,” or “employee.” Each role similar, resulting in less role strain and conflict.
involves rights, obligations, and expectations While there is no causal relationship between
that are defined and patterned by the particular role strain and mental illness, role strain often
society. For instance, American parents have legal causes high levels of stress, and stress is a signifi-
rights over their children and a duty to care for cant factor in many mental illnesses. High stress
them and typically hope that these children will levels may combine with other factors, such as an
become productive members of society, possibly individual’s temperament, to initiate a mental ill-
contributing to future parental care. ness, intensify its symptoms, or cause a relapse.
In contrast to this example, most individuals Additional issues that influence role strain, stress,
are not just dealing with one responsibility but and mental well-being include the societal expec-
instead balance many roles in their daily lives. tations of that role (i.e., how important that role
Typically, the expectations for each of these is to the community and the individual), environ-
roles are varied and may sometimes conflict. For mental factors such as poverty, or an emotionally
example, a working parent may experience role supportive network. Stress is most often linked to
conflict and considerable stress when a child is anxiety, depression, and other related clinical dis-
ill and needs to be kept home from school at orders in the Diagnostic and Statistical Manual
the same time as an important work deadline of Mental Disorders, 4th edition text revision, or
looms. This attempt to juggle two different roles DSM-IV-TR (2000).
is termed “role conflict,” while role strain refers While the DSM-IV-TR pays only limited atten-
to the difficulty of fulfilling the contradictory tion to culture, social roles are culturally relative,
obligations of one role. A mother may experi- and people experiencing role strains may manifest
ence role strain when the obligations to protect their anxiety in culturally sanctioned ways, which
her child and to let the child learn from their may not be well understood by American mental
mistakes are incompatible. The tension between health providers. These challenges add stress to
satisfying the various responsibilities of a role the immigrant experience and may be especially
may cause significant stress, which is important daunting when the reason for moving is warfare,
to understand because stress plays a major role famine, or some other disaster. Even with the
in mental illness, influencing the lives of many easiest transition, a man from a rural, agricul-
Americans. Role strain and the resulting stress tural country may experience culture shock upon
may be viewed as major components of contem- arrival in the United States when he learns that
porary life in the United States and other parts of being a worker is defined very differently than in
the developed world. his homeland and that he needs to punch a time
clock, follow formal work protocols, and com-
Role Strain in the United States plete other new obligations.
In American society today, most people lead While roles and role strain differ between
complicated lives in urban locations involving nations, they also vary within a country. In a
relationships in a multitude of settings, many of heterogeneous society such as the United States,
which entail roles and responsibilities. A woman factors such as gender, race, ethnicity, national
may be a mother, sister, daughter, neighbor, com- origin, sexual orientation, religion, and socioeco-
munity volunteer, and employee. This “role set” nomic class can affect the level of role strain that
connects her to different groups of people, each an individual experiences when performing a par-
of which may provide her with various types of ticular social role. Because the accepted patterns of
support, such as child-care assistance from her behavior and commitment associated with a par-
mother or respect from her colleagues. The frag- ticular role may differ among these groups, role
mented nature of modern existence is very differ- strain is experienced and defined differently. For
ent from how people live in rural areas or less example, a parent with an ill child may experience
developed nations and differs significantly from a higher level of strain if they are poor, lack health
the American preindustrial period. In all these set- care coverage, and the demands of caring for the
tings, there were only a limited number of roles ill child conflict with other roles, such as that of
762 Role Strains

worker or student. Because of accepted gender prevent disturbance by leaving her cell phone at
norms, men and women who may have similar home, as well as planning to spend an evening in
role obligations (e.g., that of a worker seeking a the university library working on homework. A
promotion) often react to the strain differently. father who finds that he is overwhelmed by the
A woman may experience more stress seeking a expectations of his job may eliminate that role
promotion in a male-dominated company, while relationship by quitting his job or searching for
a man may not have the same concerns. a less demanding position. He may also delegate
While individuals continually add new role by asking a coworker, colleague, or boss for assis-
relationships, they may never fully shed previous tance in completing a particular task. Similarly,
ones. This accumulation of role relationships can an overwhelmed parent may request assistance
lead to an overwhelming number of demands on from relatives, friends, or neighbors in caring
one’s time, finances, and emotional well-being, for children, simultaneously delegating tasks and
causing significant role strain, role conflict, and extending the limits of the parental role to include
stress. Some methods to reduce role strain include relatives, friends, and neighbors.
planning particular role obligations for specific
times, delegating tasks to another person, extend- Role Strain and the Future
ing the boundaries of role expectations, prevent- Role strain and its effect on mental well-being is
ing disturbance when completing a necessary role a significant concern in American society today.
obligation, or eliminating a role relationship. Since technology, industry, and globalization are
These methods of coping with strain are used in a changing the world in an unprecedented and
variety of ways and often in combination. A stu- rapid manner, it is likely that roles, role strains,
dent who is overwhelmed by her coursework may and stress will also be experienced in unexpected

Surrounded by pictures of her family in her Djibouti office in May 2006, Navy officer Christine Buckley has been home only twice to
celebrate Mother’s Day with her sons, ages 8 and 6. In the American preindustrial period, roles were limited and many people’s lives
were similar, resulting in less role strain and conflict. In American society today, most people have numerous roles and responsibilities
within complicated lives that involve relationships in a multitude of settings.
 Russia 763

ways in future years. Given the increasingly mul- dissidence during the Soviet period, and there are
ticultural nature of the United States, it is also suggestions that the Russian government is once
to be expected that roles, role strains, and stress again using psychiatry as an instrument of politi-
may be interpreted and manifested in many dif- cal repression.
ferent ways, contributing to more complicated Psychological research in 19th-century Rus-
presentation at mental health services, for those sia developed as part of the rapid growth in the
who progress to this stage of need. In addition, it natural sciences in that period. Ivan M. Sechenov
is hoped that research will continue in this area was a pioneer in the study of physiological psy-
of sociology and health provision, resulting in chology in Russia, and his work on stimulus and
improved interventions and solutions for increas- response led directly to Ivan Pavlov’s work on
ingly burdened Americans. the conditioned reflex, as well as to the work of
American behaviorists such as B. F. Skinner. The
Susan J. Wurtzburg Moscow Institute of Experimental Psychology,
Ann Curtis established by Georgii Ivanovich Chelpanov, was
University of Hawai‘i, Manoa a leading center of research in the 19th and early
20th century. Pavlov studied and worked at sev-
See Also: Business and Workplace Issues; Children; eral universities in Russia, Germany, and Poland
Gender; Life Skills; Marital Status; Stress; Women; but did his most famous work at the Institute of
Work–Family Balance. Experimental Medicine in St. Petersburg; there he
established that individuals could be trained to
Further Readings physiological functions (such as salivation) upon
American Psychiatric Association (APA). Diagnostic presentation of a stimulus they had been condi-
and Statistical Manual of Mental Disorders. 4th tioned to associate with something (such as food)
ed. Washington, DC: APA, 2000. that would normally produce that response. Pav-
Owens, Timothy J., Dawn T. Robinson, and Lynn lov was awarded the Nobel Prize for Physiology
Smith-Lovin. “Three Faces of Identity.” Annual or Medicine in 1904 for this work.
Review of Sociology, v.36 (2010).
Portes, Alejandro. “Migration and Social Change: Inpatient Hospital Model
Some Conceptual Reflections.” Journal of Ethnic Psychiatric care in the Soviet Union developed
and Migration Studies, v.36/10 (2010). around the inpatient hospital model and was far
slower to adopt reforms such as deinstitutional-
ization and community treatment, which became
common in the West. This approach, plus the use
of psychiatric hospitals to imprison and disable
Russia dissidents through the use of psychoactive drugs,
meant that the Soviet Union maintained a high
The Russian Federation is an upper-middle- level of beds in inpatient mental health facilities
income country but is also characterized by a compared to other countries at a similar level
high level of inequality, with a Gini index of 42.0 of development. This high reliance on hospital
in 2010, among the highest in Europe. Although treatment continued after the fall of the Soviet
the rights of people with mental illness have been Union; for instance, in 1989, Russia had 133.7
guaranteed by law since 1992, the systems for psychiatric beds per 100,000 population, a num-
delivering care are overburdened, and many peo- ber only reduced to 108 beds per 100,000 popu-
ple do not receive adequate care. Mental health lation by 1999.
services are still primarily delivered through inpa- During the Soviet period, the practice of psy-
tient services in large institutions, a model that has chiatry was controlled by the state, and not
been abandoned for several decades in most West- until the breakup of the Soviet Union in 1989
ern countries. The psychiatric profession must was the first independent psychiatric association
also struggle to regain credibility lost because of founded in Russia. Called the Independent Psy-
its association with government suppression of chiatric Association (IPA), it joined the Russian
764 Russia

Human Rights Network in 1992. However, the was somewhat modified in 1979, when a theory
psychiatric profession in Russia must still deal of unconscious behavior was discussed at a con-
with mistrust stemming from the well-known ference held in Tbilisi, Georgia, and during pere-
fact that during the Soviet period, psychiatrists stroika (1985–91), Russians interested in psycho-
cooperated with government and police offi- analysis began to organize meetings with foreign
cials to suppress political and religious dissent. practitioners. The Soviet Psychoanalytic Society
Reports of maximum-security psychiatry hospi- was founded in 1989 and was awarded the sta-
tals used to imprison dissidents, without medi- tus of “guest study group” by the International
cal cause, first reached the West in the 1970s; Psychoanalytical Association in 1991. After the
in 1977, the World Psychiatric Association con- fall of the Soviet Union, many Russians traveled
demned this practice. Investigations following abroad to study psychoanalysis, while a training
perestroika (restructuring) in 1989 established program in Russia was also established in the
that these practices, as well as the administra- 1990s under the auspices of the Moscow Psy-
tion of high doses of drugs such as sulfazine as a choanalytic Society. However, many more dubi-
means of punishment, were widespread and that ous institutes also claim to offer psychoanalytic
they continued into the late 1980s. training, and this has led to some public distrust
The political use of psychiatry may be on the of psychoanalysis.
rise once again in Russia. For instance, a 2011
news story in the Moscow Times reported that Contemporary Mental Health Care System
Galina Yartseva, editor of an opposition newspa- and Epidemiology of Mental Health
per, was ordered to have a psychiatric examina- Theoretically, the rights of mentally ill people in
tion and was found to have a personality disorder Russia are protected by a 1992 law, but mental
after publishing stories accusing local officials of illness still carries severe social stigma, and many
corruption. The story also reports that at least 12 patients find it difficult to find the services they
other activists have been subjected to intimida- need. Despite numerous attempts at reform since
tion through psychiatric examinations, a practice the early 2000s, service delivery remains ham-
facilitated by the fact that Russian courts have pered by the fact that mental health services in
the right to order psychiatric examinations if the Russia are largely provided through inpatient
judge deems it appropriate. facilities, and funding is largely distributed by
Psychoanalysis was well known in Russia in the government on the basis of infrastructure
the early 20th century. Nikolai Osipov, a pupil of and historical precedent rather than community
Carl Jung, was the first to practice psychoanaly- or patient needs. In 2011, Russia had 109.5 beds
sis in Russia, beginning in 1905. Moshe Wulff, a in mental hospitals per 100,000 population, but
pupil of Karl Abraham, also began practice about only three beds per 100,000 in mental health
this time, while Tatiana Rosenthal began practic- outpatient facilities, 1.8 beds per 100,000 in day
ing in St. Petersburg around 1911. In 1914, Freud treatment facilities.
commented that almost all of his works, as well The most common site of mental health treat-
as those of other psychoanalysts, were available ment is outpatient facilities, with a rate of 3002.9
in Russian translation. Sabina Spielrein, one of visits per 100,000 population, followed by men-
the first women to practice psychoanalysis, was tal hospitals, with a rate of 455.8 admissions per
born in Rostov-on-Don, studied with Carl Jung in 100,000, and 127.2 per 100,000 treated in day
Zurich, and later returned to Russia to establish treatment facilities. Persons under age 18 consti-
a kindergarten in Moscow. However, the commu- tute 13 percent of those admitted to mental hos-
nist government that ruled Russia after 1917 had pitals, and 22 percent of those treated in mental
a mixed view of psychoanalysis, particularly after health outpatient facilities.
Leon Trotsky went into exile in 1928; the Psycho- Total expenditures on health constitute 5.4
analytic Institute closed in 1930, and the Russian percent of gross domestic product; neuropsychi-
Psychoanalytic Society disbanded in 1933. atric disorders contribute 15.6 percent of the total
By the 1950s, the government’s stance toward burden of disease in Russia. Looking at the sup-
psychoanalysis was openly hostile. This attitude ply of mental health workers, Russia has 11.61
 Russia 765

psychiatrists per 100,000 population, plus 46.3 substance abuse and suicide suggest high rates of
nurses per 100,000 working in the mental health depression in Russia. A 2004 survey of adults in
sector, and 5.4 psychologists per 100,000 work- several Russian cities, conducted by Martin Bobek
ing in the mental health sector. Primary care doc- and colleagues, found that 23 percent of men and
tors or nurses are not allowed to diagnose or treat 44 percent of women were depressed (defined by a
mental disorders or to prescribe psychotherapeu- score above 16 on the Center for Epidemiological
tic medications. Payment to hospitals is made on Studies depression scale). Depression was asso-
the basis of patient bed-days, providing an incen- ciated with higher levels of education, but other
tive to keep patients in the hospital as long as pos- correlates, including excessive drinking, poverty,
sible (or at least to keep the beds filled); however, and being unmarried, were similar to those found
most (76 percent) stays in mental hospitals lasted in other countries. The suicide rate for men in
one year or less, while 21 percent lasted between Russia is one of the highest in the world, at 53.9
one and five years, and 3 percent lasted more than per 100,000 population; however, the suicide rate
five years. for women is much lower, at 9.5 per 100,000.
A high level of alcohol consumption, primarily The combined suicide rate of 23.5 in 2010 was
of distilled spirits, has been characteristic of Rus- above the limit of 20 considered critical by the
sians in many periods of history. The revenues World Health Organization; reasons for the high
obtained from the sale and taxing of alcohol has levels of suicide include general feelings of hope-
been an important source of government income lessness stemming from the disruptive nature of
for centuries (in the 1970s, it constituted about Russian society, high levels of alcohol and drug
one-third of government revenues). Although abuse, widespread poverty, and lack of effective
accurate statistics are difficult to obtain for the mental health care for those who need it.
Soviet period, in 1985, Mikhail Gorbachev, gen-
eral secretary of the Communist party, began Sarah Boslaugh
a large-scale campaign against alcohol abuse. Kennesaw State University
Measures intended to reduce alcohol consump-
tion included increasing prices and limiting the See Also: Alcoholism; Drug Abuse; Marital Status;
hours that drinking establishments could stay Patient Rights; Prison Psychiatry; Psychoanalysis,
open. After the fall of the Soviet Union, alcohol History and Sociology of; Social Control.
abuse increased markedly and is believed to play
a major role in the relatively low life expectancy Further Readings
at birth (in 2011) for Russian men (62 years) Bobak, Martin, et al. “Depressive Symptoms in Urban
compared to Russian women (74 years). Drug Population Samples in Russia, Poland and the
abuse is also an issue in post-Soviet Russia, with Czech Republic.” British Journal of Psychiatry,
injected heroin (Russia consumes about 20 per- v.188 (2006).
cent of the world production of heroin) in partic- Jenkins, Rachel, et al. “Mental Health Reform in the
ular also implicated in the country’s high levels of Russian Federation: An Integrated Approach to
HIV infection. A 2012 poll found that 87 percent Achieve Social Inclusion and Recovery.” World
of Russians consider drug abuse to be a serious Health Organization Bulletin, v.85 (2007).
problem, and an estimated 2.5 millions Russians Krainova, Natalya. “In Soviet Relapse, Critics Sent to
are drug addicts. Psychiatric Hospitals.” Moscow Times (June 28,
It is difficult to know the rates of common 2011).
mental disorders in Russia and whether they have McKee, Martin. “Alcohol in Russia.” Alcohol &
changed over the years because such information Alcoholism, v.34/6 (1999).
was not commonly available during the Soviet Mund, Adrian P., et al. “Changes in the Provision
period, and statistics released today are generally of Institutionalized Mental Health Care in Post-
regarded as unreliable. However, high rates of Communist Countries.” PLOS ONE, v.7/6 (2012).
 S
Sadomasochism adaptation. It is only when these sexual acts pro-
duce distress or impairments in common functions
Sex and sexual preferences are influenced by cul- that they are considered pathology. Consistent
ture and socially defined expectations for appro- with adaptation models, sociologists define sadism
priate behavior. Some cultures are viewed as sex- and masochism as culturally manifest phenomena
positive, indicating more permissive ideals and that are produced by a need to resolve power dif-
norms related to sex; whereas others are sex-neg- ferentials in society. This definition seemingly
ative, or generally more restrictive in their sexual rejects the deviant connotations associated with
mores. An understanding of any sexual behavior, the DSM-IV descriptions of this behavior.
especially one as controversial as sadomasochism
(SM), or the act of obtaining sexual gratification Common Traits of Sadomasochism
through domination or submissiveness, is gained The core components of sadomasochism include
by an appreciation of the culture in which the themes of pain, dominance, submissiveness, and
behavior is manifest. fantasy. Traditionally, research has placed a sig-
Writings and research on SM date back to nificant amount of attention on pain as the pri-
the 16th century, where sexual gratification was mary component of SM, though some empirical
described from the process of dominating and studies have questioned this emphasis. At best,
being dominated. Social and cultural scientists pain seems to be peripheral to the construction
have yet to establish a universal definition of the of a universal definition of SM, but common and
construct of SM. even central to the experience for many. Pain may
This may partially reflect variations in con- serve as a proxy for, perhaps, more salient aspects
text, as well as the interpretative approach held of SM, such as dominance and submissiveness.
by the many disciplines that have studied SM. For The intensity of pain may also, in and of itself,
instance, the fourth edition of the Diagnostic and produce significant autonomic arousal, changes
Statistical Manual of Mental Disorders (DSM-IV) in peripheral and central blood flow, and conse-
defines sadism and masochism as separate sexual quently sex arousal.
“disorders” when these practices are accompanied Research has pointed to submissiveness and
by significant distress or impairment. The sexual dominance as the most commonly defined ele-
acts in this definition are not inherently patho- ment of SM. The establishment and maintenance
logical and can be associated with health and of a power differential between partners based

767
768 Sadomasochism

on trust and intensity obtained via sexual fantasy using methods that are mutually agreed upon and
may serve as a key to the sexual pleasure obtained accepted exit strategies via key or safety words.
from SM. However, these roles of dominance and Scenes are often scripted, and acting ability may
submissiveness assumed in SM may not generalize determine the level of satisfaction that is gained
beyond the sexual context/arena. Individuals who from the SM experience.
assume the dominant role during SM engagement The common focus of SM is sexual gratifica-
do not necessarily endorse aggressive personal- tion. However, there are many who practice SM as
ity traits or positions of power in their nonsexual a lifestyle, who report that shifts in power and role
lives. Similarly, submissives in SM are not neces- play are sufficient, and that sexual gratification is
sarily passive or shy outside of the sexual context, often quite delayed, if not detached from the SM
and often represent a demographic of individuals experience. Often, peak sexual arousal and climax
who are powerful in their careers or homes, and occurs outside the SM setting, and privately when
for whom disengaging from power, as a fantasy, is participants masturbate alone and fantasize about
stimulating and attractive. activities that occurred during play.
Another aspect of dominance and submis- Sadistic and masochistic sexual practices are
sion in SM is the “switch” or exchange of power fairly prevalent. According to a recent review,
between partners. This switch is common among approximately 61 percent of male and female
SM practitioners and suggests that those who are college students reported being sexually aroused
dominant may also gain enjoyment from assum- while participating in imagined or real forms of
ing a submissive role and vice versa. Fantasy is mild sadism or masochism. There is little research
critical to SM sexual practices and is often framed that explicitly explores SM across ethnocultural
within a scene or play. These plays involve safely factors, specifically race or ethnicity. Research has
acting out scripts that incorporate aspects of SM, instead focused on SM behavior with regard to

A demonstrator at the Folsom Street Fair in San Francisco, California, shows how to use a suspended bondage apparatus, September
24, 2006. Numerous demonstrations of consensual sex violence take place at this annual event—the third-largest street event in
California—including “charity whipping,” flogging, master-slave role playing, and bondage. Susan Wright, founder of the National
Coalition for Sexual Freedom, asserts that sadomasochism is an inborn “sexual orientation,” worthy at some point of legal recognition.
 Sadomasochism 769

biological sex, sexual orientation, and, to a lesser States. Also, with regard to bisexuals, prevalence
degree, nationality. rates of SM behavior do not appear to differ from
those of gay or lesbian individuals.
Gender, Sexual Orientation, and Nationality The practice of SM is bound by the cultural
Gender is an important factor to consider when context in which the behavior occurs. Therefore,
understanding sadomasochism. Historically, the it is plausible that SM behavior may vastly differ
literature has all but exclusively focused on SM across nations holding differing views on sex and
among males, in part because of past emphasis on sexuality. These views are often cultivated based
SM among the homosexual community. Recent on the gender and power norms of a country. As
research, however, generally supports that both a result, the gender and power contingencies of
men and women engage in SM behaviors, seem- a nation may directly influence how SM behav-
ingly at equitable rates. There is less agreement iors are perceived (e.g., as pathology or normative
regarding gender differences in preference for par- sexual behavior). This is important for several rea-
ticular types of SM roles or behaviors. Some older sons. The recent publication of the DSM-5 is per-
studies have suggested that there are no differences, haps the most illustrative example of the influence
whereas other findings present a more nuanced of gender and power mores on SM-related issues.
view of SM preferences in men and women. Physician Richard B. Kreuger argues that sexual
For example, Denise Donnelly and James Fra- sadism and masochism should remain classified
ser reported in 1998 that men exhibited higher as sexual disorders. However, other researchers
levels of arousal compared to women over both disagree with this pathology-based view, suggest-
fantasizing and engaging in sex in which they ing that the current classification is evidence of a
were dominant. However, there were no differ- sex-negative culture.
ences in level of arousal when fantasizing about or There is little research directly comparing the
engaging in submissive SM activities. More recent SM behavior and preferences between coun-
reviews have reported that women and hetero- tries. However, the link between exposure to
sexual men may prefer more masochistic activi- and acceptance of SM behavior has been exam-
ties. This is supported by research indicating that ined. In a recent study, Dana Rei Arakawa and
a significant proportion of women across a num- colleagues examined the number of empowering
ber of studies endorsed being sexually aroused by (i.e., non-SM-like) and disempowering (i.e., SM-
fantasies involving controlled force used as part like) pornographic images that were present in
of a sexual act. Moreover, N. K. Sandnabba and pornography from three countries (Norway, the
colleagues have suggested that more hypermascu- United States, and Japan) with varying levels of
line, sadistic behavior may be associated with both egalitarianism. Results indicated that the porno-
heterosexual and homosexual males. In sum, there graphic images in Norway, which was ranked
appear to be differences in the types of SM activi- first in gender equality, depicted women in a more
ties preferred by men and women, with some over- empowering manner than pornography in Japan.
lap among heterosexual and homosexual males. There were no differences in the number of dis-
Considerable research has focused on examining empowering images across the three nations.
SM behavior among heterosexual and homosexual Culture influences the appetite for many con-
communities. Despite this, little is known regarding sumables, including sex. Although future studies
SM behaviors in lesbian and female bisexual popu- need to be done that compare countries, and cul-
lations. Some insight is provided by Juliet Ritchers tures within countries, current evidence suggests
and colleagues in perhaps the most representative that SM may be a way of managing the stress of
and comprehensive survey of SM behavior to date. empowerment or disenfranchisement from bases
In a study conducted in an Australian national of power within the society where an individual
sample, these authors reported that self-identified dwells. The powerful may seek to be dominated,
bisexual and gay men and women were more likely while the powerless may seek to dominate. Sexual
to report engaging in SM behavior compared to and nonsexual fantasy can serve as an adaptive
the heterosexual counterparts. This is consistent venue in which to experience the opposite of real
with other reports of SM behavior in the United life. When these experiences produce distress and
770 Schizoaffective Disorder

impairments in functioning, they may rise to the preceded or are followed by at least two weeks
threshold of pathology. of delusions or hallucinations without prominent
mood symptoms.” Schizoaffective disorder also
Christopher L. Edwards includes two types. These types are bipolar type
Duke University and depressive type. The active-phase symptoms
LaBarron K. Hill of schizophrenia include delusions, hallucina-
Duke University Medical Center tions, disorganized speech, grossly disorganized
Courtney Peasant or catatonic behavior, and negative symptoms.
University of Memphis In order to be diagnosed with schizoaffective
disorder, there are four criteria that must be met.
See Also: Gender; Psychiatry and Sexual Orientation; Criterion A states that there must be a constant
Sex; Sex Differences; Sexual Surgery. period of illness during which, at some point,
there is either a major depressive episode, a manic
Further Readings episode, or a mixed episode simultaneous with
Americans for Truth. “Sexual Freedom Activist Susan the symptoms from criteria A for schizophrenia.
Wright Tells LaBarbera: Sadomasochism Is a Criterion B states that during that time of ill-
‘Sexual Orientation’” (September 28, 2008). ness, there have been delusions or hallucinations
http://preview.tinyurl.com/osqqck8 (Accessed for at least two weeks without prominent mood
June 2013). symptoms. Criterion C states that symptoms that
Arakawa, D. R., C. Flanders, and E. Hatfield. meet criteria for those of a mood episode must
“Are Variations in Gender Equality Evident be present for a significant portion of the total
in Pornography? A Cross-Cultural Study.” length of the active and residual points in the ill-
International Journal of Intercultural Relations, ness. Criterion D states that the disturbance is not
v.36/2 (2012). because of the direct effect of a substance such
Kelly, B. C., D. S. Bimbi, J. E. Nanin, H. Izienicki, as drug abuse or medication; nor is it because of
and J. T. Parsons. “Sexual Compulsivity and the effects of a general medical condition. When
Sexual Behaviors Among Gay and Bisexual Men specifying a type, either bipolar or depressive,
and Lesbian and Bisexual Women.” Journal of Sex there are also standards. For bipolar type, the dis-
Research, v.46/4 (2009). turbance must include a manic or mixed episode;
Kleinplatz, Peggy J. and Charles Moser. and for depressive type, the disturbance includes
Sadomasochism: Powerful Pleasures. New York: only major depressive episodes.
Harrington Park, 2006. Schizoaffective disorder, thus far, appears to
Krueger, R. B. “The DSM Diagnostic Criteria for occur at lower rates than schizophrenia and has
Sexual Masochism.” Archives of Sexual Behavior, a better prognosis than schizophrenia. Schizoaf-
v.39/2 (2010). fective disorder, bipolar type is more common
Tomassilli, J. C., S. A. Golub, D. S. Bimbi, and J. T. in young adults, while schizoaffective disorder,
Parsons. “Behind Closed Doors: An Exploration depressive type is more common in older adults.
of Kinky Sexual Behaviors in Urban Lesbian and There has also been significant evidence to sug-
Bisexual Women.” Journal of Sex Research, v.46/5 gest that schizoaffective disorder has a relevant
(2009). genetic component in mental illness because the
risk of developing mood disorders is higher when
relatives have schizoaffective disorder.
Diagnoses of schizoaffective disorder, schizo-
phrenia, and mood disorder with psychotic fea-
Schizoaffective Disorder tures are often difficult to distinguish. There are
many elements of each that intersect and sound
According to the American Psychological Asso- analogous. The important distinction is in how
ciation, “Schizoaffective Disorder is a disorder in they differ. Schizoaffective disorder is differ-
which a mood episode and the active-phase symp- ent from schizophrenia in that mood aspects
toms of schizophrenia occur together and were (whether depressive, manic, or mixed episodes)
 Schizoaffective Disorder 771

are present continuously and simultaneously with cultures in their social acceptance, for instance,
the symptoms of schizophrenia. Mood disorders not all cultures consider hallucinations an indi-
are diagnosed if the psychotic symptoms occur cator of schizophrenia or similar disorders. Ideas
only during times of mood disturbance, unlike that may seem delusional in one culture, such as
schizoaffective disorder, in which the psychotic witchcraft, could be commonly held beliefs in
symptoms remain without mood disturbance. another culture. Additionally, religious visual or
The Diagnostic and Statistical Manual of Men- auditory hallucinations can be considered a nor-
tal Disorders (DSM) is the leading standard used mal segment of a religious experience.
to diagnosis mental illness. Difference between Language barriers must also be acknowledged
cultures has become an important issue within because they can contribute to what one culture
multiple fields, including clinical psychology and could consider disorganized speech. Different
psychiatry. To account for this, the fourth edi- cultures also communicate differently; therefore,
tion (DSM-IV-TR) was revised to include text some individuals may use different emotional
describing cultural variations of disorders and expression, eye contact, or body language than
culture-bound syndromes. These culture-bound another culture. Because these different aspects of
syndromes are not necessarily disorders, but they an individual’s culture can vary, it is important
are experiences that people within a particular to include cultural sensitivity in psychological
culture may find troubling. These syndromes assessments. These cultural issues can all attri-
may be completely unique or related to disorders bute to the variation in symptom presentation of
identified in the DSM. schizoaffective disorder cross-culturally.
At times, there may be cultural explanations Although the symptoms for schizoaffective
for an individual’s illness, such as the perceived disorder may not be recognized around the world
severity of an individual’s symptoms, particularly as they are in most Western civilizations, they are
in relation to the norms of their cultural group. still experienced on a global level. Studies thus
It is also possible that individuals outside the cul- far have noted that schizoaffective disorder and
tural norm can be diagnosed with disorders that like illness affect all racial and cultural groups.
describe behavior abnormal to dominant culture, This is all within a Westernized diagnosis; there-
while the same actions are acceptable in the cul- fore, the symptoms of schizoaffective disorder
ture of the patient. For example, the belief that may not lead to the same diagnosis in another
spirits posses an individual (as in Ethiopia, Soma- part of the world.
lia, Egypt, Sudan, Iran, and other north African There has been research to suggest that cer-
and Middle Eastern societies) may be considered tain cultural or racial groups are more likely to
pathological in the United States but is not con- receive the diagnosis of schizoaffective disorder or
sidered pathological in these cultures. schizophrenia. Studies from the United Kingdom
and the United States have suggested that African
Cultural Difference in the Symptoms and Americans and Asian Americans are more likely
Diagnosis of Schizoaffective Disorder to receive a diagnosis of schizophrenia or like dis-
Psychopathologies such as schizoaffective disor- orders than other ethnic or racial groups. There is
der can be studied using a cultural perspective. no single suggestion as to why this occurs; it could
While most major cultural research has specifi- be because of true differences between groups, or
cally focused on schizophrenia, it is possible to it could be the result of biases and cultural insen-
see the remaining cultural effects that would be sitivity in looking at what are considered symp-
applicable to schizoaffective disorder. These diag- toms. It is also suggested that the higher rates of
noses are very similar, and most of the cultural these disorders in particular cultures and races
differences and similarities look at the intersect- could be because of the misdiagnosis of disorders
ing aspects of these mental illnesses. instead of true cultural distinctions.
As Criterion B for schizoaffective disorder Although there is a worldwide trend toward
states, hallucinations and delusions must occur; higher prevalence rates for schizophrenia and
they are a prominent symptom in schizoaffective schizoaffective disorder, there are a number of
disorder. Hallucinations are found to differ across social setting characteristics within different
772 Schizoaffective Disorder

cultures that are distinguishable by uncommonly in suicide attempts with populations of patients
high or low rates of these diagnosed disorders. who were diagnosed with either schizophrenia or
The suggestions for this phenomenon include pat- schizoaffective disorder. The results showed that
terns of contradictory messages from the com- North America had the youngest age at first sui-
munity to an individual. An example within the cide attempt, while Europe had the oldest, and
United States would be the expectation for men North America had a higher number or lifetime
to be aggressive, yet when they act in a way that suicide attempts, while South Africa had the least
culture decides is overly aggressive, it suddenly amount of suicide attempts.
becomes a problem with the individual, not soci- The differences in these statistics could be due
ety. Expressed emotion and the cultural meanings to many different factors, but they suggest that
behind hallucinations are also considered possible there are several clinical variables associated with
answers to cultural distinctions. suicide attempts in schizoaffective and schizo-
phrenic disorder patients that can vary across cul-
Cultural Difference in the Course and tures. Environmental influences may play a key
Outcome of Schizoaffective Disorder role in this suggestion. For instance, it is found
The course and outcome of schizoaffective dis- that substance and nicotine abuse are variables to
order, along with like diagnoses, have a much consider when looking at these suicide rates. Cer-
higher variability than the symptoms of the dis- tain cultures may be more accepting of excess nic-
order. These differences stretch from culture to otine or alcohol consumption, and these variables
culture and may be because of cultural varia- may increase the likeliness of a suicide attempt.
tions or prevalent biological influences such Thus, culture may play a key role in the individu-
as immunizations. For instance, in Colombia, al’s schizoaffective disorder outcome.
India, and Nigeria, more people show a signifi- Research has been conducted about the genetic
cant improvement or recovery with treatment component of schizoaffective disorder (as well as
than other in countries. There are many different similar disorders). A genetic component is a sup-
ethnic characteristics that can affect the course ported, and it is an accepted theory that genetics
and outcome of schizoaffective disorder and makes some individuals more vulnerable to dis-
similar disorders. orders such as schizophrenia and schizoaffective
When studying Mexican Americans, distin- disorder. These genes, because they are inherited
guishing characteristics are related to the course from family, can remain within specific cultures,
and outcome of the disorder rather than to its fre- especially if those cultures are more isolated than
quency. For example, family members of Mexican others. This could be a factor to consider when
American schizophrenics tend to have lower lev- looking at cultural rates of a schizoaffective dis-
els of expressed emotions, which are a cluster of order diagnoses.
negative and affectively charged attitudes such as There are a multitude of different problems in
hostility, criticism, and intrusiveness. These emo- the assessment of psychopathology, also known
tions are found to disrupt diagnosed individuals’ as abnormal psychology. Looking at the rich
social functioning and to predict their relapse. diversity in culture around the world, there are
These lower than Anglo-American family norms cultural variances in how individuals develop.
of negative expressed emotions in Mexican Amer- These differences include beliefs, traditions, and
icans result in more acceptance and compassion language. Because of these differences, a variety
within their households. Because of the difference of issues including ethics in the mental health field
in environment, the outcome of schizophrenia have come to light and are continually reworked
and like diagnoses in Mexican American families to ensure that each person, regardless of their cul-
is more likely to be benign. ture, race, and ethnicity, receive equal assessment,
Schizoaffective disorder tends to take a toll on diagnosis, and treatment.
the individual who is diagnosed because symptoms
can make life increasingly difficult. This is espe- Alyssa Gretak
cially so when left untreated. Research has been Joel T. Nadler
conducted to look at the transcultural differences Southern Illinois University, Edwardsville
 Schizophrenia 773

See Also: Diagnosis; Diagnosis in Cross-National roughly as “splitting of the mind.” Schizophrenia
Context; Mood Disorders; Schizophrenia; Suicide: commonly occurs during adolescence, a feature
Patient’s View. that was captured in the earlier term dementia
praecox, which describes notions of premature,
Further Readings precocious, or early dementia or madness; dates
Aponte, J. F. and J. Wohl. Psychological Intervention back to at least the mid-19th century; and was
and Cultural Diversity. 2nd ed. Needham Heights, popularized by Emil Kraepelin (1856–1926) from
MA: Allyn & Bacon, 2000. the 1880s. One of the most striking differences
Durand, V. M. and D. H. Barlow. Essentials of between Kraepelin and Bleuler’s formulations is
Abnormal Psychology. 5th ed. Belmont, CA: that Kraepelin collected information about his
Wadsworth, 2010. patients from their records, while Bleuler obtained
Tseng, W. and J. Streltzer. Culture and the information by careful clinical observations
Psychopathology: A Guide to Clinical Assessment. and traveled within several different cultures in
New York: Brunner/Mazel, 1997. order to expand his frame of reference and obser-
vation. In 1911, Bleuler wrote the following:

I call dementia precox schizophrenia because,

as I hope to show, the splitting of the different
Schizophrenia psychic functions is one of its most important
features. In each case there is a more or less
More than 100 years after its introduction as a clear splitting of the psychological functions:
psychiatric term, schizophrenia continues to pro- as the disease becomes distinct, the personality
voke significant controversy and debate. Schizo- loses its unity.
phrenia is a mental disorder characterized by a
breakdown of thought processes and a deficit of For Bleuler, the critical defining explanation for
typical emotional response (affective disorder). schizophrenia was a “splitting of psychic func-
Although features associated with this form of tioning,” a phrase that became critically misun-
mental illness have been identified in most cul- derstood and confused in the popular and media
tures around the world, its causes, diagnoses, imagination with “split personality disorder.” If,
prognoses, and treatments vary. Recent bio- as Bleuler argued, the schizophrenic is one for
medical research has argued that the etiology of whom “the personality loses its unity,” this does
schizophrenia may be linked to the manifestation not imply that multiple personalities inhabit the
of genetic diversity associated with language and body but rather that the condition describes an
its defining role in primate and human evolution. inability to function in a consistent or holistic way.
With 21st-century brain-mapping technology, the The schizophrenic symptoms described by
visualization of distinctive and specific features Bleuler have appeared in ancient accounts from
associated with schizophrenia may soon be real- Roman, Greek, and even Egyptian literature,
ized. Once it becomes possible to mark particular although interpretations and treatments of these
visual features that correlate with schizophrenic symptoms were very different from more modern
behaviors, the long history of diagnostic ambi- medical constructions. Virtually every account
guity and cultural variation may end. Lately, the of demonic possession and every ceremonial and
term has become a key area of global debate by surgical attempt (such as trepanning) to release
medical practitioners and patients. unruly presences from an unpredictable and
The term schizophrenia was coined by Eugen inconsistent personality may lend itself to the
Bleuler (1857–1939) in 1908, in a public address extended and uncertain history of schizophrenia.
to the German Psychiatric Association in Ber- Once isolated by Bleuler, this condition soon
lin. Three years later, he expanded on his under- lent itself to philosophical and even theological
standing of this concept in Dementia Praecox analogies and paradigms because the fractur-
oder Gruppe der Schizophrenien. Schizophrenia ing and reintegration of identity is a defining
is a word derived from the Greek that translates mythos of many civilizations, Eastern as well as
774 Schizophrenia

Christian. The Egyptian mortal-immortal fig- In the early 1970s, a U.S./United Kingdom
ure of Osiris, who is violently dismembered and study concluded that diagnosis of schizophre-
slowly reintegrated, has long been considered nia was disorganized and subjective, evidenced
the inspiration for religious heroes as diverse as by widely divergent rates of international diag-
Orpheus and Jesus Christ. In order to understand nosis. Not only do observed typical symptoms
schizophrenia in a fully cultured and socialized of schizophrenia vary cross-culturally but the
way, therefore, it is important to consider ways willingness of medical practitioners to diagnose
in which understandings of fractured and slowly schizophrenia is similarly variable. The extent to
reintegrated personality inform not merely stories which the term can retain a transnational descrip-
of dysfunctional individuals but are foundational tive validity has always been contested. Studies
and constructive in how entire societies and cul- have attempted to plot incidence and variants of
tures understand themselves. symptomatic schizophrenia according to cross-
Accordingly, philosophically and theologically cultural standards of sociocentricity, attempting
informed successors of Freud and Bleuler, notably to determine whether individualist or collectiv-
Carl Jung, have used schizophrenia to illustrate ist cultures have higher rates of diagnosis, and
larger archetypal human characteristics. Under- plotting the various cross-cultural definitions of
standing schizophrenia has therefore been rather aberrant behavior that attract such diagnoses.
grandiloquently regarded as a means of under- In 2011, researchers identified key cultural dif-
standing what it means to be a complex human in ferences in the nature and frequency of halluci-
a complex world. nations experienced by people diagnosed with
schizophrenia. Auditory hallucinations were the
Causes and Diagnoses most common overall but were more marked in
The cause or causes of schizophrenia continue to West Africa. Other symptoms also demonstrate
prove elusive and culturally variant. Hereditary marked cultural variations.
concerns are known to be a factor in predicting Generally, cross-cultural research shows more
the incidence of this condition, yet not to the severe symptoms in urban settings. In societies
extent as to override environmental, social, and where strong supernatural beliefs are prevalent,
cultural issues. In 1973, the World Health Orga- schizophrenic behaviors are typically removed
nization (WHO) conducted a comparative study from a purely individual diagnostic paradigm and
of schizophrenia in developed and developing traditional support mechanisms help to alleviate
countries and discovered very wide symptomatic the condition of the individual in distress. In addi-
variations and variations in prognoses. tion, the role of extended families within tradi-
According to the fourth edition of the Diagnos- tional societies produces significant and positive
tic and Statistical Manual for Mental Disorders impacts in terms of patient prognosis. Particular
(DSM-IV), anyone classified as having schizophre- specialized occupations and competitive work-
nia must exhibit at least two positive symptoms places also prove difficult environments from the
(delusions, hallucinations, disorganized speech, or point of view of reintegrating individuals exhibit-
grossly disorganized or catatonic behavior) and/ ing schizophrenic behaviors.
or negative symptoms such as flat affect, anhe- Cultural variance has also been found to exist
donia (inability to experience pleasure), abolition within the clinical process and diagnostic proce-
(lack of drive), or alogia (poverty of speech) for dures. Psychiatrists are influenced by their cul-
a significant portion of one month, and general ture and/or the culture or race of their patient.
disturbance for at least six months. The DSM-5, For instance, in the United States, there has been
however, eliminated the subcategories of schizo- a long history of diagnosing African Americans
phrenia—the paranoid, catatonic, disorganized, with schizophrenia instead of less stigmatized
undifferentiated, and residual types—arguing disorders. From the earliest stages of diagnosis,
that they were limited in diagnostic stability, low therefore, social, cultural, and racialized assump-
reliability, and poor validity. The enforcement of tions govern or at least influence clinical processes.
these recent changes was specifically spearheaded Another example from Japan has specifically been
because of cross-cultural symptom variations. linked to the semantics of the term schizophrenia
 Schizophrenia 775

A bedsheet-sized piece of embroidery made in the 1960s by a schizophrenic woman who rarely spoke hangs in the Glore Psychiatric
Museum in St. Joseph, Missouri. The embroidery was analyzed by three researchers who, after comparing themes and accounting for the
woman’s milieu, determined that although she was silent, the patient was connected to her surrounding environment in unique ways.

and its cultural interpretations. The Japanese episodes may result in hospitalization, either vol-
term for schizophrenia (which carries a distinc- untary or (in extreme situations and if legally per-
tive resonance derived from the ideogrammatic mitted) involuntary. Since the 1950s, deinstitu-
nature of the Japanese language) involves a much tionalization has been a feature of most Western
harsher and potentially more stigmatizing “mind- nations, replaced (to a greater or lesser extent) by
split” categorization that risks over-determining various community support services, drop-in cen-
patients to the extent that Japanese physicians ters, and home visits.
are reluctant to apply this diagnosis if others are Pharmaceutical treatments have been the pre-
available. As a result of informed-consent legis- ferred choice in more developed nations. Further-
lation, an inability to declare and communicate more, the effectiveness of antipsychotic drugs in
this diagnosis has resulted in withholding various maintenance therapy for schizophrenia has been
medications. This same stigma extends to fami- established by numerous studies. The limitations
lies, and as a result, some of the (highly effective) of such drugs become apparent in a number of
family treatment options that have been identified respects, however. Their short-term effects are
as key variables in the prognosis of schizophrenia impressive, but they are unsustainable over a lon-
are not made available. ger period, especially when treating symptoms of
chronic schizophrenia—including flat affect. In
Cultural Variance in Prognosis and Treatment addition, a pharmacological program of treat-
Cross-culturally, treatment for schizophrenia falls ment cannot adequately address the challenge of
into the categories of pharmaceutical, psycho- deinstitutionalization: learning how to adjust to
logical, and psycho-educational therapies. Severe the world outside the hospital.
776 Schizophrenia

Often applied in combination with pharmaceu- Psychiatrist Adolf Meyer declared in 1928, “The
tical treatments, cognitive or psychological thera- history of dementia praecox is really that of psy-
pies are often employed in many cultures. Such chiatry as a whole.” In the 1970s, schizophrenia,
strategies generally encompass treatments such its diagnoses, and misdiagnoses became central to
as counseling, group therapy, and the structured the antipsychiatry movement typified by Thomas
relearning of domestic and day-to-day life skills. Szasz. Within a new climate of cultural relativ-
Such therapies offer the opportunity to plot lon- ism, the idea of a normative behavioral standard
ger-term self-management of this illness within a according to which varieties of mental illness could
framework of reflexive understanding. be measured was subjected to ontological scru-
Family therapy now plays a major role in tiny. Diagnoses of schizophrenia, which illustrate
the treatment of patients with schizophrenia in cross-cultural inconsistencies, may therefore be
a number of countries around the world. It has more revealing of the norms of value assumed by
been argued that patients suffering from schizo- authorities than of the medical status of individu-
phrenia in different countries have much better als so designated. Szasz suggested that if (as now
long-term outcomes in developing countries than seems likely in the 21st century) it became possi-
in developed countries, despite the fact that many ble to biomedically isolate a physical condition of
pharmaceutical treatments are not often widely schizophrenia, then it would no longer be possible
available in these countries. Many clinicians have to institutionalize diagnosed schizophrenics.
concluded that community and family factors are In 2011, the centenary of Bleuler’s first publica-
key to these improved outcomes. Thus, family tion of the term schizophrenia provoked a wide-
therapy has become a preferred treatment option. spread medical and academic revaluation of the
It has been hypothesized (by both clinicians and concept. There was a perceived need to go back to
researchers) that these improved outcomes are the Bleuler for the original context for the term and to
consequence of a greater sense of social connect- free its conception from the later assumed mean-
edness and social acceptance. Self-fragmentation ings of the word. Terminological disputes concern-
and social anomie are intimately linked, just as ing schizophrenia, among both medical practitio-
social cohesion and holistic well-being are equally ners and patient advocacy groups, particularly with
codependent. the most recent editing of DSM-5 manuals and the
One example of how a traditional society ICD 11 (International Classification of Diseases,
responds to schizophrenic behavior has been to be published in 2014), continue to unfold.
offered by the case of Ireland, which provides For the first time, these two clinical heuristics
examples of how schizophrenics identify with are coordinating in order to formulate a global
patterns and images of sainthood. Most contro- diagnostic consensus. The contested nature of the
versially, Nancy Scheper-Hughes, in her award- term schizophrenia has sponsored international
winning book Saints, Scholars and Schizophrenics efforts to rename the condition within less cul-
(1971), attempts to impose a schizophrenic para- turally specific terms, which may result in more
digm upon behaviors, which may illustrate social global acceptance. However, such is the famil-
cohesion rather than isolation. Individuals within iarity of the term schizophrenia and the body of
such communities may be strongly marked, and experience and literature that it has organized
apparently stigmatized, while they are accepted over the past century that the study both of schizo-
and integrated. phrenia and of the societal and cultural anxiet-
Family is a key feature that defines perceptions ies it provokes is likely to remain for decades to
of this condition. Family members of diagnosed come. In the meantime, the very real sufferings
schizophrenics recognize that social rather than and needs of individuals (as well as their families
biological factors are responsible for the onset and friends) whose experiences have been used to
of schizophrenia. The preeminence of family-­ organize such diagnoses will continue to provoke
oriented treatment paradigms yet again sug- urgent and practical social and cultural demands.
gests that schizophrenia is a domain that tests
the strengths and limitations of biomedicine’s Tanya M. Cassidy
authority to govern aberrant behaviors. University of Windsor
 Scientology 777

See Also: Adolescence; Antipsychiatry; Dementia Hubbard first described his views on the opti-
Praecox; Family Support; Genetics; Hallucinations; mization of the brain in the May 1950 issue of
Stigma: Patient’s View; Szasz, Thomas; Urban Versus Astounding Science Fiction. He then developed
Rural. his ideas of a new psychotherapy in a series of
published texts, and in 1953 he opened the first
Further Readings Scientology organization to further his ideas,
Blakeman, John R., Sheryl J. Samuelson, and dubbing it the Church of Scientology of Califor-
Kimberly N. McEvoy. “Analysis of a Silent Voice: nia, founded in February 1954.
A Qualitative Inquiry of Embroidery Created For Scientologists, the optimal mental state to
by a Patient With Schizophrenia.” Journal of achieve is that of “being clear.” This is a state in
Psychosocial Nursing and Mental Health Services, which people are free from all pains experienced
v.51/6 (June 2013). in this and all previous lives. All the painful expe-
Doubt, Keith. Towards a Sociology of Schizophrenia: riences of current and previous lives are said
Humanistic Reflections. Toronto: University of to be stored in the human subconscious, called
Toronto Press, 1996. “engrams.” These engrams prevent the individual
Kim, Y. and G. E. Berrios. “Impact of the Term from functioning at full potential in daily life.
Schizophrenia on the Culture of Ideograph: The Hubbard developed a technique called “dianet-
Japanese Experience.” Schizophrenia Bulletin, ics” to discover the origins of the engrams and to
v.27/2 (2001). clear people from them. Part of these exercises
Moskowitz, Andrew and Gerhard Heim. “Eugen include following the indications of a belief sys-
Bleuler’s Dementia Praecox or the Group of tem manual and the reading of an e-meter (elec-
Schizophrenias (1911): A Centenary Appreciation tro-psycho-meter), a machine inspired by the
and Reconsideration.” Schizophrenia Bulletin, lie detector. After various exercises in dianetics,
v.37/3 (2011). the scientologist is argued to be able to read his
Phillips, Michael R., Yongyun Li, T. Scott Stroup, and or her emotions on the e-meter and detect the
Lihua Xin. “Causes of Schizophrenia Reported unconscious pains accumulated from his or her
by Patients’ Family Members in China.” British past lives.
Journal of Psychiatry, v.177 (2000). A series of courses on the principles of dianet-
Scheper-Hughes, Nancy. Saints, Scholars and ics are offered by the Church of Scientology, and
Schizophrenics. Berkeley: University of California as people move from one course to another, they
Press, 2001. progress a level closer to the “clear state.” In a
linear developmental fashion, participants have
to move one level at a time.
One of the chief aims of Scientology is to erad-
icate and replace the psychiatric profession, espe-
Scientology cially the psychiatrists’ use of pharmaceuticals
to treat mental health issues. Scientology seeks
Scientology is a claimed alternative mental well- to replace psychiatry with its mental well-being
being therapy and belief system movement that therapy and belief system auditing technique. Sci-
began in the 1950s as an oppositional group to entology attempts to position itself as a rival sys-
traditional mental health therapies. The move- tem to psychiatry.
ment was formed by Lafayette Ronald Hubbard
(L. Ron Hubbard), an American. Hubbard and Teachings and Practices of Scientology
his followers alleged that the human mind could According to the teachings of L. Ron Hubbard
be greatly improved in ways that would give peo- regarding mental well-being therapy and belief
ple greater mental dexterity. Hubbard began pub- systems, humans are spiritual beings known
lishing books on Scientology in the early 1950s. as Thetans (from the Greek letter theta, θ), liv-
His first two Scientology books were Dianetics: ing through countless lifetimes, past and future.
The Modern Science of Mental Health (1950) and Life is compartmentalized into eight dynamics
Science of Survivals (1951). of impulses (self, family, group, humanity, life,
778 Scientology

universe, spirit, and allness). The process of audit- mind takes note of all the particulars of the expe-
ing confronts and transcends one’s negative time rience, even though the individual may not be
track and facilitates orientation through the eight consciously aware of it. He defined the analyti-
dynamics of impulses, gradually transforming the cal mind, engrams, as a complete recollection of
Thetans to clear. Participants of this auditing pro- every perception occurring during unconscious-
cess become more aware as they advance through ness. Because of the unconscious nature of these
each of the eight dynamics until discovering truth. engrams, an individual may not remember the
This process is concerned with the passage of the traumatic experience. Nevertheless, the engram
Thetan or spirit or soul of human beings through remains firmly placed in the mind of the individ-
the eight dynamics of impulses and the ultimate ual. The inability to attain full human potential
release of the Thetan from the bondage of the is considered the result of nondeleted engrams.
body. Thus, the belief in the transmigration or Auditing, as a mental well-being therapy, allows
infinite reincarnation of Thetans is a belief in a an individual to explore engrams while reliving
supernatural principle. them in order to inactivate them.
Hubbard advanced the idea that the human As established in Scientology’s foundational
being is neither a mind nor a body. All humans documents, an auditor conducts the auditing ses-
are actually Thetans, immortal spiritual entities sions and listens to the preclear, a term associated
possessing virtually infinite powers. Individuals with the individual being audited. The auditor and
do not have Thetans, they are considered Thet- the preclear meet in an undisturbed room with an
ans. Without Thetans, there would be no mind e-meter, which measures the energy of the mind
or body. Hubbard believed that Thetan was the created when the preclear pictures an engram.
foundation of creation and life. The preclear focuses on the engram with the help
Because of various traumas and negative expe- of an inquiry process led by the auditor. Scien-
riences, the Thetans become clouded. The objec- tology beliefs establish that the levels of the clear
tive of the auditing sessions is for an individual state allow an individual to progress toward the
to be free of any engrams. When this occurs, the bridge of total freedom, freedom from physical
individual is said to be clear and the analytical constraints of their material bodies and the mate-
mind can now function without the effects of the rial universe, which is matter, energy, space, and
reactive mind and its engrams. The purpose of time (MEST). Participants who progress toward
this system is to help the Thetans become clear or the operating Thetan (OT) may know immortal-
untroubled. Before attaining a state of clear, one ity and freedom from the cycle of birth and death.
is known as a “preclear.” Trauma and negative The individual’s goal is to come into full aware-
experiences lead people to commit wrong deeds, ness of his existence as a being that transcends
not nature. People are by nature good. A cumu- MEST and is guided into the journey toward a
lative record of stored mental images amassed state of transcendent near-perfection.
through a person’s many lives is called a “time
track.” When individuals have become clear, Controversies With Psychiatric
they gain a greater understanding of their human Mental Health Treatments
potential according to this belief system. L. Ron Hubbard’s successor, David Miscavige,
In Hubbard’s foundational book, Dianetics, he continued Hubbard’s agenda to replace the psy-
establishes the belief that the two components of chiatric profession with an alternative model for
the human mind are the analytical and the reactive addressing mental health issues. The model they
mind. The analytical mind is the component of promote aims to eradicate the psychiatric practice
the mind that a person consciously utilizes. How- (especially psychiatrists’ use of pharmaceuticals)
ever, beneath the analytical mind is the reactive and replace it with its mental well-being therapy
mind. During moments of troubling emotional and belief system auditing technique. Scientology
and physical pain, the analytical mind is inter- attempted to position itself as a rival profession
rupted, and the reactive mind takes control of the to psychiatry and tried to provide an explana-
functions commonly associated with the analyti- tion in terms of traumatic incidents in which the
cal mind. During this time of tension, the reactive individual had been unwittingly involved, and
 Self-Esteem 779

thereby relieved him of any responsibility for Stephen, A. Kent and Terra A. Manca. “A War Over
his failure. Scientology’s Citizens Commission Mental Health Professionalism: Scientology Versus
on Human Rights (CCHR) promotes the move- Psychiatry.” http://dx.doi.org/10.1080/13674676.2
ment’s ideological criticism of psychiatry. CCHR 012.737552 (Accessed November 2012).
is an informational and lobby group functioning
under Scientology’s code of ethics. According to
a CCHR publication, it is necessary to eliminate
destructive psychiatric practices. CCHR conducts
national campaigns in order to inflict severe losses Self-Esteem
on the ranks of psychiatry.
One of the most noticeable campaigns led by Self-esteem (also known as self-regard) is defined
CCHR is characterized by its attacks against as people’s evaluations about their worth, compe-
particular psychotropic medications. CCHR and tence, and desirability. Self-esteem is a personality
its Scientology’s Office of Special Affairs (OSA) trait that has been widely studied by psychologists
launched a major campaign against Prozac and and other social scientists. There are different kinds
Ritalin in the 1980s. Through mass media, this of self-esteem. “Explicit” measures ask respon-
commission and department insisted that Rit- dents to self-report to what extent they agree that
alin and Prozac, with the approving support of they are a person of worth, that they have good
the American Psychiatric Association (APA) and qualities, and that they have positive attitudes
the Food and Drug Administration (FDA), alleg- toward themselves. “Implicit” measures of self-
edly cause damaging effects among some chil- esteem assess beliefs about the self that operate
dren, including violent and assaultive behavior, below respondents’ conscious awareness. Explicit
stunted growth, hallucinations, suicidal depres- and implicit measures of self-esteem are not neces-
sion, headaches, and nervous spasms. Scientol- sarily correlated with each other. This means that
ogy’s critics accused it of utilizing psuedoscience people can believe that they have high self-esteem,
to seek public support. They denounce that Sci- but have low self-esteem “deep down.” Similarly,
entology remained unable to provide a workable, people might think that they have low self-esteem,
effective alternative to psychiatric pharmaceuti- but they may secretly love themselves.
cal practice. There are ongoing debates about whether the
desire to hold positive self-views is a human uni-
Héctor E. López versal that is valued in most cultures, or whether
Inter American University of Puerto Rico it is much more valued within individualistic
nations. Individualistic nations promote a sense
See Also: American Psychiatric Association; of uniqueness and independence from others,
Attention Deficit Hyperactivity Disorder (ADHD); while collectivistic nations promote interper-
Prozac; Ritalin. sonal connections and a sense of interdependence
with group members. People from individualistic
Further Readings nations (e.g., the United States and Canada) typi-
Chamblin, Laura and Craig W. Hirsch. “The cally score higher on explicit self-report measures
Church of Scientology.” World Religions and of self-esteem compared to people from collectiv-
Spirituality Project, Virginia Commonwealth istic nations (e.g., Japan and China). They also
University. http://www.has.vcu.edu/wrs/profiles/ tend to be more likely to self-enhance (e.g., exag-
ChurchOfScientology.html (Accessed October gerate their abilities) when given the opportunity.
2012). People from more collectivistic nations place a
Church of Scientology. The Scientology Handbook. high value on self-criticism and self-improvement
Los Angeles: Bridge Publications, 1994. rather than self-esteem.
Melton, J. Gordon. The Church of Scientology. Salt One attempt at resolving the debate has been
Lake City, UT: Signature Books, 2000. to say that there is a difference between per-
Possamai, Adam. Sociology of Religion for sonal self-esteem and collective self-esteem. Per-
Generations X and Y. London: Equinox, 2009. sonal self-esteem is how people typically define
780 Self-Esteem

self-esteem—as applying to their individual char- The modern self-esteem movement began in
acteristics and abilities. Collective self-esteem is a earnest in 1969 when psychotherapist Nathan-
feeling of self-worth that is based on group mem- iel Branden published The Psychology of Self-
berships (e.g., family, occupation, or gender). Even Esteem. Boosting self-esteem was viewed as a
though people from collectivistic cultures have panacea for all personal and social ill; according
lower personal self-esteem, they tend to have high to Branden: “I cannot think of a single psycho-
collective self-esteem, and they also selectively logical problem—from anxiety and depression,
self-enhance on collectively relevant attributes. to fear of intimacy or of success, to spouse bat-
Thus, some researchers argue that what appear to tery or child molestation—that is not traceable to
be cultural differences in self-esteem are actually the problem of low self-esteem.” Branden’s ideas
measurement artifacts, and that all people need to caught on quickly and soon became implemented
feel good about themselves, whether they define in the American educational system.
their self as a separate individual or more broadly There are a number of documented benefits
to include relationship partners and group mem- associated with high self-esteem. People with
bers. These scholars point out that the evolution- high self-esteem have better psychological health,
ary function of self-esteem is to allow people to have lower depression and anxiety, and report
know to what extent they belong in their social higher life satisfaction. However, there are also
environment, so it has to exist universally across negative connotations of high self-esteem (e.g.,
cultures. When implicit measures of self-esteem vanity, egotism, arrogance, and narcissism),
are compared across such cultures, no differences which is why more collectivistic cultures dis-
are found. courage it. High self-esteem has been linked with
Several studies have found that immigrants defensiveness, prejudice, aggression, and over-
who have lived in Western individualistic nations optimistic task persistence. In addition, in some
for longer periods have higher self-esteem lev- cases, unrealistically positive views of the self
els. Longitudinal studies that track individual (i.e., grandiosity or delusions) can signal men-
immigrants over time find that their self-esteem tal illness. Some researchers see high self-control
levels rise after living in Western individualistic and high other-regard as more prototypical of
nations for as little as one year and that this rise mentally healthy people, regardless of cultural
is associated with levels of acculturation. In other background.
words, the more people internalize their new There have been increases in explicit measures
culture’s norms and values, the more their self- of self-esteem in American culture from the 1960s
esteem grows. In addition, immigrants to West- to the present. Research that examines such
ern individualistic nations who primarily speak changes in collectivistic cultures is still needed.
the language of their new homeland have higher
self-esteem than immigrants who primarily speak Sara Konrath
in their original language. Such studies suggest University of Michigan
that it is possible for self-esteem to rapidly change
within certain cultural contexts. See Also: Acculturation; Delusions; Grandiosity;
Self-esteem is typically seen as a sign of robust Identity; Munchausen Syndrome; Self-Help.
mental health, but there are debates about its
value, even in individualistic cultures. Even Further Readings
though the term self-esteem is relatively new, phi- Baumeister, R. F., J. D. Campbell, J. I. Krueger, and
losophers have long debated the relative merits K. D. Vohs. “Does High Self-Esteem Cause Better
of loving oneself. For example, Aristotle weighed Performance, Interpersonal Success, Happiness, or
in on whether self-love and selfishness were syn- Healthier Lifestyles?” Psychological Science in the
onymous and concluded that self-love could be a Public Interest, v.4/1 (2003).
virtue or a vice. The New Testament reflects an Heine, S. J. and D. R. Lehman. “Move the Body,
awareness of the human tendency to prioritize the Change the Self: Acculturative Effects on the
self, as in Jesus’s command to “love your neigh- Self-Concept.” In Psychological Foundations of
bor as yourself” (Mark 12:31). Culture, Mark Schaller and Christian S. Crandall,
 Self-Help 781

eds. Mahwah, NJ: Lawrence Erlbaum Associates, sense of belonging, ability to share experiences,
2004. and general social support. To date, research on
Jordan, C. H., C. Logel, S. J. Spencer, and M. P. self-help resources has been difficult to conduct
Zanna. “Nonconscious Self-Esteem: Is There because those who use self-help resources can
Something You’re Not Telling Yourself?” In Self- do so without anybody ever knowing (e.g., buy-
Esteem Issues and Answers: A Sourcebook of ing a book). Thus, most self-help resources have
Current Perspectives, M. P. Zanna, S. J. Spencer, not been studied empirically, and their effective-
and M. H. Kernis, eds. New York: Psychology ness is unknown. However, of the few self-help
Press, 2006. techniques studied, research has shown that fears,
Sedikides, C., L. Gaertner, and Y. Toguchi. depression, headaches, and sleep disturbances
“Pancultural Self-Enhancement.” Journal of tend to be the most responsive to self-help tech-
Personality and Social Psychology, v.84/1 (2003). niques, and that disturbance of habit, such as
drinking and smoking, tend to be less responsive
to self-help resources.

History of Self-Help
Self-Help According to some sources, the earliest self-
help resource can be traced to Benjamin Frank-
Self-help, also referred to as self-improvement, is lin’s Poor Richard’s Almanac (1732), in which
the act of improving oneself personally, profes- he promoted the idea that those who wish to
sionally, or spiritually, without direct reliance on help themselves can do so. However, it was
others, or more particularly, professional thera- not until 1859 that Self-Help, the first book
pists. Self-help resources have become a large on self-improvement, was published by Sam-
source of guidance for many Americans, and uel Smiles. The genre of self-help rapidly grew
reports from the research firm Marketdata indi- after this publication. In 1936, Dale Carnegie’s
cate that the self-help industry was worth $10.5 How to Win Friends and Influence People was
billion in 2010. There are numerous self-help published, and it is one of the best-selling self-
movements that have varying focuses and use a help books to date. Shortly thereafter, Alcohol-
variety of techniques; however, many are based ics Anonymous (AA), the first self-help support
on psychological principles and focus on improv- group founded in 1935 by Bill Wilson and Dr.
ing mental health issues. The aim of these self- Bob Smith, became well known to the public in
help resources is to provide assistance and sup- 1944. Since its founding, AA has become one
port in order to aid the individual in improving of the largest and best-known self-help groups
his or her psychological health, without the help in existence. The formation of other self-help
of a professional or traditional psychotherapy. groups that addressed drug addiction (Narcot-
Although self-help can be initiated through ics Anonymous, NA) and mental health quickly
various avenues including motivational speakers, followed, including Recovery, Inc., founded in
public seminars, workshops, retreats, training 1937 by Abraham Low, and Synanon, founded
organizations, and various media sources (e.g., in the 1950s by Charles Dedrich.
Web sites and CDs/DVDs), the largest source of In 1967, the publication of psychiatrist Thomas
ideas and techniques for those seeking self-help Harris’s I’m OK, You’re OK set the self-improve-
are books and support groups. Many self-help ment genre up for growth. Since this publica-
resources include a gathering of a group of people tion, thousands of books on self-help have been
who have shared similar experiences and are join- published by professionals and nonprofessionals
ing together to support one another. The topics alike, and many support groups that address a
addressed by self-help resources include smoking wide range of mental health problems have been
cessation, anxiety, depression, relationship issues, founded. By the 1980s, clearinghouses for sup-
weight loss, and alcohol and drug problems. port groups began to form and offered informa-
Some of the benefits associated with self-help tion regarding not only how to find appropriate
resources include educational information, a groups but also how to begin a new group. As
782 Self-Help

time has progressed and technology has grown, by trained professionals, many are written by
so has the means by which self-help resources individuals with personal, but not professional,
can be accessed. Beginning in the 1990s, several experience with the given topic area.
Internet Web sites became available as a means Most self-help books explain psychological dis-
of self-help, and today many Internet sites pro- orders in common, understandable terms for the
vide information and advice for those looking reader. They often have a conversational tone and
for mental health help for all types of psycho- offer advice to the reader while providing specific
logical suffering. Psycho-educational materials therapeutic guidelines designed to help alleviate
and online support groups can be found in abun- suffering. These books often place emphasis on
dant supply on the Internet. With such extensive control and effort, and the main focus is usually
growth, self-help has become a popular topic in on increasing satisfaction in an individual’s life.
psychology, and information on self-help can Self-help books can be a valuable resource for
easily be found at national conferences and in those who may be too fearful to attempt tradi-
research publications. tional psychotherapy; however, they frequently
put forth the idea that individuals need “fixing”
Self-Help Books and should never be satisfied. The limited research
The use of self-help books, sometimes referred to on self-help books has found them to be effective
as bibliotherapy, is a popular source for mental in helping to alleviate symptoms.
health information. Self-help books are published
with the intention of helping to alleviate some Self-Help Support Groups
type of specific problem, and many focus on pop- Self-help support groups, sometimes referred to
ular topics including depression, anxiety, marital as mutual help or mutual-aid groups, consist of
issues, parenting, eating disorders, and attention a group of people with a common problem who
deficit hyperactivity disorder. Some estimates work together so that each member of the group
suggest that approximately 2,000 new self-help experiences some benefit. These groups can be
books are published each year. The majority of found online and in person in the community.
self-help books are published without reference to They generally operate under the assumption
research examining their effectiveness. Similarly, that those who have experienced or are currently
although some self-help books have been written coping with a problem are better at helping one
another than professionals who have not had the
same firsthand experience. They also subscribe
to the idea that by helping others, individuals are
also helping themselves.
Members commonly lead self-help support
groups, and participation is usually voluntary and
free. One common process that takes place in self-
help groups is shared experiences, giving members
an immediate sense that they are understood and
are not alone, which can help alleviate feelings
of shame. Thus, the group becomes an ongoing
support network for its members. A significant
amount of education occurs, and members may
find models in other members of the group while
gaining feedback on their behavior. Additionally,
other cognitive processes that occur within the
groups can include increasing self-understanding
and self-esteem, improving self-efficacy, and rede-
Charles Fremont Winbigler’s How to Heal and Help One’s Self fining norms.
(1916) and John Kearsley Mitchell’s Self Help for Nervous Women Through his research on self-help groups,
(1909) are two early examples of mental self-help literature. Leon Levy determined four distinct types of
 Self-Injury 783

groups. Type I group objectives involve behav- Further Readings

ioral control, and the members are looking for Gould, Robert and George Clum. “A Meta-Analysis
help in controlling or eliminating a problematic of Self-Help Approaches.” Clinical Psychology
behavior. Type II groups are looking for help Review, v.13 (1993).
reducing stress through the support that they Katz, Alfred. Self-Help: Concepts and Applications.
receive from one another but are not looking to Philadephia: Charles Press, 1992.
change the situation. Type III groups are aimed Leon, Levy. “Self-Help Groups: Types and
at helping support and enhance the lives of those Psychological Processes.” Journal of Applied
who are in minority groups and often face dis- Behavioral Science, v.12 (1976).
crimination. Type IV groups focus on personal
growth where no major problems are present. In
this type of group, the members are hoping to
obtain support and strategies for living the best
life possible. Self-Injury
Self-Help Versus Traditional Psychotherapy Self-injury (sometimes called “self-harm,” “para-
There are several differences between self-help suicide,” “self-laceration,” “self-wounding” or
resources and traditional psychotherapy. In tradi- “self-abuse”) refers to deliberate harm to a per-
tional psychotherapy, the therapist is profession- son’s own body without a conscious intent to
ally trained, and clients are required to pay fees commit suicide. It is socially unacceptable vio-
and make appointments, which occur in a tradi- lence to the self. It is now accepted that self-injury
tional therapeutic setting (e.g., a psychologist’s is not, as once perceived, an attempt at suicide
office). In such cases, the client is not expected but rather a coping action for emotional pain that
to provide any support in return. With self-help seems intolerable or overwhelming.
resources, users are able to determine times for
participation, and it can occur in informal set- Why Self-Injury? The Intensity of Pain
tings, such as at a church or in a home. The emotional pain or distress experienced by the
Although there are many differences, there is sufferer may be either too intense or not intense
also some overlap between self-help resources and enough. When feelings are too intense, the emo-
traditional psychotherapy, including emphasizing tional pain behind the self-injury is often from
day-to-day success, holding people responsible for sexual or physical abuse; relationship distress (for
their actions, and involving family members when example, rejection, a breakup, loss by death, or
possible. Some self-help resources may even occa- some other significant emotional deprivation);
sionally be incorporated into traditional therapy. work or unemployment difficulties; academic dif-
Yet, much controversy exists concerning the rela- ficulties; feeling badly about oneself; or feeling
tionship between trained professionals and self- abandoned or in need of attention from others.
help; while many professionals embrace and sup- Some of the intense feelings involved are tension,
port the self-help movement, others believe that anxiety, anger, depression, hurt, and a loss of con-
self-help resources may undermine traditional trol over a person’s own body.
psychotherapy by providing false information When feelings are not intense enough, the
and ineffective treatments. self-injury is done in response to numb feelings.
Persons may report that the behavior makes
Heather Zucosky them feel alive. For some, the sight of blood is
Hope Brasfield described as comforting. The body as a target for
Ryan Shorey harm represents a transitional object on which
Gregory L. Stuart the person attempts to re-create pain for a sense
University of Tennessee, Knoxville of connection. If the person carves or burns
words or symbols onto the body, these tend to
See Also: Help-Seeking Behavior; Milieu Therapy; be indicative of the person or the nature of their
Patient Accounts of Illness. emotional pain. A change in the body part that
784 Self-Injury

is targeted tends to indicate a shift in psychologi- abandonment, often in a context of family dys-
cal states. function. The individuals may account for their
The self-injury is an effort to modify conscious- behaviors with ritualistic or religious symbolic
ness by bringing a feeling of temporary relief, thus language commonly as a response to feeling guilt.
reinforcing the behavior’s likely reoccurrence. The This is different from body modifications that are
injury is normally in an area that is concealed. It accepted as a part of cultural or religious norms
commonly involves swallowing nonfood objects in other countries.
(such as glass, utensils, bleach, lighter fluid, nails, The disorder excludes occasionally pulling the
stones and needles); hitting (for example, slap- hair out and nail biting. It also excludes body
ping themselves or tossing their head, arm, or piercing, tattooing, and branding because these
leg against a wall or object); burning (often with are done by others. The disorder further excludes
cigarettes, lighters, or blow dryers); cutting (often single and extremely bizarre conduct during psy-
with knives, razors, or scissors); biting; plac- chotic delusions, such as gouging out one’s eye or
ing their fingers in doors; inserting objects such self-amputation. In older (1970s) literature, “self-
as pins, nails, and knives into body orifices or injury” was called “self-mutilation.” Self-mutila-
the skin; poking the eyes; severe trichotilloma- tion is now considered something else, a symptom
nia (pulling out hair); excoriation (digging into of a disorder more serious than self-injury. Muti-
wounds); and abrasive actions (or rubbing a part lation refers to permanent disfigurement.
of the body until it is sore).
The pain of self-injury serves as a distraction Demographics and Occurrence
from the individual’s emotional pain. It may be an Self-injury has been recorded across cultures and
expression of anger toward the perceived perpe- from early times. For example, in the Bible, Ezra
trator of the pain or as a way to shame the self if 9:3 reads: “And when I heard this thing, I rent
the person feels responsible for the negative feel- my garment and my mantle, and plucked off the
ing they are experiencing. The person may be re- hair of my head and of my beard, and sat down
enacting some abuse endured from another. Like astonished.” As head shaving and self-injury (a
the original shaming act, the self-injury will be superstitious and dramatized show of grief com-
done in secret. Cutting is the most common self- mon among the peoples surrounding the Isra-
injury behavior. In some cases, the self-injury is elites at the time) was forbidden for Israelites,
done to exact guilt from the person who caused Ezra’s hair pulling has been explained as a pos-
the person emotional pain; for example, cutting sible way for him to get around this command
after feeling abandoned by the loss of a relation- while still expressing his grief. There is some sug-
ship. In some cases, the self-injury is a response to gestion that his actions represent possible tricho-
post-traumatic stress disorder. It can also occur tillomania; however, this particular demonstra-
during some dissociation or lack of awareness, tion of agony by Ezra is only mentioned once in
which can result in rather severe harm given that the Old Testament.
the person is not fully aware of the gravity of the Similar laws against extravagant, choreo-
harm being done to self. graphed displays of grief are found in Athens
Alcohol may be used in addition to the self- in the 6th century b.c.e., forbidding “mourners
injury to relieve bad feelings; it can also be one tearing themselves to raise pity,” and the Twelve
of the causes of bad feelings. The role and use of Tables of Roman law in the 5th century b.c.e.,
alcohol with the disorder varies. which forbade mourning women to lacerate their
The disorder is usually first noticed in high cheeks.
school or tertiary educational settings. Disorders Alicia Clarke reported in 1999 that the inci-
that are similar to self-injury in etiology include dents of self-injury are likely underreported, but
anorexia and bulimia; as such, it is sometimes estimates are that about 2 million persons in the
characterized as a “narcissistic disturbance” United States have this illness. She also notes
linked to the quality of parenting experienced. that the behavior commonly begins in adoles-
A related idea is that the behavior has elements cence and is most frequent in the 20s, thereaf-
of attention seeking given an underlying fear of ter declining with age. Referring to the United
 Serotonin Reuptake Inhibitors 785

States, Matthew Nock in 2010 noted that sam- Further Readings

ples suggest a prevalence of 13 to 45 percent Bible Hub. “Ezra 9:3: Commentary: Gill’s Exposition
among adolescents and 4 percent among adults. of the Entire Bible.” http://biblehub.com/ezra/9-3
The disorder is most often identified in females. .htm (Accessed May 2013).
Theories to explain this gender disparity include Clarke, Alicia. Coping With Self-Mutilation: A
a societal emphasis on physical ideals for women Helping Book for Teens Who Hurt Themselves.
and girls. Some adolescents learn self-injury as a Center City, MN: Hazelden, 1999.
coping action after seeing the attention it garners D’Onofrio, Amelio. Adolescent Self-Injury: A
for others while committed in a juvenile facility Comprehensive Guide for Counselors and
or mental health hospital. Healthcare Professionals. New York: Springer,
2007.
Response and Treatment Harrison, Robert Pogue. The Dominion of the Dead.
In treating individuals who self-injure, it is impor- Chicago: University of Chicago Press, 2003.
tant for the clinician or counselor to ascertain the Jewish Heritage Online Magazine. “Hair: Holiness in
nature of the behavior, which includes the intent Mourning.” http://jhom.com/topics/hair/mourning
of the behavior. Treatment can be complicated .html (Accessed May 2013).
when substance abuse appears to be the dominant Nock, Matthew. “Self-Injury.” Annual Review of
condition. In those cases, a therapist must be care- Clinical Psychology, v.6 (2010).
ful to not only learn the patient’s history but also Scherzer, Andrea. “Understanding Self-Destructive
assess the risk for suicide and self-injury. Treat- Behavior in Adolescence.” In Violent Adolescents:
ment approaches include antidepressant drug Understanding the Destructive Impulse, Lynn
therapy and directing the person to other coping Greenwood, ed. London: Karnac, 2005.
techniques. The response to therapy is more effec- Walsh, Barent. Treating Self-Injury. 2nd ed. New
tive if the patient feels understood and if the care York: Guilford Press, 2012.
matches the intensity of the disorder.
Therapists must note that adults around the
person who self-injures may not be aware of a
minor’s harming behaviors, so information must
come from the minors themselves. There are stan- Serotonin
dardized inventories for self-injury such as the
Self-Injury Inventory. One therapeutic approach Reuptake Inhibitors
with self-injury patients has been dialectical
behavior therapy (DBT). This cognitive behav- Selective serotonin reuptake inhibitors (SSRIs)
ioral approach is delivered both individually and are currently the most widely prescribed antide-
in groups. The goal of DBT is to assist the patient pressants and the second most widely prescribed
to learn effective coping skills, emotional regula- class of medications overall (behind statins) in the
tion, and frustration tolerance. When the behav- United States. The Centers for Disease Control
ior produces serious injury, treatment will be in a (CDC) reports that 11 percent of all U.S. resi-
psychiatric inpatient unit. dents, 20 percent of U.S. women between the ages
of 40 and 59, and 4 percent of U.S. children were
Camille Gibson taking antidepressants as of 2007.
Aisha Asby Eli Lilly specifically developed SSRIs as antide-
Prairie View A&M University pressants in an effort to develop a drug capable
of selectively inhibiting the reuptake of serotonin.
See Also: Adolescence; Children; Chronic Pain; This intentional development of an antidepressant
Dangerousness; Dissociative Disorders; Eating marked a distinct change in drug development
Disorders; Gender; Help-Seeking Behavior; from the chance discoveries of the monoamine
Munchausen Syndrome; Post-Traumatic Stress oxidase inhibitors (MAOIs) and the tricyclic
Disorder; Sadomasochism; Self-Esteem; Suicide; antidepressants (TCAs). The shift was due to
Suicide: Patient’s View. multiple factors, not least to the development of
786 Serotonin Reuptake Inhibitors

biochemical assays (rather than those based on disorders. Due to his persistence, Lilly created a
behavioral responses of rats) that could identify serotonin-depression study team, consisting of
potential antidepressant compounds. Further- Fuller, biochemist David Wong, organic chemist
more, in the 1970s, depression became much Bryan Molloy, and pharmacologist Robert Rath-
more widely diagnosed and was transformed bun. They embarked on a series of studies to find
from a consistently serious inpatient condition to a molecule that was able to more efficiently and
an outpatient disorder, which varied in severity, a specifically inhibit serotonin reuptake than the
transformation made even more dramatic by the TCAs. The phenoxyphenypropylamines emerged
introduction of Prozac. as the most promising compounds, and in 1972,
During the 1950s and 1960s, a large number of after testing 55 derivatives, Jon-Sin Horng, a
researchers were studying the roles of neurotrans- member of Fuller and Wong’s team, found fluox-
mitters and finding evidence of a critical role etine chlorhydrate to be the most effective, with
played by the monoamine 5-HT, or serotonin. In significantly fewer side effects than the TCAs.
the late 1960s, investigators postulated that the Over the next eight years, Lilly conducted a series
antidepressant effects of the MAOIs and TCAs of promising, but unpublished, studies before
were due to their ability to increase monoamines fully committing to the drug, now named fluox-
at the synaptic cleft, especially dopamine and nor- etine, in 1980 and launching a program of inten-
epinephrine. This became known as the catechol- sive clinical trials from 1984 to 1987. After the
aminergic hypothesis of depression. At the same trial results supported fluoxetine’s effectiveness
time, a few researchers believed that a functional and low toxicity, Lilly brought the drug to market
deficiency in serotonin in the synaptic cleft also with the trade name Prozac at the end of 1987. In
might play an important role in the development less than five years, it became the most frequently
of depression. prescribed drug in psychiatry.
Alec Coppen and his colleagues at the Neu- Despite Prozac’s commonly accepted status
ropsychiatric Research Institute in London and as the first SSRI, Zimeldine, developed by Astra
Herman van Praag and his research team at Gron- Pharmaceuticals, had in fact beaten Prozac to the
ingen University were highly influential in the market by five years. However, it was quickly
eventual development of the serotonergic hypoth- withdrawn due to serious side effects. In addition
esis. Coppen and his team showed that the effects to Prozac, four new SSRIs were rapidly released
of MAOIs were boosted by the administration in the decade that followed: fluvoxamine (Luvox/
of the precursor to serotonin. Van Praag and his Faverin) by Solvay in 1983 (Europe), citalopram
group hypothesized that serotonergic dysfunction (Celexa/Cipramil) by Lundbeck in 1989 (Europe),
was related to the development of certain forms of sertraline (Zoloft/Lustral) by Pfizer in 1990 (UK)
depression. However, because there was no direct and 1992 (United States), and paroxetine (Paxil/
demonstration of the neurobiochemical effects Seroxat) by SmithKline Beecham in 1991 (UK)
of serotonin at that time, it was not immediately and 1993 (United States). It was SmithKline Bee-
investigated as a possible candidate for treatment. cham that coined the term SSRI for the 5-HT
In 1968, however, Arvid Carlsson and his col- reuptake inhibitors in order to distinguish Paxil
leagues at the University of Gothenburg dem- from their other antidepressants. The name
onstrated that TCAs blocked the reuptake of quickly caught on with the other companies and
serotonin, as well as that of norepinephrine, in highlights the fact that SSRIs are similar in the
the brain. Further studies showed that TCAs biological process on which they act but not in
improved the neurotransmission of serotonin their chemical structures, which are very diverse.
through the mediation of 5-HT receptors, leading The name TCAs, in contrast, reflects the tricyclic
to the conclusion that reduced serotonin levels in structure that is common to them all.
the synaptic cleft were at least partially causal in Media coverage of SSRIs not only made anti-
depressive disorders. depressant usage more acceptable to mainstream
In 1971, pharmacologist Ray Fuller joined Eli society but also sold the idea of depression as an
Lilly, with a strong conviction that neurotrans- illness affecting a large number of the popula-
mitters played a key role in the origin of mood tion. SSRIs were lauded as not only being able to
 Service Delivery 787

treat this hitherto unforeseen epidemic but also importance of the pharmaceutical industry in
as a potential cure for the malaise people experi- defining the nature of illness and what constitutes
enced in everyday life. The phrase better than well its scientific treatment, and broad cultural mean-
became popularized through Listening to Prozac ings of psychological distress and how our culture
by Peter Kramer, an ode to SSRIs. However, in the solves those difficulties. In the future, treatment
late 1990s, after a decade of unprecedented and for depression will likely be based on a more con-
unexpected success—Prozac alone had garnered crete understanding of the changes in brain cir-
more than $20 billion in sales and accounted for cuitry and chemistry associated with depression.
30 percent of Lilly’s revenue—reports began to However, despite the concerns about known side
emerge of potentially serious negative side effects effects, as well as possible long-term toxicity,
of SSRIs. The three that caused most immedi- SSRIs are likely to remain the frontline treatment
ate concern were akathisia (a feeling of intense for depression well into the 21st century.
and unpleasant inner restlessness), suicidal-
ity, and aggression. Up to this point, SSRIs had Rebecca Wilkinson
been widely prescribed to adolescents and young University of California, Los Angeles
adults, but when the evidence showed youth to
be especially susceptible to these dangerous side See Also: Adolescence; Antidepressants; Monoamine
effects, the Food and Drug Administration (FDA) Oxidase Inhibitor (MAOI) Antidepressants; Prozac;
insisted on stricter guidelines for the treatment of Side Effects.
youth with SSRIs. There continues to be debate
around this issue—one side convinced that the Further Readings
risks of SSRI for adolescents are too high for even Healy, D. The Antidepressant Era. Cambridge, MA:
limited use and the other side concerned about Harvard University Press, 1997.
the ethics of not treating depressed youth with the Liebert, R. and N. Gavey. “‘There Are Always Two
best currently available treatments for depression. Sides to These Things’: Managing the Dilemma
of Serious Adverse Effects From SSRIs.” Social
Marketing and Rebranding Science & Medicine, v.68 (2009).
In the early 2000s, the SSRI patents began to Lopez-Munoz, F. and C. Alamo. “Monoaminergic
expire and generics came onto the market, cre- Neurotransmission: The History of the Discovery
ating a business problem for the pharmaceutical of Antidepressants From 1950s Until Today.”
companies that had earned a major percentage of Current Pharmaceutical Design, v.15 (2009).
their profits from the sales of SSRIs. In response, McClean, B. “A Bitter Pill Prozac Made Eli Lilly.”
they developed new possible uses for SSRIs. In Fortune Magazine (August 13, 2001).
fact, shortly before the Prozac patent ran out in Stone, K. J., A. J. Viera, and C. L. Parman. “Off-
2001, Eli Lilly rebranded its prize drug as Sera- Label Applications for SSRIs.” American Family
fem and marketed it for premenstrual dysphoric Physician, v.68/3 (2003).
disorder (PMDD), ensuring continuance of pro-
tection through 2007. Other disorders for which
SSRIs are now approved include major depressive
disorder, bulimia nervosa (an eating disorder),
obsessive-compulsive disorder, and panic disor- Service Delivery
der. In 2003, an article by Kimberly Stone and
colleagues in American Family Physician foresaw A variety of practitioners and settings serve as
multiple off-label uses for SSRIs and suggested, as the locus for delivery of medical and human ser-
a few examples, general anxiety disorder, erectile vices for mental illnesses, including treatment of
dysfunction, migraines, pain from diabetic neu- substance abuse disorders. For much of the 19th
ropathy, fibromyalgia, and neurocardiogenic syn- century, and through the first decades of the 20th
cope. century, the mentally ill were confined in large
The history of the SSRIs reveals the compli- numbers in asylums, renamed mental hospitals
cated relationships between science, the growing around 1900.
788 Service Delivery

Today’s mental health services extend well were confined to jails, cellars, prisons, stalls,
beyond the carceral techniques of the past to pens, and cages. Advocates urged the construc-
cover diagnosis and treatment in a much broader tion of special institutions devoted to humane,
array of settings. Following changes in state and restorative treatment of those with mental disor-
federal policy in the late 1940s and 1950s, the ders. This movement was followed by the men-
location of service provision shifted dramatically tal hygiene movement of the late 19th and early
from institutions to the community, where most 20th centuries. Accompanying the emergence of
services for the mentally ill are provided today. psychiatry and medical psychology worldwide,
However, the fragmented nature of the health the mental hospital and clinic became the primary
care system impedes delivery of services to people settings for mental health treatment. The late
with severe and persistent mental illness. To meet 1940s and early 1950s witnessed early efforts to
this challenge, polic ymakers and practitioners develop community-based prevention, care, and
have made efforts to bring about greater system recovery. In-patient populations began to decline
integration and coordination in order to opti- at the national level in the mid-1950s.
mize access, availability, and continuity of care. Patients received services from community men-
Agencies such as the National Institute of Mental tal health centers, thanks to the passage of social
Health (NIMH) in the United States and Commu- welfare legislation aimed at treatment of the men-
nity Mental Health Teams (CMHT) in the United tally ill, such as the National Mental Health Act
Kingdom were established to coordinate provision (1946), the Mental Health Study Act (1955), the
of comprehensive quality services. Community Mental Health Centers Act (1963),
Mental health services are available in four and Social Security Act Amendments (1965,
major health and human service sectors. These Medicare and Medicaid). Because the process of
are specialty mental health, general medical and deinstitutionalization proceeded rapidly and with-
primary care, human services, and voluntary net- out adequate community resources, many former
works. Specialty mental health refers to mental and potential patients experienced a severe lack of
hospitals, residential treatment facilities, and psy- services. The result was a rise in the number of
chiatric wards within general hospitals. Specialty mentally ill who were homeless and incarcerated.
mental health provision also takes place in com- A spate of urgent legislation, such as the Com-
munity mental health centers, day programs, and munity Support Program of the NIMH (1977),
outpatient and rehabilitation programs. Special- sought to highlight the social welfare needs of
ists providing these services include psychiatrists this population, with attendant emphasis on pro-
and psychiatric nurses, psychiatric social workers, vision of community support services such as
and clinical psychologists. In the general medical transportation, housing, employment, and educa-
and primary care sector, mental health care is a tion. The 10 elements of comprehensive commu-
component of comprehensive health care services. nity support services included responsible teams,
Sites for service delivery include clinics, physician residential care, emergency care, Medicare sup-
offices, community health centers, and hospitals, port, halfway houses, supervised housing, outpa-
as well as jails and prisons, where many mental tient therapy, vocational and social training, and
patients are found in the aftermath of deinstitu- strengthening of family and network supports.
tionalization. Last, self-help groups, voluntary Today, with the passage of the Affordable Care
associations, families, and relatives of clients Act (2009), it is hoped that expanded coverage
deliver mental health services in the community. for 32 million adults, about 12.4 million with
mental disorders and substance abuse problems,
Background will provide greater parity for people with mental
Four major reform movements dealt with issues health conditions.
salient to mental health services and the treat-
ment of those with mental disorders. The asylum Case Management
movement, led by Dorthea Dix in the mid-19th Every society organizes, delivers, and pays for
century, sought to counter the inhumane and neg- its mental health services in ways that reflect the
ligent treatment of the mentally ill who typically unique historical, political, economic, and cultural
 Service User Involvement 789

forces shaping that society. In the United States, Further Readings

the mental health system, like the broader health Kemp, D. Mental Health in America. Santa Barbara,
system, is a hybrid of providers, payers, and cli- CA: ABC-CLIO, 2007.
ents. Fragmentation of the mental health system Pescosolido, B. A., E. R. Wright, and W. P. Sullivan.
influences delivery of services, which is especially “Communities of Care: A Theoretical Perspective
problematic for people with severe and persistent on Care Management Models in Mental Health.”
mental illness, people with limited resources, and In Advances in Medical Sociology, Gary Albrecht,
racial and ethnic minorities. To address these defi- ed. Greenwich, CT: JAI Press, 1995.
cits, polic ymakers and practitioners have devel- Smith, T. E. and L. I. Sederer. “A New Kind of
oped a number of different models of mental Homelessness for Individuals With Serious Mental
health management systems to integrate services. Illness? The Need for a ‘Mental Health Home.’”
Case management has emerged as one such Psychiatric Services, v.60/4 (2009).
important model in which clinical case manag- U.S. Department of Health and Human Services
ers and management teams attempt to coordi- (HHS). “Mental Health: A Report of the Surgeon
nate professionally based service systems. Bro- General.” Atlanta, GA: HHS, 1999.
kered case management is the simplest form of U.S. Department of Health and Human Services
basic service delivery and entails a case manager (HHS). “Mental Health: Culture, Race, and
who responds to client problems by locating Ethnicity, A Supplement to Mental Health: A
appropriate services. Juxtaposed to brokered Report of the Surgeon General.” Atlanta, GA:
case management is clinical case management. HHS, 2001.
Clinical case management emphasizes a thera-
peutic, rather than simply brokered, relationship
between client and manager. One version of this
kind of case management system is called the
strengths model. Other versions of the clinical Service User
case management relationship are the advocacy/
empowerment approach and the contextual case Involvement
management model.
The team approach, in contrast to these man- Since the creation of the first lunatic asylums in the
ager-centered approaches, relies on multidisci- 19th century, patients with mental health issues
plinary groups of professionals to provide a range have campaigned for improvements in their care.
of services to clients. The assertiveness commu- More recently, as attitudes have changed, men-
nity team (ACT) and the family aided assertive- tally ill people—like their physically unwell coun-
ness community treatment (FACT) models pro- terparts—have become more informed about the
vide better assessment of client needs because options available to them and less willing to be
information is drawn from a number of vantage passive recipients of medical care. Growing num-
points. Teams also improve continuity of care bers of service users now expect to make informed
by ensuring that no one individual is responsible choices about their treatment and participate as
for comprehensive service provision. Teams are equal partners in developing personalized care
mutually responsible for their client, wherever the plans for their recovery. Recovery in this context
client may be receiving services (hospital, commu- does not necessarily imply being completely cured
nity, or home), and therefore are more likely to of a severe and enduring illness; it means choosing
make preemptive decisions when difficulties arise. the best way to manage mental health and to live
as purposefully and independently as possible.
Matthew E. Archibald For service user activists, user involvement
Colby College has extended much further than personal care
to include participating in developing or qual-
See Also: Case Managers; Community Mental ity-assuring services, helping with the training
Health Centers; Community Psychiatry; Group of mental health students and staff, sitting on
Homes. recruitment panels for staff appointments, helping
790 Service User Involvement

with service delivery, and collaborating in mental internationally in countries such as the United
health research studies. States, Canada, Scandinavia, Australia, and New
Zealand.
Background The entitlement of users to be recognized as
In the 1970s, radical protesters from many dis- consumers with rights was strengthened by equal-
advantaged groups were demanding more eman- ity legislation in 2010 in the UK, which outlaws
cipation; among them were groups who formed discrimination in areas such as employment and
themselves into the Mental Patients Union (in strengthens the civil rights of all disabled people,
the United Kingdom) and the Mental Patients including those with mental health issues. The
Liberation Front (in the United States). At that UK government’s quality standards watchdog,
time, mental health campaigners were supported the Care Quality Commission, requires all mental
by radical mental health professionals, notably R. health services to have a user involvement strat-
D. Laing, who argued against a purely medical egy and an implementation plan showing how
model to explain and treat mental illness and pro- they seek service-user feedback and involve ser-
posed a more humanistic approach. vice users in decision making. The literature on
In 1985, service user activists from many coun- service user involvement has become extensive, in
tries met at the Mind/World Mental Health Con- particular, books and articles written by promi-
gress in the United Kingdom (UK) to share expe- nent service user activists such as Peter Beresford
riences of campaigning, and Mad Pride, a mass or by groups of users working collaboratively.
movement of mental health service users and Qualitative studies and service user narratives
their allies, held its first major event in Toronto, indicate that there can be a positive correlation
Canada. During this period, the concept of people between involvement and recovery.
who used public services as being “consumers” Nevertheless, in practice, many medical pro-
rather than “patients” or “clients” became wide- fessionals dealing with acutely unwell people
spread, coinciding with a less subservient attitude are concerned that they would be failing in
toward the medical profession. Although champi- their duty of care if they allowed the patient to
ons such as Judi Chamberlain in the United States choose a course of action that the professional
were starting to demand patient-controlled alter- believed was not in that person’s best interest.
natives to the mental health system, it was another Family members may also feel that people with
two decades before service users’ rights as citizens long-term mental health problems are not able
became more universally acknowledged. to make sensible choices and that what is most
The social model of disability was an impor- important is for them to comply with their drug
tant influence during the 1990s. It challenged the regime. Family carers often feel excluded by men-
view that hailed developments in antipsychotic tal health professionals in any discussions about
medication as having revolutionized the lives of their loved one’s treatment, and yet when the
many patients, and argued that stigma, family patient is discharged or if there is a crisis, it is
relationships, poverty, discrimination, and other the family member who has to deal with the con-
social problems should also be recognized as sequences. In the UK, the concept of a tripartite
key contributors to negative or positive mental collaboration between the service user, carer, and
health. Mind Freedom International, a 14-coun- health professionals has been introduced as best
try coalition of grassroots groups such as the practice; this more inclusive approach to involv-
Canadian-based Coalition Against Psychiatric ing carers has reduced some opposition to user
Support, established a U.S.-based Web site with involvement.
global information about the struggle for safe,
humane, effective alternatives to a strictly medi- Common Demands of Service User Groups
cal approach. The social campaigners began to Many surveys have been undertaken to determine
reap results during the first decade of the 21st the views of service users about both inpatient
century when the mantra of “nothing about us and community services. The results are fairly
without us” was promoted in UK public pol- consistent across the board. Key issues for inpa-
icy, and similar strategies were being developed tients normally include the following:
 Service User Involvement 791

• Being given information about the discrimination, or options to participate

reasons for their admission, legal rights, in mainstream leisure activities
probable length of stay, and proposed • A clear pathway to access acute care
treatment options should they have a breakdown
• Being given information about drugs and • A number they can call for help in a crisis
their side effects and a degree of choice • Effective alternatives to hospital care if
about treatment they become unwell
• Feeling safe in the hospital, which is
particularly an issue for women who Examples of Service User Involvement
want women-only wards in Innovative Developments
• Being treated with respect and Service users are now regularly involved in the
compassion planning and delivery of services. For example,
• A pleasant environment with opportuni- they help to do the following:
ties for engaging in activities, accessing
fresh air, and diverse religious observance • Develop care pathways
• Having available a choice of nutritious • Design new or refurbished wards
food, including options to meet religious • Advise on programs for specialist
or cultural needs resource centers
• Being able to speak in private on a • Write quality standards, policy guidance,
regular basis with a mental health profes- involvement strategies, or mental health
sional who will listen with empathy curriculum
• Keeping in touch with loved ones
• Being cared for by staff who are trained Service users regularly sit on panels to appoint
in cultural awareness and understand mental health staff and may also help with the
that religious beliefs/customs or spiritual- recruitment and selection of mental health student
ity in some cultures can be mistaken for nurses or social workers. They provide valuable
symptoms of mental illness input into training through a narrative approach,
• Being supported at discharge in which they tell their story in ways that exemplify
• Being involved in a person-centered care good or poor professional practice; working with
planning process with professionals and students on case studies by offering the service-
family carers user perspective to the discussion; or coevaluat-
ing student’s assignments and performance in the
In the community, people with mental health practice setting. Service users have been proactive
issues say they want the following: in organizing effective antistigma campaigns by
using electronic and other media; running mental
• A discharge plan that ensures continuity health awareness sessions for schools and work-
and support from hospital to community places; and often using theater, creative writing,
• Comfortable housing with practical sup- music, or art to convey their message.
port that does not isolate them from the In acknowledgment of users’ complaints that
community they were always the subjects of research and did
• Access to a mental health professional not have a chance to decide on the issues that
or general practitioner who understands needed investigation, they are now involved in
mental health identifying research questions, designing or edit-
• Support with daily living skills to enable ing tools such as user-friendly interview schedules,
them to exercise maximum control over and conducting interviews. There is some evidence
their lives to suggest that users will speak more openly with
• Access to training and employment peers than with professional researchers.
• A therapeutic setting to meet with other Mental health service providers are increas-
service users and support each other, ingly establishing peer support projects whereby
especially in dealing with stigma and people who have had experience in mental health
792 Sex

issues are used in a paid or voluntary capacity to Sex

support individuals who are unwell or vulnerable.
Not only does this significantly reduce a sense of The dominant cultural model of human sexuality
isolation for the recipient but it also contributes narrowly defines sexual functioning as a ubiqui-
to the recovery of the peer support worker by tous progression of physiological responses, and
enhancing self-esteem and providing a sense of failure to experience this progression as sexual
purpose. Peer support projects are one example dysfunction, and therefore mental illness. This
of a new policy objective known as coproduc- decontextualized and medicalized approach pro-
tion. The New Economics Foundation describes vides vast profit to the pharmaceutical industry
coproduction as “delivering public services in an but does not effectively address the causes of
equal and reciprocal relationship between profes- sexual problems. The current status of sexuality
sionals, people using services, their families, and in the United States can best be seen as a host
their neighbors.” This takes user involvement a of paradoxes. While people possess the knowl-
stage further by acknowledging that people who edge to address many problems in the area of
use services, their carers, and communities are sexuality, they have not brought these resources
assets rather than passive recipients of care and to bear where they would be most effective. For
that they can offer strength and knowledge that example, people know how to reliably prevent
can be harnessed to improve the quality and fit- unwanted conception, yet 49 percent of preg-
ness of public services such as mental health. nancies are unintended, including four out of
five pregnancies among women aged 19 years
Jenny Weinstein and younger.
Kingston University People know how to prevent sexually trans-
mitted diseases, yet there are 19 million new
See Also: Community Mental Health Centers; infections every year in the United States. People
Family Support; Integration, Social; Life Skills; also know that most women can reliably achieve
Patient Activism; Patient Rights; Public Education orgasm, yet the majority (71 percent) do not expe-
Campaigns; Self-Esteem; Service Delivery; Stigma: rience orgasm in heterosexual encounters. Finally,
Patient’s View. people know that sex can be a source of joy, stress
reduction, and improved quality of life, yet medi-
Further Readings cal professionals often fail to address sexual con-
Chamberlain, J. On Our Own: Patient Controlled cerns in senior populations.
Alternatives to the Mental Health System. New The prevailing diagnostic nosology for sexual
York: Hawthorne, 1978. dysfunctions is the Diagnostic and Statistical
Simpson, E. L., A. O. House, and M. A. Barkham. Manual of Mental Disorders, fourth edition, text
Guide to Involving Users, Ex-Users, and Carers revision (DSM IV-TR), which divides sexual prob-
in Mental Health Service Planning, Delivery, or lems into four categories of sexual dysfunction:
Research: A Health Technology Approach. Leeds, sexual desire disorders, sexual arousal disorders,
UK: University of Leeds, 2002. orgasmic disorders, and sexual pain disorders.
Stephens, L., J. Ryan-Collins, and D. Boyle. The most recent demographically representative
Co-Production: A Manifesto for Growing the Core study in the United States found that 43 percent
Economy. London: New Economics Foundation, of women and 31 percent of men reported at least
2008. one sexual dysfunction.
Wallcraft, J., J. Read, and A. Sweeney. On Our Own Among women, the following sexual symp-
Terms: Users and Survivors of Mental Health toms were reported:
Services Working Together for Support and
Change. London: Sainsbury Centre for Mental • 33 percent lacked interest in sex
Health, 2003. • 24 percent were unable to achieve
Weinstein, J., ed. Mental Health Service User orgasm
Involvement and Recovery. London: Jessica • 14 percent experienced pain during sex
Kingsley, 2003. • 21 percent reported trouble lubricating
 Sex 793

influenced by the pharmaceutical industry in the

direction of research and interpretation of results,
ultimately leading to the proposal of new diag-
noses for which pharmaceutical products can be
marketed.
Rewarded by billions of dollars in profit, the
pharmaceutical industry has aggressively mar-
keted medications for male dysfunction, includ-
ing Viagra, Levitra, and Cialis, using public
relations, direct-to-consumer advertising, and
promotion of off-label prescribing to create a
sense of widespread sexual inadequacy and inter-
est in drug treatments. Both Pfizer and Procter &
Gamble have spent significant capital in efforts
to develop a female version of Viagra, but failing
this, the original Viagra is prescribed off-label to
women diagnosed with a branded catch-all term,
“female sexual dysfunction,” or FSD. To date,
this approach to women’s sexual problems has
not yielded broad success, and some have con-
cluded that it is not useful to conceptualize wom-
A couple enjoys intimacy at Barefoot Cay Resort in Honduras, May en’s sexual problems in this manner.
2009. One U.S. study found that despite ample sexual freedom For men, with a panoply of erection-facilitating
and the availability of pharmaceutical aids, 43 percent of women drugs available, the relational context in which
and 31 percent of men reported at least one sexual dysfunction. these medications are used is frequently ignored,
often resulting in painful and unwanted inter-
course in older female partners and frustration
and alienation for both partners. The market for
Among men, the following was reported: these virility drugs tops $5 billion in annual sales
to tens of millions of men, yet less than one-third
• 16 percent lacked interest in sex of Viagra prescriptions are refilled. Despite this
• 8 percent were unable to achieve orgasm evidence of the drawbacks of a pharmaceutical
• 29 percent climax too early approach, often no other treatment is offered
• 10 percent have trouble maintaining or for men reporting erectile difficulties. Rarely are
achieving an erection these medications offered in conjunction with sex
therapy, which has been found to improve satis-
Sex, Medicalization, and Economics: faction for both partners in a relationship. When
The Impact on Diagnosis and Treatment lack of an erection is the sole focus and a drug is
Reducing sexual problems to physiological thought to be the cure, other issues such as fear
responses and stripping them of social con- of intimacy, relationship conflicts, or unrealis-
text paves the way to inadequate medicalized tic performance expectations are not addressed.
approaches. While the DSM diagnostic categories Many older male patients find that their sexual
may be descriptive, they are incomplete. In the arousal is not always a function of having an erec-
absence of understanding the context in which tion, nor does having an erection heal a broken
these problems occur, these dysfunctions are relationship.
assumed to be physiological failures in a ubiq-
uitous pattern of human sexual response. While Alternative Approach to Sexual
the DSM authors contend that it is a neutral and Problems: The New View
empirically based compendium of mental illness, The most prominent and organized challenge to
the entire field of psychiatry is heavily funded and the dominant paradigm of sexual dysfunction is
794 Sex

the New View of Women’s Sexual Problems, a dysfunctions are remarkably consistent with ear-
collaboration of feminist academics, researchers, lier findings over several decades ago, in a study
scholars, clinicians, and activists. This group has of self-identified happily married couples, which
proposed an alternative classification of wom- also assessed the social context of reported sex-
en’s sexual problems that challenges the cultural ual dysfunctions. Both studies found that women
assumptions embedded in the DSM, reductionist experience much higher rates of disinterest and
research, and the marketing of medicalized solu- lack of orgasm, while men most commonly suf-
tions by the pharmaceutical industry. Using this fered from climaxing too quickly. In the earlier
approach, sexual disorders defined by the field of study, the most common contextual difficulties
psychiatry as mental illness can alternatively be reported by women included inability to relax
understood as problems tied to lack of informa- (47 percent), too little foreplay before intercourse
tion, lack of access to health care, powerlessness, (38 percent), lack of interest (35 percent), and
relational issues, or the result of violent trauma. partner chooses inconvenient time (31 percent).
Individual distress and inhibition are seen as aris- Among men, the most commonly reported diffi-
ing within a broader framework of cultural and culties were too little foreplay before intercourse
relational factors. (21 percent) and attraction to person other than
As stated by Tiefer, its primary author, the mate (21 percent).
New View nomenclature does not define normal The most recent national survey of sexuality
sexual function per se. It rejects the definition reported that, while 75 percent of heterosexual
of normal sexual response in terms of arousal, men reported having orgasms from partnered
desire, orgasm, and then the identification of sex on a regular basis, only about 29 percent
sexual problems as deviations from that norm. of women reported the same. Related research
Rather, the New View nomenclature begins by found that among women, knowledge of the cli-
acknowledging that women (or men) may be dis- toris was related to their ability to have orgasm
satisfied with any emotional, physical, or rela- on their own, but was not related to their fre-
tional aspect of sexual experience. It then goes quency of orgasm with partners. The authors
on to specify many different causes of such dis- conclude that unapplied knowledge about the
satisfaction, arising from social, relational, per- clitoris suggests that women and/or their part-
sonal, or physical causes. The competent clini- ners do not give priority to orgasm for women,
cian should take a history inclusive of all of these and that women may recognize that revealing
etiologic issues in mind. For medical or mental their knowledge or asserting their desires may be
health care providers, it offers a blueprint for a incompatible with conceptions of female attrac-
comprehensive assessment with inherent impli- tiveness and desirability in heterosexual relation-
cations for treatment, depending on the informa- ships. Since most women can reach orgasm, diag-
tion obtained. nosing them with a mental illness and offering
The New View approach, although developed pharmacological treatment does not address the
in regard to women’s sexuality, is more broadly social context in which this problem occurs and
applicable to all genders. This approach is based is ineffective treatment.
on a definition of sexual health from a declara- Treatment might well encompass offering
tion of sexual rights authored by the World Asso- corrective sexual education; addressing sex role
ciation of Sexology. These sexual rights include expectations; improving sexual communication;
sexual freedom that excludes all forms of sexual addressing relationship issues concerning sex-
coercion, exploitation, and abuse; the right to ual initiation, timing, power issues in couples,
sexual autonomy and safety; the right to sexual and sharing of familial work load; examining
pleasure; the right to accurate sexual information; unrealistic expectations; and learning to make
the right to comprehensive sexuality education; sexual interactions more about connection than
and the right to sexual health care. performance.
Viewing sexual problems in a relational con- Unwanted pregnancy, the spread of sexually
text allows for alternative formulations and solu- transmitted diseases, lack of sexual communica-
tions. For example, the current rates of sexual tion, failure to equally privilege women’s sexual
 Sex Differences 795

pleasure in heterosexual encounters, failure to personality disorder), and attention deficit hyper-
address sexuality in aging populations, and medi- activity disorder. Additionally, the specific symp-
calized approaches to sexual problems can be tom patterns and courses of some psychological
more effectively addressed by including social disorders differ for women and men, or girls and
and relational context in practice, using a holis- boys. Because some disorders are more common
tic, socially informed, and comprehensive model in one sex than in the other, particular treatments,
of sexuality. including pharmaceutical ones, are significantly
more common for one sex than for the other. For
Wendy Ellen Stock instance, methylphenidate, known by the trade
Independent Scholar name Ritalin, is used by more boys and men than
girls and women.
See Also: Diagnosis in Cross-National Context;
Gender; Medicalization, History of; Mental Illness Depression
Defined: Sociological Perspectives; Pharmaceutical Major depressive disorder (MDD) is the most
Industry; Psychiatry and Sexual Orientation; common psychological mood disorder. The core
Sadomasochism; Sex Differences; Sexual Surgery; symptom of MDD involves mood—either sad or
Social Causation; Women; Work–Family Balance. blank mood, or an inability to experience pleasure
or interest. Additionally, a number of other symp-
Further Readings toms are typically present, including (1) cogni-
Finer, L. B. and M. R. Zolna. “Unintended Pregnancy tive symptoms, such as low self-esteem, negative
in the United States: Incidence and Disparities.” thoughts about human nature, pessimism, hope-
Contraception, v.84/5 (2011). lessness, helplessness, and thoughts of suicide;
Klotz, T., M. Mathers, R. Kloz, and F. Sommer. “Why (2) generalized low motivation, including a lack
Do Patients With Erectile Dysfunction Abandon of interest in activities that used to bring plea-
Effective Therapy With Sildenafil (Viagra)?” sure, low sex drive, and lack of interest in work;
International Journal of Impotence Research, v.17 (3) motor symptoms, most often a slow-down in
(2005). movement, which involves talking slowly, mov-
Morgentaler, A. The Viagra Myth: The Surprising ing slowly, failure to maintain eye contact, and
Impact on Love and Relationships. Hoboken, NJ: shoulder slumping; and (4) physical symptoms
Wiley, 2003. such as a change in sleeping (either sleeping more
Moynihan, R. and A. Cassels. Selling Sickness: How or sleeping less) and change in eating (either eat-
the World’s Biggest Pharmaceutical Companies Are ing more or eating less).
Turning Us All Into Patients. New York: Nation To be diagnosed with MDD, the symptoms
Books, 2005. must last for at least two weeks. Most often,
Wade, L., E. Kremer, and J. Brown. “The Incidental symptoms last for longer, perhaps months or even
Orgasm: The Presence of Clitoral Knowledge and years. The period of active symptoms is called a
the Absence of Orgasm for Women.” Women & major depressive episode. Most people who suffer
Health, v.42/1 (2005). from one episode suffer from another or others
in the future. In the United States and Canada,
women are two to three times more likely than
men to experience at least one depressive episode
in their lifetime. Up to 26 percent of U.S. women
Sex Differences and 12 percent of U.S. men will experience at least
one major depressive episode in their lifetimes.
Sex differences in incidence rates occur in a num- Sex differences in depression, with women experi-
ber of major psychological disorders, particularly encing more depression, exist for all major ethnic
depression, eating disorders, several anxiety dis- groups in the United States: European American,
orders, antisocial personality disorder (formerly African American, Latino/a, Asian American,
called sociopathy or psychopathy), conduct dis- and Native American. Results of cross-cultural
order (a childhood disorder similar to antisocial research reveal that women are more likely than
796 Sex Differences

men to suffer from depression in a wide variety work and develop depression. Another expla-
of countries, including Germany, Lebanon, Israel, nation related to stressful circumstances is the
Chile, South Korea, Taiwan, Uganda, and New inordinate concern that many girls and women
Zealand. However, it appears that sex differences tend to have about their appearance. According
in depression do not exist in young children. to this explanation, women in many societies are
Around puberty, girls begin to describe more conditioned through the media, from their own
symptoms of depression than boys. parents, and from other sources to believe that
In a review of the literature, psychologist their value is largely determined by their physical
Margaret Matlin discusses and evaluates the beauty.
many explanations that have been proposed Psychologist Susan Nolen-Hoeksema and her
for the sex difference in depression diagnoses. colleagues have proposed another explanation
Matlin begins by considering biological expla- that has been extensively researched. Nolen-
nations that have been proposed, for instance, Hoeksema’s explanation centers on the ways that
genetic factors directly related to having two X women and men respond when they experience
chromosomes and hormonal fluctuations. As a sad or blue mood. Research indicates that men
Matlin describes, several careful reviews of the have a tendency to distract themselves from the
research have concluded that biological expla- mood, whereas women are more likely to revisit
nations are not supported. She proceeds to dis- and explore the mood in a process called “rumi-
cuss the explanations that have engendered some nation.” Further research indicates that this rumi-
support. One explanation is a sex difference in native style is associated with enhancing the neg-
seeking therapy, with women seeking therapy ative, depressed mood, increasing the likelihood
more often than men. Other researchers have of developing a diagnosable major depression.
proposed that therapists, because of their own The results are so well established that Nolen-
stereotypes about women and men, may tend to Hoeksema recommends against responding with
overdiagnose women and underdiagnose men a ruminative style when one experiences a sad
for depression. Matlin concludes that both of mood. Instead, she suggests other reactions, such
these explanations may account for part, but not as constructive forms of distraction, for instance,
all, of the sex difference. engaging in an interesting activity. Nolen-Hoek-
Other explanations hold that a real sex differ- sema is not opposed to introspection in general.
ence exists in depression. Most of these explana- However, she suggests that exploring one’s nega-
tions involve stressful circumstances that women tive mood and thinking about the source of one’s
face. Women may experience discrimination feelings could be postponed until a period of time
more than men. Research has substantiated that when one is less psychologically vulnerable.
discrimination is associated with an increased MDD is commonly treated by psychotherapy
incidence of depression in women. Women and or antidepressant medication or both. Common
girls are often targets of violence and abuse, forms of psychotherapy are cognitive therapy,
including childhood sexual abuse, rape, sexual in which the client’s negative thinking patterns
harassment at school or at work, and interper- are examined, and interpersonal psychotherapy,
sonal violence. Women suffer higher rates of which is a collection of approaches and techniques
poverty than men and are more often single par- that focus on treating the particular interpersonal
ents than are men. Some women are single moth- problems that the depressed client is experiencing.
ers who subsist below the poverty line. In cases For instance, the depression may involve a pro-
where women and men live together as married longed grief reaction after suffering the loss of a
or unmarried partners, women typically do the loved one through death or abandonment. Or the
bulk of the housework and childcare, whether or depressed client may be suffering because she has
not they are employed. Some research indicates never had a satisfying long-term romantic rela-
that many women full-time homemakers find tionship. Another common treatment is antide-
this work unrewarding, increasing the risk of pressant medication. According to the Centers for
depression. Those who work full-time and do the Disease Control and Prevention (CDC), antide-
bulk of housework may become overloaded with pressants were the third most common prescription
 Sex Differences 797

medication taken by all people in the United States bulimia are serious disorders that may have medi-
from 2005 to 2008 and were the most commonly cal consequences, some of which are associated
prescribed medication for people between the ages with permanent damage. Some examples include
of 18 and 44. About 10 percent of Americans over heart, liver, gastrointestinal, dental, bone density,
age 17 take antidepressants. Women are 2.5 times and metabolic problems. Some people suffering
more likely to take antidepressants than men. Not from anorexia die from a medical complication
all prescriptions of antidepressants are for treating related to anorexia or from suicide. The mortality
depression. Antidepressants are also used to treat rate for anorexia is between 5 and 10 percent.
some anxiety conditions and bulimia nervosa and
to help an individual to quit smoking. Anxiety
Women also suffer a number of anxiety disorders
Eating Disorders at higher rates than men, particularly generalized
Another major category of psychological disor- anxiety disorder (GAD), phobias, and panic disor-
ders, eating disorders, is significantly more com- der. People with GAD worry continuously about
mon in women than in men. The two most serious many general life situations. The anxiety takes a
eating disorders are anorexia nervosa and bulimia toll on them, such that they may feel restless most
nervosa. Anorexia nervosa involves a refusal to of the time, are fatigued, have trouble concentrat-
maintain at least 85 percent of normal weight, an ing, experience tension in their muscles, and have
intense fear of gaining weight, and usually also a sleep difficulties. A phobia is an intense fear of a
distorted body image, which means that the indi- specific object or situation, for instance, snakes,
vidual believes that he or she is overweight (while dogs, blood, flying, public speaking, closed
he or she is significantly underweight). The most spaces, or high places. People with panic disorder
common age range for the onset of anorexia is experience panic attacks, in which the anxiety felt
14 to 18 years old. Between 0.5 and 2 percent of is so intense that the individual believes that he or
females in Western countries suffer from the dis- she is having a heart attack, is going crazy, or is
order in their lifetime. It is estimated that 90 to 95 going to die. The attack occurs suddenly and may
percent of cases of anorexia occur in females. The include heart palpitions, shortness of breath, feel-
incidence may be increasing in men. Men who are ing of choking, sweating, trembling, chest pain,
required to be small or have low body fat for their faintness, dizziness, and a feeling of unreality.
professions or athletic activities are particularly Panic attacks usually peak within 10 minutes and
vulnerable, such as jockeys, wrestlers, distance will gradually lessen.
runners, body builders, and swimmers. These disorders are likely caused by multiple
Bulimia nervosa involves frequent episodes of factors. Common explanations for both GAD
binge eating followed by compensatory behavior and phobias are societal stress. For instance, eco-
meant to prevent weight gain. Examples of com- nomic stresses may contribute to both of these
pensatory behavior are vomiting, use of laxatives, disorders, and other societal stress such as dis-
use of enemas, excessive exercise, and fasting. crimination and vulnerability to crime may con-
People who suffer from bulimia nervosa may be tribute to GAD. Various treatments are used for
average weight, underweight, or overweight. Buli- these disorders. Phobias are most often treated
mia typically begins in late adolescence or young with conditioning techniques, that is, the feared
adulthood. Data from several surveys in Western object or situation is paired with a pleasant stimu-
countries suggests that up to 5 percent of women lus, such as a feeling of relaxation, over a number
experience bulimia. Like anorexia, 90 to 95 per- of treatment sessions, and frequently the phobia
cent of sufferers are female. Also like anorexia, greatly diminishes. Common treatments for GAD
bulimia may be becoming more common in males. are several types of psychotherapy and antianxi-
Courses for both anorexia and bulimia are highly ety medications, including alprazolam (Xanax),
variable. Most people recover, although they may lorazepam (Ativan), and diazepam (Valium).
continue to struggle with subclinical difficulties Based on CDC data from 2005 to 2008, women
related to the disorder (e.g., continuing to over- are about 1.5 to two times more likely to take an
emphasize their appearance). Both anorexia and antianxiety medication than men. Panic disorder
798 Sex Differences

is treated with cognitive therapy and with antide- family factors are the most significant contrib-
pressant and antianxiety medications. uting causes, including poor parenting, conflict
between parents, family conflict, and family hos-
Antisocial Personality Disorder tility. Treatments include family therapy, parent
Men are diagnosed with antisocial personality management training, and a variety of cognitive
disorder (APD) more often than women. APD behavioral and coping skills treatment approaches
involves a consistent disregard for the rights of with the children. Additionally, since about 2000,
others and lack of empathy for others. People stimulant drugs similar to drugs used for atten-
with APD repeatedly lie. They also tend to be tion deficit hyperactivity disorder are increasingly
impulsive and may therefore find themselves in prescribed for some children with conduct disor-
frequent fights and display other forms of aggres- der. These medications require further study but
sion. Most are reckless, showing little regard for may reduce aggressive behavior in these children.
their safety or the safety of others. They usually
have difficulty maintaining close relationships. Attention Deficit Hyperactivity Disorder
They may be careless with money, fail to pay their Another disorder that is significantly more com-
debts, and may have difficulty holding a job. They mon among boys and men than girls and women is
are nearly always unconcerned about the pain or attention deficit hyperactivity disorder (ADHD).
damage that they cause to others. It is estimated About 5 percent of children in the United States
that about 2 to 3.5 percent of people in the United suffer from ADHD and up to 90 percent are boys.
States are diagnosable with APD. The disorder is Diagnostic criteria for this disorder involve expe-
much more common in men than in women, pos- riencing a number of symptoms of inattention,
sibly four times higher in men. such as frequent failure to pay close attention
The childhood disorder most similar to APD is to details, sustain attention, listen when directly
conduct disorder, the core of which is also a per- spoken to, and follow through on instructions;
sistent violation of the rights of others. Addition- avoidance of tasks that require prolonged mental
ally, children diagnosed with this disorder may be effort; frequent loss of items; and easy distraction.
physically cruel to animals or people, intention- Additionally, for diagnosis, the child or adult must
ally destroy others’ property, and steal, including display a number of symptoms of hyperactivity-
shoplifting, breaking into cars or buildings, mug- impulsivity, such as fidgeting or squirming, fre-
ging, or armed robbery. Also, they may frequently quent wandering from one’s seat, running about
be absent from school or run away from home. when it is inappropriate, difficulty playing quietly,
Conduct disorder typically begins between ages excessive talking, difficulty waiting for one’s turn,
7 and 15. Up to 10 percent of children meet the and interrupting others. For diagnosis, some of
diagnostic criteria for this disorder. Conduct dis- these symptoms must have been present before
order is three times more common in boys than in age 7, and they must be associated with signifi-
girls. However, in recent years, criminal behavior cant impairment in at least two settings. About 35
among girls has increased, and conduct disorder to 60 percent of children with ADHD also have
may also be increasing in girls. The antisocial ADHD in adulthood.
behavior of many of these children decreases into The manner in which ADHD has been diag-
adulthood, but other children develop from con- nosed in the United States has caused some con-
duct disorder to APD. cern among many ADHD experts. Diagnosing
Treatments for adult APD typically are not ADHD is not simple; ADHD involves a large num-
successful. However, treatment for conduct dis- ber of symptoms and significant impairment must
order can be helpful, often resulting in modest to exist. Thus, diagnosis should be made based upon
moderate improvement in the child. It is believed a large amount of information obtained from dif-
that multiple factors contribute to conduct dis- ferent settings and should be made by someone
order, including biological and genetic factors, who is highly knowledgeable about ADHD and
drug abuse, poverty, and exposure to violence in the variety of ways in which symptoms may pres-
the community, including consorting with vio- ent themselves. However, some research suggests
lent peers. However, most experts believe that that a large number of children receive diagnoses
 Sexual Surgery 799

from general practitioners or pediatricians. Addi- Sexual Surgery

tionally, only one-third to one-half of ADHD
diagnoses are based on the results of psychologi- The term transgender is an umbrella term used to
cal or educational testing. Some experts, including refer to individuals whose internal sense of gender
authorities in the U.S. Drug Enforcement Admin- does not match their biological sex. They may use
istration (DEA), as discussed in a report in 2000, medical technology to change their external gen-
are concerned that overdiagnosis is occurring. der appearance (transsexuals), dress as another
The most common treatment for ADHD is medi- gender (cross-dressers), or reject the gender
cation, for instance, methylphenidate, known by binary altogether and present as more androgy-
the trade name Ritalin. The prescribing of Ritalin nous (gender queer). Moreover, some transgender
to children has increased since the early 1980s. In individuals may appear as either male or female
2000, the DEA estimated that between 10 and 12 at different times (bigender). Individuals may
percent of boys in the United States took Ritalin identify as gender nonconforming, gender vari-
for ADHD and that the use of Ritalin for girls was ant, or use other terms to refer to their gender
on the increase. Ritalin and other stimulant drugs identity. Transgender individuals may be further
are also used for adults with ADHD. Because of subdivided into those who have changed their
both the potential overdiagnosis of ADHD and gender appearance from male-to-female (MTF),
the high rate of use of Ritalin and other drugs, or from female-to-male (FTM).
ADHD is a psychological disorder associated Forms of gender variance have been accepted in
with a long history of controversy. various cultures, including the Two Spirit among
Sex differences in incidence rates occur for a many Native American groups; transgender sha-
number of serious psychological disorders. For mans in parts of Africa, South America, and South
some disorders, such as eating disorders and Asia; as well as the hijra in India. Transgender
conduct disorders, the gap in diagnosis rates for identities have also been noted in the Western
females and males may be narrowing. Medica- world throughout history, including pagan wor-
tions are used to treat most of the major disorders, ship of transgender deities, ancient Greek cross-
and, in general, use of mediations is on the rise. dressing rituals, medieval cross-dressing societies,
as well as transgender clubs in Victorian England.
Gretchen M. Reevy Increasingly rigid gender codes were reified by
California State University, East Bay Christianity and the socioeconomic changes asso-
ciated with feudalism, industrialization, and capi-
See Also: Anxiety, Chronic; Attention Deficit talism. These religious and economic changes led
Hyperactivity Disorder (ADHD); Depression; Eating to increased stigmatization of transgender identity.
Disorders; Gender; Women. Transgenderism was labeled a psychiatric dis-
order with the inclusion of gender identity disor-
Further Readings der (GID) in the fourth edition of the American
Bourne, Edmund. The Anxiety and Phobia Psychological Association’s Diagnostic and Sta-
Workbook. Oakland, CA: New Harbinger, 2011. tistical Manual of Mental Disorders (DSM-IV).
Comer, Ronald J. Abnormal Psychology. New York: GID is a controversial diagnosis within and out-
Worth, 2010. side the transgender community, given the tension
Hallowell, Edward M. and John J. Ratey. Driven between avoiding stigma and garnering insurance
to Distraction: Recognizing and Coping With reimbursement for hormone therapy and sex
Attention Deficit Disorder. New York: Anchor, reassignment surgery. In addition, this diagnosis
2011. has been used as part of a legal defense in cases
Matlin, Margaret W. The Psychology of Women. of discrimination. Gender dysphoria replaces this
Belmont, CA: Wadsworth, 2012. diagnosis in the most recent edition of the diag-
Siegel, Michele, Judith Brisman, and Margot nostic manual (DSM-5), published in May 2013.
Weinshel. Surviving an Eating Disorder: Strategies This change is meant to emphasize the presence
for Family and Friends. New York: Harper of psychological distress regarding one’s gen-
Perennial, 2009. der in order to warrant a diagnosable disorder.
800 Sexual Surgery

Nonetheless, there is a troubling history of iden- and the effects are reversible. Later administra-
tifying transgender identity as a mental illness. tion of cross-sex hormone therapy can occur
Many contemporary gender identity specialists around age 16, with the age of legal consent for
view transgender identity as simply a variance in surgery at age 18. A slight elevation in anxiety,
gender expression and link the diagnosis of GID mood, and behavioral problems has been found
to the previous inclusion of homosexuality in the among subsamples of transgender youth, with
DSM in the 1970s. some cases of self-harm and suicidality reported.
This incidence has been attributed to peer bul-
Transgender Individuals With Mental Illness lying, family distress, parental rejection, history
While transgender identity alone should not be of abuse, co-occurring psychiatric problems, and
viewed as a mental illness, there is an increased body dissatisfaction. Individual and family psy-
rate of mental illness among individuals with chotherapy and hormone treatment have been
transgender identity. In this context, a mental ill- associated with reductions in behavioral and
ness refers to impairment from a major mental emotional symptoms among this group.
disorder that interferes with self-care, as well as
social and vocational functioning. Transgender Sex Reassignment Surgery
individuals with mental illness tend to have an The development of anesthesia and synthetic
earlier onset of mental disorders and report less hormones led to the opportunity for transgen-
treatment satisfaction than their cisgender (non- der persons to utilize medical technology to alter
transgender) counterparts. Mental health prob- their appearance. Physician Harry Benjamin
lems among transgender groups have been associ- established what is now known as the World
ated with maladaptive coping such as substance Professional Association for Transgender Health
abuse, sexual risk taking, and suicidality. (WPATH) in the 1970s. The organization’s stan-
One of the key contributors to mental health dards of care remain a fixture for treatment. Key
problems among transgender individuals is principles involve increasing knowledge about
stigma—negative attitudes, prejudice, and dis- health care needs, facilitating access to care, and
crimination. Transgender individuals and people supporting transsexual patients within their fami-
with mental illness face double barriers to employ- lies and communities. These standards also apply
ment, housing, medical care, and social accep- to different therapies and medical procedures,
tance. Stigma has been associated with greater such as hormone and voice therapy.
impairment in social and vocational function- These standards of care involve assessing psy-
ing, prolonged psychiatric symptoms, increased chological and physical preparedness for life as
frequency of psychiatric hospitalizations, and someone of a different gender. Prior to surgery,
delayed treatment seeking. These factors can fur- the patient begins the diagnostic phase, which is a
ther worsen mood and functioning among trans- two-stage process. The first stage consists of assess-
gender individuals who also have a mental illness. ing the intensity of the patient’s gender dysphoria,
identifying patients who qualify for a diagnosis
Transgender and Gender-Variant and would benefit from surgery, and fully inform-
Children and Adolescents ing the patient about types of treatment and sur-
With increased awareness and acceptance of gery. The second stage, the “real-life test,” involves
gender variance, many children and adolescents living as someone of the preferred gender.
have begun seeking medical treatment in gender A number of different procedures are included
specialty clinics. Adolescence may be a time of in male-to-female sex reassignment surgery (SRS).
marked distress, given the pubertal development For example, patients may undergo vaginoplasty,
of secondary sex characteristics that differ from a procedure that consists of dissecting the penis
one’s internal sense of gender. As a result, trans- and completely removing the corpus cavernosa.
gender youth may begin to seek therapy and con- The glans of the penis is divided into sections and
sider pubertal suppression or cross-sex hormone transformed into the neoclitoris and the neocervix.
therapy. One advantage of pubertal suppression is This vagina is then located to the perineal cavity.
the possibility to discontinue if discomfort occurs, This procedure is followed by vulvoplasty, where
 Shell Shock 801

the labia are created from the remaining penile as Psychiatric Conditions.” Archives of Sexual
and scrotal skin. Various methods used in vagino- Behavior, v.29 (2010).
plasty may include nongenital skin grafts derived World Professional Association for Transgender
from the abdominal area, penile skin grafts, penile Health. Standards of Care for the Health
skin flaps, and nongenital skin flaps from the thigh of Transsexual, Transgender, and Gender
and abdominal areas. Male-to-female surgery may Nonconforming People. 7th ed. Minneapolis, MN:
also include breast augmentation, facial feminiza- World Professional Association for Transgender
tion, chondrolaryngoplasty (reduction of the thy- Health, 2012.
roid cartilage), and vocal cord surgery.
Female-to-male (FTM) sex reassignment sur-
gery may include phalloplasty. One type of phal-
loplasty is metoidoplasty, which involves creating
external genitalia that allows for urination while Shell Shock
standing. Other SRS techniques for FTMs include
hysterectomy, oophorectomy (removal of the ova- The term shell shock (sometimes also called com-
ries), and bilateral mastectomy. Sex reassignment bat neurosis or war neurosis) was first used to
surgery has often been overemphasized in the describe a wide range of symptoms seen in soldiers
gender transition processes. Not all transgender during World War I. Although symptoms were
individuals decide to or can afford SRS or other diverse, they were believed to share a common
medical technologies. cause: close proximity to exploding shells. It was
believed that when a shell exploded, a vacuum
Lauren Mizock was created, and that when air rushed into this
Boston University vacuum, the cerebro-spinal fluid was disturbed,
Daniel Rowland which then upset brain functioning. Over time,
Worcester State University this view was challenged, and instead psychologi-
cal and behavioral explanations were offered. It
See Also: Gender; Hypersexuality; Labeling; is now accepted that the origins were rooted in
Psychiatry and Sexual Orientation; Stigma; Stigma: psychological strain arising from the stress of
Patient’s View. combat. Early symptoms of shell shock included
irritability, fatigue, dizziness, physical shaking,
Further Readings headaches, and loss of concentration. These later
Gates, Gary J. How Many People Are Lesbian, Gay, develop into much more serious somatic symp-
Bisexual, or Transgendered? Los Angeles: Williams toms such as blindness, paralysis, deafness and
Institute on Sexual Orientation and Gender loss of speech, and mental breakdowns. Symp-
Identity Law and Public Policy at UCLA School of toms were so extreme that individuals could not
Law, 2011. remain in active service at the front line. This led
Kidd, Sean A., Albina Veltman, Cole Gately, Jacky to unsympathetic views held of sufferers. Shell
Chan, and Jacqueline N. Cohen. “Lesbian, Gay, shock is no longer in use as a term. Instead, behav-
and Transgender Persons With Severe Mental ioral and psychological symptoms arising from
Illness: Negotiating Wellness in the Context of exposure to war situations would more likely be
Multiple Sources of Stigma.” American Journal of described as combat stress reaction or combat
Psychiatric Rehabilitation, v.14 (2011). fatigue. This contemporary concept has similari-
Leibowitz, Scott F. and Cynthia Telingator. ties to acute stress reactions seen outside military
“Assessing Gender Identity Concerns in Children situations. Combat stress reactions can precursor
and Adolescents: Evaluation, Treatments, and full-blown post-traumatic stress reactions, includ-
Outcomes.” Current Psychiatry Reports, v.14 ing post-traumatic stress disorder (PTSD).
(2012).
Meyer-Bahlburg, Heino F. L. “From Mental Divided Views
Disorder to Iatrogenic Hypogonadism: Dilemmas At the time, views on shell shock were divided
in Conceptualizing Gender Identity Variants as to whether it was a genuine illness reaction
802 Shell Shock

or merely a strategy employed by soldiers who be carried out in a place that was within range
wished to escape from combat. Those serving at of enemy fire, meaning that physical injury or
the front quickly recognized shell shock symp- death was likely. There were also executions for
toms in their peers, but the military hierarchy dereliction of duties. Other individuals commit-
was less convinced, as was wider society. Views ted suicide.
regarding sufferers were generally unsympathetic, More sympathetic views on shell shock admit-
with shell shock seen as a sign of weakness and ted that engagement in war constituted such a
a lack of character in the individual. It was also reversal of society’s civilized standards that the
regarded as a black mark against the individual’s individual could not sufficiently adapt. The behav-
military unit, taken to indicate disloyalty and a iors required of soldiers, specifically aggression,
lack of discipline in the command structure. killing, inflicting mutilation, and sending others
Some soldiers suffering symptoms were for- to death, all contravened their normal socialized
mally classified as malingerers, essentially labeled and accepted behaviors. Seen this way, shell shock
cowards trying to avoid active duty, and were sent sufferers had not lost their reason but instead
back to active service. There were many deser- were unable to put aside that reason in order to
tions by shell shock sufferers, and incidents where engage in what they and their society would nor-
individuals refused to carry out their orders. Con- mally consider barbaric practices.
sequences of such refusals were severe. Punish- When shell shock was viewed as an illness, rather
ments often happened in situ; for example, being than cowardice, sufferers were given treatment,
attached to a fixed object for an extended period and many recovered. For some, this occurred rap-
of time, which could range from two hours a day idly enough to be able to return to active service,
to three months. Often, this punishment would a key intention of treatment programs. Others,

Thomas W. Salmon’s The Care and Treatment of Mental Diseases and War Neuroses (“Shell Shock”) in the British Army (1917), used
the term conversion hysteria to describe World War I soldiers’ somatic symptoms of paralysis, muscular contracture, and loss of sight,
speech, and hearing (left). A nurse bandages the head of a soldier at the Canadian base hospital in the Hotel du Golf, Le Touquet,
France, during World War I (right). Originally, shell shock was thought to be caused by close proximity to exploding mortar.
 Side Effects 803

however, were unable to recover and continued Further Readings

to suffer the effects for many years. The shift in Jones, Edgar, Nicola T. Fear, and Simon Wessely.
thinking around the origins of shell shock had “Shell Shock and Mild Traumatic Brain Injury:
significant implications for the types of treatment A Historical Review.” American Journal of
interventions that sufferers received. When the Psychiatry, v.164 (2007).
symptoms were physical, the treatments involved Makari, George. Revolution in Mind: The Creation of
massage, rest, and dietary regimes. Electric shock Psychoanalysis. New York: Harper, 2008.
treatments were also used, with shocks admin- Winter, Jay. “Shell-Shock and the Cultural History of
istered to the relevant part of the body (e.g., to the Great War.” Journal of Contemporary History,
the throat if mute, to the legs if paralyzed). When v.35 (2000).
the symptoms were psychological, the treatments
altered and instead focused largely on psychoana-
lytic methods involving talk, hypnosis, and rest.
These methods could be lengthy and meant that
soldiers could be kept from active service for pro- Side Effects
longed periods. Some doctors refused to engage
in such extended methods of treatment. Instead, Psychoactive drugs produce a myriad of physio-
individuals were exposed to their main fears (such logical effects, or side effects, in the body, in addi-
as noise), and kept them from their pleasures tion to offering the intended benefit of relieving
(such as reading). The development and encour- psychological symptoms. Patients often find these
agement of masculinity was threaded throughout discomfiting and may choose to discontinue med-
treatment, and shaming was considered an appro- ications as a result. Although physicians consider
priate aspect within this. Occupational training most side effects to be tolerable and manageable
also played a part. with adjuvant drugs, a number can become seri-
The symptoms seen in officers and regular ous with prolonged use and may shorten life.
soldiers differed in nature and frequency, with Pharmaceutical manufacturers devote consid-
regular soldiers experiencing many more somatic erable effort to the development of compounds
symptoms (e.g., paralysis, deafness, and blindness) closely related to currently known drugs but with
and speech disorders (such as mutism), whereas milder side-effect profiles. The placebo effect,
officers experienced more psychological disor- the partial relief of symptoms as a psychological
ders (e.g., depression, nightmares, and insomnia). response to the administration of any medication,
Officers were more likely to receive treatment for even an inert substance, is also a much-debated
shell shock than ordinary soldiers. This may have side effect of psychoactive drugs.
been because of the military hierarchy showing
more sympathy for officers than it did for ordi- Side Effects of Antipsychotic Drugs
nary serving men, but it may also have reflected Chlorpromazine and the other phenothiazines
increased shell shock diagnosis because of their often cause sedation, lethargy, slurred speech, dry
less physical symptoms. There may also actually mouth, increased appetite and weight gain, hypo-
have been higher incidence in officers because of tension with dizziness, urinary retention, and
their increased feelings of responsibility for the constipation. Other known effects include loss
death of others, and because of having to repress of libido and other reproductive dysfunction, sei-
their emotional reactions in front of their troops, zures in genetically susceptible patients, blindness
increasing the level of their psychological strain. with prolonged use, and neuroleptic malignant
syndrome, which can be fatal.
Vivienne Brunsden Haloperidol (U.S. trade name Haldol) and tri-
Nottingham Trent University fluoperazine (trade name Stelazine), two high-
potency typical antipsychotics, cause extrapyra-
See Also: Post-Traumatic Stress Disorder; midal side effects more often than chlorpromazine;
Psychoanalysis, History and Sociology of; the most troublesome of these are akithisia, or
Psychoanalytic Treatment; Trauma, Psychology of. dystonia, and tardive dyskinesia. Akathisia is
804 Side Effects

characterized by an internal aching with restless- With meticulous monitoring of white blood cell
ness, ranging from intense discomfort to acute levels and other parameters, clozapine appears to
pain, that forces the patient to remain in motion; have been made safer for use and is highly toler-
he or she cannot sit or lie still until overtaken by able for most patients. Moreover, a 2009 obser-
fatigue. The condition can be alleviated by reduc- vational study of more than 60,000 patients in
ing dosage or adding another drug, most often Finland found that clozapine users had a statisti-
propanolol or a benzodiazepine; the symptoms cally significant lower mortality from all causes,
usually disappear if the patient stops taking the and a significantly lower rate of suicide, than
antipsychotic but, in some cases, can persist for those patients on five other major antipsychotic
a long time. Patients afflicted by akithisia often drugs, However, the drug is also associated with
compare it to a kind of torture and in extreme increased risk of myocarditis and with substantial
cases may commit suicide or reject all treatment. weight gain (as are some other atypicals, such as
Tardive, or slow-onset, dyskinesia manifests olanzapine), with more than 50 percent of users
itself in involuntary, repetitive movements of the becoming substantially overweight and at risk for
face, limbs, torso, or fingers, appearing after long- diabetes. The final verdict on clozapine was still
term dosage. Facial grimaces and blinking almost open in the early 21st century.
invariably increase self-consciousness and social
isolation and may make it difficult for the patient Side Effects of the Antidepressants
to communicate; dyskinesia of other parts of the The monoamine oxidase inhibitors (MAIOs),
body may hinder walking or handling objects. including iproniazid, isoniazid, and phenelzine,
The condition may persist for years after the were the first antidepressants to be introduced
patient withdraws from the drug or even become in the late 1950s but soon fell into disfavor after
permanent. Tardive dyskinesia is treated with tet- being linked to hypertensive crises following
rabenazine, which depletes dopamine in the body; interactions with specific common foods. Psy-
some researchers have recommended the use of chiatrists now see them as relatively safe when
anti-Parkinsonian drugs or preventive treatment correctly prescribed and used. MAOIs can also
with vitamins. Patients often cite this side effect as cause fatal effects in interaction with epinephrine
a reason for refusing to take antipsychotic drugs. or with other antidepressants, the tricyclics or the
The atypical, or second-generation, antipsy- serotonin specific reuptake inhibitors (SSRIs), or
chotics, including drugs such as aripripazole other psychoactive drugs.
(U.S. trade name Abilify), olanzapine (trade name The tricyclic antidepressants (TCAs), includ-
Zyprexa), and risperidone (trade name Risperdol), ing drugs such as amitriptyline (U.S. trade name
have similar side-effect profiles to the typical anti- Elavil) and imipramine (trade name Tofranil),
psychotics, including akithisia, tardive dyskinesia, may have multiple side effects, including drowsi-
significant weight gain, and neuroleptic malignant ness, emotional blunting, restlessness, sexual dys-
disorder. The lone exception is clozapine (U.S. function, dry mouth and nose, blurred vision,
trade name Clozaril), the first atypical to be syn- nausea, urinary retention and constipation, cog-
thesized, in 1958, which is virtually free of risk of nitive or memory impairment, tachycardia, and
extrapyramidal symptoms. Clozapine appeared on hypotension. There have been reports of akithisia
the European market in 1971 but was withdrawn and muscle twitches. The patient usually devel-
after only four years, when several patients were ops tolerance to these symptoms with continued
diagnosed with agranulocytosis, the fatal inhibi- use, and the physician may assist this by initial
tion of white blood cell manufacture in the bone prescription of a low dosage to be increased over
marrow. Other serious potential side effects of this time. Patients often experience some withdrawal
medication include seizures, myocarditis, bowel symptoms, such as headaches, nausea, insomnia,
infarction, and diabetes. The enormity of this risk or malaise, with discontinuing the drugs, which
relegated clozapine to the Sandoz back shelves for again can be managed by dosage adjustment.
15 years, but the Food and Drug Administration The SSRIs, including drugs such as fluox-
(FDA) approved its use for patients resistant to etine (Prozac), escitalopram (Lexapro), parox-
chlorpromazine and other antipsychotics in 1990. etine (Paxil), and sertraline (Zoloft), may cause
 Side Effects 805

a variety of side effects, which appear as the body the deliberate misreporting of relevant data. For
adapts to the drug and may disappear after a few example, the Eli Lilly company’s reports on its
weeks; these vary with the patient, and physicians drug paroxetine (trade name Paxil) in adolescents
generally manage by switching to another SSRI showed misclassification of suicides as deaths
until the drug most tolerable for that individual from other causes, grouping of suicidal thoughts
is found. The most common adverse effects with with other symptoms under the heading of emo-
this class of drug are drowsiness, headache, dizzi- tional liability, and overstating of suicides occur-
ness, insomnia, diarrhea, change in appetite and ring in placebo control groups. After reviewing
weight gain or loss, sexual dysfunction, tremors, the evidence, the U.S. Food and Drug Administra-
hypotension, photosensitivity, and cognitive defi- tion (FDA) in 2005 required all SSRIs to carry
cit. Patients have also reported increased depres- black box warnings of increased suicidal risk and
sion and suicidality, increased anxiety and panic the need for physician monitoring and specifically
attacks, akithisia, mania, and cognitive deficit. disapproved paroxetine for pediatric use; the UK’s
There may also be increased risk of fracture and Medicines and Healthcare Products Regulatory
bleeding. The risk of toxicity from overdose is Agency (MHRA) and the European Committee
low compared to that from other antidepressants. for Medicinal Products for Human Use (CHMP)
Patients often experience some withdrawal symp- have also restricted prescription of this drug to
toms when discontinuing the drugs, which can be patients under the age of 25.
managed by gradually reducing the dosage.
For SSRI users, the most troubling side effect Side Effects of Lithium
is a sense of anhedonia or emotional blunting: Lithium, the most common medication for bipo-
not only negative emotions, such as depression, lar disorder, is likely to cause a somewhat dazed
guilt and grief, disappear, but positive feelings, feeling and hand tremors. The drug causes thirst
such as joy, love, and excitement. Patients report electrolyte imbalances, often with accompanying
experiencing detachment from others and no lon- nausea and headaches; patients are advised to
ger being able to care deeply about anything— drink increased amounts of water to counteract
feeling like a zombie, a robot, or a brick. While these symptoms. The risk of dehydration inhib-
many view this relative apathy as preferable to ited widespread use prior to development of a test
their dysfunctional illness, others find the numb- for blood levels of lithium. Weight gain, hypothy-
ness unbearable and discontinue the drug, resign- roidism, and involuntary eye blinks (nystagmus)
ing themselves to depression or seeking assistance are also possible adverse effects. Physicians man-
through psychotherapy instead. age these by prescribing the lowest effective dose,
Suicidality, particularly in adolescents and monitoring blood levels, and advising appropri-
young adults, is probably the most dangerous risk ate diet and fluid intake.
of these medications. Soon after SSRIs appeared
on the market in the 1980s, the manufacturers The Placebo Effect
began to receive reports of suicidal thoughts and Many patients will show some subjective response
attempts; the incidence appeared relatively low to any medication, and the placebo effect may be
and the relative risk difficult to evaluate in indi- considered a positive side effect, enhancing the
viduals with varying levels of depression prior to therapeutic benefit. The acknowledgment of a pla-
taking the drugs. Several published reviews of the cebo mechanism, however, complicates the evalu-
clinical trial data appeared to minimize concerns ation of psychoactive drugs. Researchers have
of increased risk, but the diverse selection criteria, reported relief of mood disorders like depression
dosing schedules, and assessment time points of from a number of active placebos, that is, drugs
the various trials raised multiple methodological that have measurable subjective or physiologi-
issues. Ethically, it was impossible to construct a cal effects. Even patients with a cognitive illness
trial to evaluate suicidality as a primary outcome. like schizophrenia may show some behavioral
Class action lawsuits by the families of suicide improvement when receiving physician interest
victims in the 1990s, however, led to public dis- and attention as part of a medication trial. Some
closure of internal company documents revealing researchers indeed have questioned whether
806 Sleep Disorders

antidepressants are significantly more effective Price, J., V. Cole, and G. M. Goodwin. “Emotional
than active placebos and whether their prescrip- Side Effects of Selective Serotonin Reuptake
tion warrants the attendant risk of troubling or Inhibitors: A Qualitative Study.” British Journal of
toxic side effects, while others have argued that Psychiatry, v.195 (2009).
such active placebos should be employed as adju- Salamone, J. D. “A Critique of Recent Studies
vant therapies. of Placebo Effects of Antidepressants:
Importance of Research on Active Placebos.”
Management of Side Effects Psychopharmacology, v.152 (2000).
and the Problem of Polypharmacy Schwartz, T. L., J. Megna, and M. E. Topel, eds.
Side effects of psychoactive drugs are managed Antipsychotic Drugs: Pharmacology, Side Effects
through careful physician monitoring; dosage and Abuse Prevention. Hauppauge, NY: Nova
adjustment to the minimum level needed for ther- Science Publishers, 2013.
apeutic benefit; and prescription of adjuvant med-
ications to alleviate problems such as sedation,
nausea, constipation, weight gain, and hypoten-
sion. Individuals receiving antipsychotic medica-
tions for schizophrenia and related disorders may Sleep Disorders
experience anxiety and depression as they readjust
to life in the community as a mentally ill patient Health influences and is influenced by a range of
in recovery, and physicians may prescribe antide- biological, genetic, psychological, social, and cul-
pressants or anxiolytic drugs, such as benzodiaze- tural factors. Sleep normality and pathology con-
pines, to alleviate these symptoms. Multiple drug tinues to receive very little attention from health
regimens raise the potential for toxic interactions, experts, and very few studies exclusively focus on
particularly with long-term use, where not all this factor within the context of culture and health.
such risks may be known. Despite the significant Sleep disorders and their impact on general
improvement in quality of life promised by the health have gained increasing attention in recent
psychopharmacologic revolution of the late 20th years. However, most of what is known about the
century, the mental health patient faces a lifelong field stems from studies based on non-Hispanic
burden of chronic illness and the necessity of whites (Caucasians and European whites), and
medical oversight and management. to a lesser extent from studies including African
Americans. Sleep normality and pathology varies
Marcia Meldrum considerably from individual to individual. The
University of California, Los Angeles majority of Hispanics living in the United States
come from Latin American countries. The 2005
See Also: Atypical Antipsychotics; Clozapine; U.S. census reported 42 million Hispanics in the
Lithium; Monoamine Oxidase Inhibitor (MAOI) United States and a growth from 4.5 to 13.9 per-
Antidepressants; Serotonin Reuptake Inhibitors; cent of the population. However, these numbers
Tricyclic Antidepressants. may not reflect a large percentage of Hispanics
without legal entry. The complexity of the His-
Further Readings panic population lies in the fact that it is an eth-
Apter, A., et al. “Evaluation of Suicidal Thoughts nic group descended from multiple races such as
and Behaviors in Children and Adolescents Taking European whites, African, and Indian tribes of dif-
Paroxetine.” Journal of Child and Adolescent ferent origin with Spanish as a common language.
Psychopharmacology, v.16/1–2 (2006). Some research identifies minority status as a
Jureidini, J. N., L. B. McHenry, and P. R. Mansfield. risk factor for sleep problems. Acculturation into
“Clinical Trials and Drug Promotion: Selective the United States is often associated with nega-
Reporting of Study 329.” International Journal of tive health outcomes and changes in deep sleep
Risk and Safety in Medicine, v.20 (2008). patterns. The 2006 AARP Hispanic Sleep Study
Leader, D. “The Creation of the Prozac Myth.” The found that 67 percent of Hispanics ages 40 and
Guardian (February 26, 2008). older reported getting enough sleep—the average
 Sleep Disorders 807

in comparison to all of the gender/race groups.

Black women were reported to have an average
SOL of 28.36 minutes, TIB of 7.55 hours, SD of
5.9 hours, and SE of 78.2 percent.
The study by Lauderdale and colleagues in 2006
also indicated that black men spent an average of
82 minutes per night less sleeping compared to
white women. Y. Song and colleagues found that
older black men demonstrated longer SOL (28.7
minutes), significantly less total sleep time (TST:
6.1 hours), lower SE (80.6 percent), and diminished
slow-wave sleep (SWS: 4.9 percent) compared to
whites. This study also controlled for social status,
various comorbidities, body mass index (BMI),
and sleep-disordered breathing (SDB).
Anatomical differences between racial groups
A student snoozes in class in Nakhon Sawan, Thailand, are another important issue to consider with
seemingly contradicting research findings that Asians tend respect to SDB. Cephalometric differences have
to self-report the least sleep-related complaints compared to been observed with regard to race. In particu-
Hispanic, black, and white populations. lar, black men have differences with respect to
the sella-nasion-subspinale angle in comparison
to white and Hispanic men. Differences are also
observed for the sella-nasion-supramentale angle
accumulated sleep was 6.6 hours each weeknight. when compared to white men, according to J. Lee,
Approximately 57 percent reported sleep depriva- S. Ramirez, and M. Will. This type of study high-
tion. The most common reasons for sleep depri- lights the need to further investigate and recognize
vation were excessive stress, anxiety, and depres- anatomical and physiological differences among
sion. Hispanics were also more likely to choose races and their possible relations to sleep patterns.
herbal remedies than over-the-counter medica- Insomnia is a condition involving difficulties
tions to resolve sleep disturbance compared to with sleep initiation, maintenance, early sleep
their white and African American counterparts. termination, and/or nonrestorative sleep. This is
commonly encountered in health care settings,
African Americans and is observed as either an independent condi-
Studies targeting specific and comparative sleep tion or as co-occurring with various forms of psy-
parameters across race and gender are rare. One chopathology and illnesses. Although insomnia
of the best efforts to address this problem was an research is well represented in the literature, stud-
ancillary study from the Chicago section of the ies related to gender and race is limited.
Coronary Artery Risk Development in Young D. Blazer and colleagues studied a community-
Adults (CARDIA). This work published data based elderly population of African Americans
regarding gender (male and female) and race and reported fewer sleep complaints compared to
(black and white) in middle-aged adults across European Americans. This study also indicated
four commonly utilized sleep parameters: sleep that females reported greater insomnia than men.
onset latency (SOL), time in bed (TIB), sleep effi- Still, age is an important factor because another
ciency (SE), and sleep duration (SD). The study study involved a preliminary examination of
controlled for employment, socioeconomic sta- insomnia among older women and found signifi-
tus, household, and lifestyle factors but still indi- cant differences. This study suggested that black
cated the presence of notable disparities among women reported fewer insomnia symptoms com-
race and gender. Black men had the longest SOL pared to whites, as noted by G. Jean-Louis and
(35.93 minutes), least TIB (7.1 hours), shortest colleagues. This was attributed to differences in
SD (5.1 hours), and poorest SE (73.2 percent) coping styles and that older black women utilize
808 Sleep Disorders

more positive self-regulation, which results in less discriminate subpopulations. Labels such as “His-
impact from dysfunctional thought processes. panic” or “Native American” are also plagued by
These researchers also suggest that this same the same factors and fail to appropriately segre-
quality may lead to other health issues such as gate samples to maximize internal validity and
an underappraisal of sleep disturbances related to reduce intragroup variance.
SDB and other medical concerns. This difference Asians tend to report less sleep insufficiency and
may also be one of the few preliminary studies are less likely to report feeling excessively sleepy
to examine basic cultural differences in the way as compared to their white counterparts. Asians
that various racial and age groups approach chal- also report the least sleep-related complaints com-
lenges in their lives. pared to Hispanic, black, and white populations.
Sleep-disordered breathing represents a broad Research related to genetics and culture in the
spectrum of conditions involving respiratory experience of sleep in Asians has been conducted
functions during sleep. The two most commonly as well. Compared to their white counterparts,
studied manifestations are obstructive sleep apnea Asian men who are separated, widowed, or never
(OSA) and central sleep apnea (CSA). Although married have more sleep complaints, while Asian
SDB is problematic as an independent condition, women who have lower levels of education tend
it further carries significant risks for morbidity to report the greatest sleep complaints.
and mortality. The literature on SDB is vast, but Sleep research has also been conducted with
only a select few studies have examined issues of specific groups of ethnic minorities, including
race and gender as a primary focus. women going through menopause, and children.
Measuring subjective sleepiness is another Despite Chinese women reporting lower levels
important consideration with respect to racial dif- of depression and less vasomotor symptoms in
ferences. The Sleep Heart Health Study reported comparison to the larger Chinese population as
that the mean scores on the Epworth Sleepiness well as blacks and whites, they do not have better
Scale were significantly higher for blacks com- sleep profiles, according to M. Hall et al. They
pared to non-Hispanic whites, even after con- tend to have less slow wave sleep than Cauca-
trolling for age and BMI. Although this study sian women, and Chinese and Japanese women
included a large sample size (>10,000 partici- also report more early morning awakening when
pants), it can only be considered for those over going through menopause.
the age of 40 years. The use of the Pittsburgh In regard to snoring as used to identify sleep-
Sleep Quality Index (PSQI) and Epworth Sleepi- disordered breathing, it appears that there are
ness Scale has also been recently validated for use cultural differences in how parents interpret their
among older black and white women. Continuing child’s breathing during sleep. For instance, white
to seek information regarding racial differences parents are more likely to report that their chil-
among measures of subjective sleep quality, sleep dren have noisy breathing versus snoring, while
hygiene, and responses to cognitive behavioral Asian, black, and Hispanic parents are more likely
therapy will be important to study. to report snoring. Habitual snoring appears to be
common among Chinese, Malaysian, and Indian
Asians and Native Americans children living in Singapore, as well as Chinese,
Although minimal information is available in Malaysian, and Indian children.
reference to Hispanics in regard to sleep science, Research has indicated that despite being non-
even less is available on other ethnic minority obese, Japanese, Korean, and Chinese individuals
populations. Of the literature that is available report greater obstructive sleep apnea syndrome
on groups such as Native Americans and Asians, (OSAS) and greater severity of OSAS in com-
there are often problems with research methodol- parison to Caucasian individuals. When BMI is
ogy or execution that ultimately challenge the reli- controlled for in analyses, Japanese and Cauca-
ability of the findings. For example, often studies sians present with a similar prevalence of sleep-
group Asians into one category, despite the great disordered breathing. Results also indicate that
diversity in experience, location, genetics, disease greater fat mass in Pima Indians is related to less
susceptibility, diet, health, and other factors that time in REM sleep and more time in NREM sleep
 Social Causation 809

stages in comparison to whites. Research has sup- See Also: Assessment Issues in Mental Health;
ported that obesity-related health problems occur Depression; Diagnosis in Cross-National Context;
at lower BMIs in Asian individuals. Ethnicity; Military Psychiatry; Mind–Body
Relationship; Policy: Military; Post-Traumatic Stress
Conclusion Disorder.
As the fastest-growing minority population in
the United States, there is an increased need for Further Readings
health research in the Hispanic population com- Baron, K. G., K. Liu, C. Chan, E. Shahar, R. Hasnain-
plicated by limitations in health care insurance Wynia, and P. Zee. “Race and Ethnic Variation in
coverage. Discrimination, limited language profi- Excessive Daytime Sleepiness: The Multi-Ethnic
ciency and socioeconomic status, and accultura- Study of Atherosclerosis.” Behavioral Sleep
tion are relevant aspects that need to be included Medicine, v.8/4 (2010).
because they can impact levels of stress and men- Beaudreau, S. A., A. P. Spira, A. Stewart, E. J.
tal health. Understanding cultural values will be Kezirian, L.-Y. Lui, K. Ensrud, S. Redline, S.
paramount to develop appropriate treatments in Ancoli-Israel, and K. L. Stone. “Validation of the
health-related sleep disorders. Asian individuals Pittsburgh Sleep Quality Index and the Epworth
may tend to minimize symptom severity in regard Sleepiness Scale in Older Black and White
to sleep. Using polysomnographic results, Asians Women.” Sleep Medicine, v.13 (2012).
had greater severity of illness and greater propor- Grandner, M. A., L. Hale, M. Moore, and N. P. Patel.
tions of individuals suffering from obstructive “Mortality Associated With Short Sleep Duration:
sleep apnea, but lower self-reported severity of The Evidence, the Possible Mechanisms, and the
symptoms than white counterparts. Future.” Sleep Medicine Reviews, v.14/3 (2010).
Research has been initiated by scientists inves- Silva, G. E., J. L. Goodwin, S. Parthassarathy,
tigating the relationship between sleep and eth- K. D. Vana, A. A. Dreschier, and S. F. Quan.
nicity in Asian and Native American populations, “Longitudinal Association Between Short Sleep
focused specifically on weight, gender, and age. Body Weight and Emotional and Learning
The results of this review suggest that these sub- Problems in Hispanics and Caucasian Children.”
groups are at significant risk for developing sleep- Sleep, v.34 (2011).
related problems but may be likely to minimize Song, Y., S. Ancoli-Israel, C. E. Lewis, S. Redline,
the severity of their symptoms on self-report. The S. L. Harrison, and K. L. Stone. “The Association
fact that obesity is often used as an indicator of of Race/Ethnicity With Objectively Measured Sleep
sleep-disordered breathing is problematic for these Characteristics in Older Men.” Behavioral Sleep
populations, whose BMI is often lower than com- Medicine, v.10 (2011).
parative populations. Low BMI and minimized
self-reporting may contribute to underdiagnosis
and undertreatment of sleep-related symptoms in
Asian and Native American populations.
Social Causation
Christopher Edwards
Duke University Social determinants of health inequities, that is,
W. Jeff Bryson the association of socioeconomic status with men-
Alabama Psychological Services Center tal disorder, are studied by applying the methods
Sapna Doshi of epidemiology to populations. This involves
Potomac Behavioral Solutions determining the cumulative prevalence (overall
Camela McDougald rate), as well as the differential incidence (new
B and D Behavioral Health cases) of specific noncommunicable and com-
Miriam Feliu municable diseases. The presence or absence of
Duke University Medical Center these nonmedical social determinants may either
Keith E. Whitfield be protective against disease or be risk factors
Duke University for it. For example, higher socioeconomic status
810 Social Causation

is protective from developing mental illness and disorders makes diagnosis as well as intervention
lower socioeconomic status is a risk factor for probabilistic.
it, occurring prior to the onset of mental illness. Social causation is determined through meet-
The experience of upward social mobility would ing three criteria: observing covariation, estab-
be interpreted as a possible way to reduce men- lishing temporal priority, and controlling for rival
tal illness. Social causation is understood as an explanatory factors.
explanation that may compete with social selec-
tion and social drift or may complement these Covariation
explanations in accounting for socially patterned In the simplest case, involving only two variables,
differences such as the association between socio- the two variables must covary so that a change
economic status and psychiatric disorder. in one variable is accompanied by a change in
Social causation is prominent in the study the other variable. This change can be positive
of the etiology of mental illness, positing that (direct) or negative (inverse). A positive relation-
socially patterned neighborhood, household, or ship between two variables means that as one
workplace characteristics, for example, contrib- variable increases, the other does too. A negative
ute to the development of psychiatric disorder in relationship means that as one variable increases,
individuals. Social selection seeks the etiology in the other decreases. Whether the relationship is
individuals, including biological factors, differ- positive or negative, its size (or strength) typi-
ences in motivation or ability that may be associ- cally is measured by a correlation coefficient,
ated with mental disorders, and the stigma that with larger coefficients indicating stronger rela-
accompanies being labeled mentally ill, as well as tionships. Regardless of the strength of the rela-
behavioral disorders or symptoms of mental dis- tionship between two variables, the likelihood
order that interfere with interpersonal relations in that a relationship of that strength could occur
workplaces. The related social drift explanation by chance alone must also be assessed. This
focuses on these differences in explaining down- assessment is done by means of a test of statis-
ward mobility. The downward drift in the social tical significance, with higher values indicating
structure of mentally ill persons is attributed to a greater likelihood that a relationship between
their disorder, with alcoholism, for example, two variables of a given strength could occur by
understood as a cause of unemployment. Social chance alone.
causation implies the opposite, that unemploy- Most tests of statistical significance are based
ment is a cause of alcoholism rather than simply on the assumption of a linear relationship between
an effect. the variables, that is, as one increases, the other
To study these explanations empirically, rather increases or decreases. The standard threshold for
than relying on cross-sectional data collected at statistical significance is 0.05, which indicates a
one time in a respondent’s life, longitudinal data 5 percent probability that a relationship between
is collected at different times in the same individu- any two variables of a given size could have
al’s life, or across two or more generations. In this occurred by chance alone. When a relationship
way, the relative contribution of each explanation between two variables results in a statistical sig-
in relation to specific mental disorders of varying nificance level higher than 0.05, this relationship
severity may be assessed. typically is interpreted as statistically nonsignifi-
Social causation, like social selection and drift, cant. That is, it is regarded as too likely to have
may be understood as probabilistic: once an out- been produced by chance alone to be regarded
come such as a psychiatric diagnosis based on as a real relationship between the two variables.
social determinants is identified, this almost never Variables related in a curvilinear, rather than a lin-
implies that all individuals with those characteris- ear, pattern also result in nonsignificance, unless
tics or experiences have that disorder, or even that a significance test is used that is based on the
all individuals with that disorder have those char- assumption of curvilinearity. For example, auto
acteristics or experiences. This lack of certainty accidents may be related to age in a curvilinear
that particular factors either put people at risk pattern, with the youngest and oldest categories
for having or protect them from having specific of individuals at highest risk for an accident. This
 Social Causation 811

is a starting point for a social researcher who then Rival Explanatory Factors
would need to identify the intervening variables Even in the absence of the original causal vari-
that make young and old age related to high acci- able, the intervening variable or variables are
dent rates. interpreted as causes of depression. For example,
even though gender and help seeking are related,
Temporal Priority regardless of gender, help seeking may be related
A second criterion of causation is the tempo- to rates of treated depression. A much more com-
ral priority of the variables, that is, determining plex causal ordering than that provided by either
which variable came first. To empirically investi- contributing or intervening variables is provided
gate the question of which is the cause (the inde- by antecedent variables. An antecedent variable
pendent variable) and which is the outcome or explains why the original statistically significant
the effect (the dependent variable), a hypothesis covariation occurred. It makes the causal interpre-
is formulated, specifying which variable is tempo- tation of the original two variables spurious: the
rally prior to the other. reason they are related is not because one causes
A third criterion for causation is the attempt to the other but because both are caused by a third
control for alternative explanations for a statisti- prior variable. For example, the original relation-
cally significant relationship. To establish causa- ship between education and self-reported health
tion, it must be determined whether the hypoth- may be weakened by the introduction of the ante-
esized cause of a particular effect (or event) is cedent variable of age, possibly to the point of
the only cause. This is accomplished by identi- rendering that relationship nonsignificant.
fying and measuring variables that are implied Causation is established only when all three cri-
by alternative explanations for the same event. teria (covariation, temporal priority, and control-
Alternative explanations potentially challenge ling for alternative explanations) are met. Guided
any relationship that posits a single cause for any by these tenets of scientific research, experimental
outcome. Through the analytical process of elab- scientists are able to establish causation. Most
oration, additional variables are introduced. Con- social scientists, however, do not conduct experi-
trolling for multiple potential causal influences on ments. Reasons for not conducting experiments
a variable is necessary before it is possible to con- include ethical as well as practical and financial
clude that any particular variable is the sole cause concerns. It is also not necessary to experimen-
of any outcome. tally manipulate social situations: variations in
In the simplest case, potential multiple causes causes of outcomes of interest to social scientists
of the same outcome contribute to explaining occur in society anyway. Inequalities in socioeco-
that outcome. When combined, these variables nomic status as well as inequalities in the preva-
account for some or all of the reasons why a par- lence of mental illness, for example, already exist.
ticular outcome occurs; for example, race and eth- These are among the inequalities that engage
nicity, marital status, age, socioeconomic status, social researchers, who develop their systematic
and gender may be related to clinical depression. body of knowledge by identifying, measuring,
A more complex causal sequence involves one or and monitoring data on socially patterned inequi-
more variables that intervene between the causal ties. This analysis is accomplished by statistically
variable and the outcome variable; for example, manipulating data, rather than by experimentally
help-seeking behavior may explain part of the manipulating people whose cultural, social, and
association of gender with prevalence rates of economic conditions and characteristics already
treated depression. An intervening variable such differ. Evidence for these inequities is understood
as help seeking interprets the original relationship theoretically by invoking explanations such as
between two variables, helping explain why these social causation, sometimes opposed by and
two variables, which covary at a statistically sig- sometimes complemented by social selection or
nificant level, are related to each other. The iden- drift explanations.
tification of one or more intervening variables
indicates one or more reasons why the original Brent Mack Shea
relationship exists in the first place. Sweet Briar College
812 Social Class

See Also: Depression; Help-Seeking Behavior; in poverty also contribute to understanding the
Inequality; Measuring Mental Health; Social Class; prevalence of mental illness.
Unemployment.
Conceptualizations and Measures
Further Readings of Social Class and Mental Illness
Commission on Social Determinants of Health. Evidence for the existence of social classes was
Closing the Gap in a Generation: Health Equity found in the United States in the mid-20th cen-
Through Action on the Social Determinants of tury by the reputational method, which involved
Health. Geneva: World Health Organization, asking people who lived in small communities
2008. to rank other members of their community in
Friedli, Lynne. Mental Health, Resilience, and relation to their own social status. Urbanization
Inequalities. Copenhagen, Denmark: World Health made this method impractical, and objective mea-
Organization Regional Office for Europe, 2009. sures of social class were devised. These measures
Hudson, Christopher G. “Socioeconomic Status of socioeconomic status (SES), also referred to
and Mental Illness: Tests of the Social Causation more recently as socioeconomic position (SEP),
and Selection Hypotheses.” American Journal of are based on one or, in the case of socioeconomic
Orthopsychiatry, v.75/1 (2005). status indexes, more than one status character-
Rosenberg, Morris. The Logic of Survey Analysis. istic of individuals, typically educational attain-
New York: Basic Books, 1968. ment, occupational status, or amount of income
or wealth. SES indexes, with categories that are
exhaustive and mutually exclusive (so that every-
one can fit into one and no one can fit into more

Social Class
The association of social class with mental illness
has been analyzed with consistently strong sup-
port for the inverse character of this relationship:
regardless how either social class or mental illness
is defined and measured, higher rates of mental
illness usually are associated with lower social
class. Even though diagnoses of mental illnesses
are found in people of all social classes, those in
higher classes usually have prevalence rates lower
than those in lower classes. One way to make
sense of this gradient is to regard lower class
position as a potential nonmedical risk factor for
mental illness.
Alternatively, mental illness itself may be a risk
factor for lower social class. From this perspec-
tive, either higher social class or lower rates of
mental illness can be seen as a potentially protec-
tive factor for the other. The social class–mental
illness relationship is not limited to characteristics
of individuals, even though most research on this
topic is about individuals, who are categorized in
ways that make research on large numbers pos- Two men on Canal Street in New Orleans reflect the sometimes
sible. Aggregate data for ecological or popula- striking class differences within society, May 23, 2005. Higher
tion-level variables such as the overall extent of social class or lower rates of mental illness can be seen as a
inequality in a society or the proportion living potentially protective factor for the other.
 Social Class 813

than one) are useful in studying concomitants of The most comprehensive analyses of the social
social class, such as mental illness. class–mental illness nexus include longitudinal
Another way to measure social class is to cat- data at two or more points in an individual’s life
egorize an individual as an owner, a manager, and combine that with data on the incidence of
self-employed, or an employee. Other measures mental illness for the same individuals. Panel
categorize occupations of individuals as profes- studies such as these enable researchers to observe
sional, managerial, sales, clerical, or manual possible interrelationships between mental ill-
(skilled, semiskilled, or unskilled). These con- ness and social class by studying social mobility.
ceptualizations of social class permit the cat- Yet another line of research explores the overall
egorization of individuals in relation to their extent of inequality in neighborhoods, regions, or
places in systems of social stratification, enabling nations, resulting in estimates of the association
researchers to analyze both causes and effects of of factors such as absolute poverty and mental
an individual’s class position, and mental illness illness as well as relative poverty in the midst of
can be studied as either a cause or an effect of affluence.
this class position.
Discrepant findings about the relation of social Measurements of Mental Illness and
class to mental illness may reflect differences in Associations With Social Class
the conceptualizations of social class, making Like social class, mental illness is variously defined
research results difficult to compare. However, and measured. Clinical diagnoses of mental disor-
when the same pattern persists over decades, even ders typically are made on the basis of whether a
in different populations that are sampled by dif- patient meets enough of the criteria for a particu-
ferent methods and using different conceptual- lar disorder to qualify for that specific diagnosis.
izations and measures of social class and mental These symptoms of specific mental disorders are
illness, the accumulated evidence is convincing. delineated in the many editions of the Diagnostic
For example, August Hollingshead and Freder- and Statistical Manual of Mental Disorders (DSM)
ick Redlich’s landmark study of social class and of the American Psychiatric Association and the
mental illness in New Haven, Connecticut, used International Classification of Diseases (ICD)
an index of social class based on an individual’s of the World Health Organization. In order to
occupational status, years of education, and area study mental illness in large samples of untreated
of residence. populations in the community, the DSM criteria
A study coauthored by Charles Holzer and his were adapted in the Diagnostic Interview Sched-
colleagues, also at Yale, almost three decades later ule (DIS) for use in field interviews conducted by
analyzed the socioeconomic status of approxi- nonclinicians, such as the ECA project.
mately 18,000 Epidemiologic Catchment Area Much of what is known about the class-related
(ECA) community interview respondents with an rates of mental illness in the community is based
index based on the average of U.S. Census per- on surveys that use either the DIS or the Com-
centiles for education, occupation, and household posite International Diagnostic Interview (CIDI),
income. Both studies found the greatest risk of designed according to the definitions and criteria
having a mental disorder is in the lowest socio- of the ICD. Either survey results in a dichotomous
economic category; the risk is not simply linearly disorder/no disorder categorization of respon-
related to SES. The relation of SES to mental dents in relation to specific disorders. In some
disorder varied among specific disorders in both studies, disorders are aggregated in a global vari-
studies, with the highest prevalence of schizo- able that permits comparisons of individuals meet-
phrenia, the most serious disorder, also found in ing criteria for one or more disorders with indi-
the lowest SES category. In both studies, com- viduals meeting criteria for none. In analyses of
pared to schizophrenia, major depression was not these survey data, the social class of an individual
as strongly related to SES, with prevalence rates can be studied in relation to the presence of one
of mood and anxiety disorders being much more or more mental disorders characterizing that indi-
similar across SES categories, sometimes slightly vidual. Analyses of the relative effect of various
higher in upper than lower categories. components of social class (usually occupational
814 Social Class

status, years of education, or amount of personal in relation to mental disorder that is conceptu-
or family income or wealth) on rates of specific alized not as a global variable but as separate
mental disorders are useful in understanding their disorders. For example, cognitive impairment is
socially patterned prevalence. When SES indeces very strongly related to SES, with individuals in
are used rather than individual components, it is low SES categories having much higher rates than
more difficult to determine what it is about over- those in high SES categories. Cognitive impair-
all social class that is associated with a mental ment is so strongly related to SES that some con-
illness. Income-based and wealth-based compo- cepts of overall mental disorder omit it because
nents of SES seem to be especially important. including it would overestimate the contribution
The association of social class with mental ill- of SES to the overall prevalence of mental dis-
ness is analyzed in both descriptive and explan- order. By analyzing the components of SES, it is
atory research. Descriptive research presents possible to see that education is the most impor-
the sociodemographic characteristics of survey tant component accounting for the SES–cognitive
respondents, including indicators of their socio- impairment relationship.
economic status but also ascribed characteristics
such as race/ethnicity, age, and gender. Explana- Mitigating Social Inequity and
tory research on social class and mental illness Intervening Variables
often studies population subgroups categorized The persistence of the social class–mental illness
by ascribed characteristics in order to explore pos- gradient can be understood as a social struc-
sible differences. For example, the higher preva- tural health inequity. It is difficult for a person to
lence of mental illness among Hispanic and black change their social class, especially for individuals
persons is explained by both SES and race. Their without the work-related skills acquired through
lower SES would be expected to be associated with education, training, and experience. However,
higher prevalence of mental illness. In the United health behaviors can be modified by individu-
States, being black or Hispanic is an additional als who have accurate information about them.
risk factor for mental illness beyond SES. Availability of health care plans or employee
Some studies pursue the issue of directional- assistance programs can increase the likelihood
ity of the social class–mental illness relationship of diagnosis and treatment. Changes in the social
by observing individuals at more than one time organization of workplaces can mitigate factors
and getting data on both SES and mental disor- affecting the health and safety of those who work
der each time. This research yields data suitable in them. The chronic environmental stress cre-
for addressing the questions of whether the social ated by uncomfortable or dangerous workplaces
inequities of class affect mental illness (social can be addressed by government regulators and
causation), whether the symptoms of mental ill- employers. Beyond that, the chronic economic
ness affect one’s social class (social selection), or stress that accompanies underemployment (typi-
whether both of these processes occur in an indi- cally temporary, part-time work, often below
vidual’s life. Social causation formulations con- one’s education or skill level) presents problems
sider social class as a social determinant of health that might be met at least in part through govern-
inequities such as differential rates of mental ill- ment safety net programs.
ness, sometimes including class-specific social- Analyses of data on the social class–mental ill-
ization differences in this explanation. Social ness association sometimes incorporate interven-
selection formulations, which seek the etiology ing variables such as stress that is experienced
of mental illness in the individual, can include as distress. Additional intervening variables
factors such as genetic endowment, ability, or such as life events can also be a potential result
motivation. Social selection can imply a down- of social class as well as a cause of mental dis-
ward drift in occupational status that is related to order. Life events or other environmental and
behaviors interfering with interpersonal relations economic stressors may be buffered by social
in the workplace. support, potentially reducing the distress expe-
Social class may be analyzed by each of its rienced by individuals. However, social support
components (education, occupation, and income) functions of families of unemployed workers may
 Social Control 815

be compromised by the loss of income, and unem- Economic Stress and Social Support.” Journal of
ployed people experience distress that can result Health and Social Behavior, v.19 (1978).
in depression, anxiety, or anger and hostility that Price, Rumi K., Harsha N. Mookherjee, Brent M.
may be internalized or directed toward others. Shea, and Sebastien Reichman. “Sociology’s
Neighborhoods are also differentially affected by Contribution to the Study of Mental Health.”
sources of environmental and economic stressors, Partners for Mental Health: The Contribution of
including unemployment and underemployment Professionals and Non-Professionals to Mental
but also by air and water pollution, noise, crime, Health. Geneva: World Health Organization,
and discrimination. Segregation of residential 1994.
areas by social class increases the probability of Wilkinson, Richard and Kate Pickett. The Spirit
mental illness resulting from or precipitated by Level: Why Greater Equality Makes Societies
these factors, which may be independent of the Stronger. New York: Bloomsbury Press, 2009.
SES characteristics of individual residents.
The extent of overall economic inequality in a
society is itself a risk factor for mental illness and
appears to account for some of the variation in
prevalence rates of mental illness among nations. Social Control
Increases in the average family income in a soci-
ety may help reduce the prevalence of mental ill- Social control consists of the resources and mech-
ness. Reducing the proportion of people in a soci- anisms by which members of society attempt to
ety who live in poverty in the lowest social class assure the norm-conforming behavior of oth-
may be even more effective in reducing the overall ers. There are three basic types of social control,
prevalence of mental illness. although in the real world, the three forms com-
bine in sometimes complex ways. The three forms
Brent Mack Shea of control amount to a range of normative pre-
Sweet Briar College scriptions and proscriptions covering the areas of
interpersonal relations and group living (informal
See Also: Economics; Environmental Causes; control), the law and legal systems (legal control),
Inequality; Mental Illness Defined: Psychiatric and behavior more generally, irrespective of the
Perspectives; Social Causation; Social Control; Social nature of the ties between persons in interaction
Isolation; Stress; Unemployment; Vulnerability; (medical control). These three areas of the human
Welfare. experience—relationships, law, and behavior—
have three respective systems of control.
Further Readings
Duncan, Greg J., Mary C. Daly, Peggy McDonough, The Three Types of Social Control:
and David R. Williams. “Optimal Indicators Relationships, Law, and Behavior
of Socioeconomic Status for Health Research.” For most of human history, informal control pre-
American Journal of Public Health, v.92 (2002). vailed, namely, self-help. Informal control is the
Hollingshead, August and Frederick Redlich. Social stuff of socialization, of living in groups, of asso-
Class and Mental Illness: A Community Study. ciating with other human beings, however inti-
New York: John Wiley, 1958. mate or socially distant they may be. The key here
Holzer, Charles E. III, Brent M. Shea, Jeffrey W. are those norms and values embedded in the cul-
Swanson, Philip J. Leaf, Jerome K. Myers, tural horizons of everyday life that provide stocks
Linda George, Myrna M. Weissman, and Phillip of knowledge and guidance for day-to-day living,
Bednarski. “The Increased Risk for Specific which steer persons (ideally) toward conforming
Psychiatric Disorders Among Persons of Low behavior and away from deviant behavior.
Socioeconomic Status.” American Journal of Social A second basic type of control emerges with
Psychiatry, v.6 (1986). the growth of human populations and the rise
Liem, Ramsay and Joan Liem. “Social Class of the state. As Max Weber argued, states are a
and Mental Illness Reconsidered: The Role of type of political authoritarian association that
816 Social Control

hold monopoly over the legitimate use of coercive sanctions wherever they appear. For example,
force over some designated territory, assigning a person who is known as a gossip may not be
specific agents of formal control (e.g., police) to invited to a neighborhood party. A person who
ensure compliance of the citizenry with statutes steals may be fined or imprisoned. On the other
as promulgated by lawmaking bodies. This type hand, as Talcott Parsons argued with regard to the
of control, predominant across modern Western “sick role,” persons who are ill are placed under
society, is legal. custodial care with therapy or treatment in mind,
A third type of social control hinges on notions rather than punishment. Most of the time, when a
of propriety regarding normal or sane behavior. It person is hospitalized for a physical illness, medi-
is not illegal, for example, to talk to yourself, be cal tests are conducted that discover some prob-
shy or nontalkative, or to have wild mood swings. lem that gave rise to the pathological or disvalued
However, these are considered abnormal or irra- condition. This is Wakefield’s second condition,
tional on some level. These types of problems, internality. This means that the observed disorder
often emerging in everyday life, may be seen as is because of some internal dysfunction within the
so disruptive, strange, unnerving, or even threat- individual. But unlike medical tests and proce-
ening that they may call forth agents of medical dures that are accurate enough to uncover a prob-
control, that is, doctors or nonmedical personnel lem with regard to physical illness, it is often the
(e.g., counselors or managers in employee rela- case that there is no verifiable evidence of internal
tions programs) who place such persons into their pathology with regard to mental disorders. As
care. Medical care is basically custodial care, not Wakefield argues, in the case of mental disorders,
for the sake of punishment (as is the case for pris- it is far too easy to assume that disvalued condi-
ons), but rather for the sake of treatment or ther- tions are generated by internal pathologies, when
apy. In this sense, medical control may be seen as in fact the evidence of this internality is either
a stopgap that picks up odd cases that cannot be elusive or never shown to exist according to the
adequately handled by the methods of self-help in guidelines of empirical science.
everyday life but that simultaneously do not (typi- The implication for mental disorders, then, is
cally) rise to the level of legal culpability. that in close calls where a clinician is facing a dis-
In the 1950s and 1960s, pioneers of the antipsy- valued condition meeting some or all of the noso-
chiatry movement such as Thomas Szasz, Erving logical guidelines of the Diagnostic and Statistical
Goffman, and Thomas Scheff argued that beyond Manual of Mental Disorders (DSM), he or she
a purely scientific or technical orientation toward is apt to treat that person as ill. This is a form
identifying illnesses with the aim of curing them, of Type II error, treating a well person as if he
mental illnesses were often merely labels applied to or she were sick, thereby producing a number of
social deviance. These critics asked: What do we false positives and contributing to the problem of
gain beyond the informal, everyday sanctioning of medicalization. The production of such false posi-
certain behaviors that are deemed weird, strange, tives within mental health evaluation leads to the
or inappropriate? What is gained by applying suspicion that rather than identifying and treating
medical labels or orientations to disturbances aris- bona fide mental disorders, the concept of mental
ing in everyday life? Why and under what circum- illness serves more of a social control function.
stances do medical notions of illness come to the
fore whenever such behaviors present themselves? James J. Chriss
Jerome Wakefield has argued that the concept Cleveland State University
of mental disorder must satisfy two conditions
simultaneously, disvalue and internality. The dis- See Also: Antipsychiatry; Antisocial Behavior;
value condition refers to judgments made that a Deviance; Law and Mental Illness; “Normal”:
particular behavior, structure, or process in soci- Definitions and Controversies; Peer Identification.
ety is harmful to some persons, groups, or soci-
ety more generally. Disvalued conditions show up Further Readings
across the spectrum of social control, and they Chriss, James J. Social Control: An Introduction. 2nd
are met with an array of punishments or negative ed. Cambridge, UK: Polity, 2013.
 Social Isolation 817

Wakefield, Jerome C. “False Positives in Psychiatric overall mortality. Social isolation in adolescence
Diagnosis: Implications for Human Freedom.” is associated with an increased risk for depressive
Theoretical Medicine and Bioethics, v.31/1 (2010). symptoms, suicide attempts, and low self-esteem.
Wakefield, Jerome C. “Values and the Validity of It is still not entirely clear how social isola-
Diagnostic Criteria: Disvalued Versus Disordered tion affects health. Early attention focused on
Conditions of Childhood and Adolescence.” In the potential role of social connections in pro-
Descriptions and Prescriptions: Values, Mental moting social control of health behaviors—the
Disorders, and the DSMs, J. Z. Sadler, ed. idea that friends and family encourage people to
Baltimore, MD: Johns Hopkins University Press, sleep, eat, and exercise well, among other behav-
2002. iors. Social contacts may also provide informa-
tion about health and help out during an illness.
Another idea is that people tend to select men-
tally and physically healthy friends (and friends
with health-promoting psychological profiles and
Social Isolation behaviors) so that rather than isolation leading to
poor health, people in poor health have difficulty
Social isolation is the phenomenon of sharing attracting friends. Neither of these ideas (social
little or no contact with other people. Social iso- control or positive selection) is strongly supported
lation may also be perceived when a person feels by research findings as major contributors to the
excluded from the surrounding social group. social isolation effect on health.
Sometimes social interaction does not decrease Also, social isolation has been shown to influ-
loneliness, and an individual may experience ence health, even in nonhuman species in captiv-
social stress rather than support in a relation- ity when they have little control over their health
ship. A sense of social isolation that occurs when behaviors. This suggests a more direct influence
the person is experiencing social contact, but not of social relationships on how the body func-
in the desired amount, or which is temporary, is tions, likely by influencing physiological regula-
often called loneliness, rather than isolation. tion and stress processes. Thus, the consensus in
People may be isolated involuntarily or because the research has shifted to emphasize the role of
they retreat into silence and their homes. Vol- social connectedness both in reducing the nega-
untary social isolation may result from various tive effects of stress on health through improved
mental health conditions, such as agoraphobia or coping and in better recovery from existing health
depression. Social stigma because of social identi- problems. Socially isolated individuals report
ties, mental health issues, physical disability, and greater reactions to stressors and more difficulty
other conditions can make it difficult to socially recovering. They heal more slowly and have
engage. worse sleep quality.
Often, specific negative life events such as the
death of someone close or another traumatic expe- Current Importance
rience may trigger one to withdraw from social Social isolation is taking on new importance as a
contact. Thus, isolation tends to be self-perpetu- contributor to health in recent decades because of
ating. How individuals perceive their social lives increasing longevity, changes in how people live,
matters, too; those who see themselves as more and changes in how people interact. As life expec-
isolated are at greater risk. Perceived social isola- tancy in the United States approaches 80 years,
tion is called loneliness. The perception of loneli- more people are living with functional limitations
ness is comparative; people in more densely con- or cognitive decline, or on low, fixed incomes.
nected communities expect more social contact. Increasing migration means that families often
Social isolation is not just a possible conse- live farther apart than in the past, and neighbors
quence of mental health issues but is also a risk may not know each other well enough to visit the
factor for poor mental and physical health. Long- elderly. Many people who live alone are not iso-
term social isolation has been associated with a lated because they enjoy close social connections
variety of mental and physical conditions and outside the home, even people who live in dense
818 Social Security

quarters may not have fulfilling social contacts. Cacioppo, J. T., L. C. Hawkley, G. J. Norman, and
However, living alone can be particularly isolat- G. G. Berntson. “Social Isolation.” Annals of the
ing for those whose mental and physical health New York Academy of Sciences, v.1231 (2011).
or cognitive functioning limits their ability to seek Kawachi, I. and L. F. Berkman. “Social Ties and
interaction outside the home or online. Older Mental Health.” Journal of Urban Health, v.78/3
adults, without children or family, are particularly (2001).
at risk. The increased risk of dying when socially McPherson, M., L. Smith-Lovin, and M. E. Brashears.
isolated is one reason why when one partner dies, “Social Isolation in America: Changes in Core
the other partner’s likelihood of dying increases. Discussion Networks Over Two Decades.”
The benefits of social ties for mental health American Sociological Review, v.71/3 (2006).
vary by gender. Women report greater psycho-
logical distress, and much of this is attributable
to gender differences in social networks. On aver-
age, women’s social ties are emotionally closer
and also more helpful in times of stress. In older Social Security
adults, ties tend to be same-gender, and women
provide more frequent and more effective social The U.S. Social Security Administration (SSA)
support to others than men. pays cash benefits to millions of Americans based
Overall, the average number of close friends on two main chapters or titles of the Social Secu-
reported by Americans is down from 2.94 in rity Act. Title II benefits (traditional Social Secu-
1985 to 2.08 in 2004. Along with this decline in rity benefits) are financed and paid based on a
the average number of friends, the proportion of worker’s connection to employment under the
adults living alone has also been increasing, from U.S. payroll tax system. Title XVI benefits (Sup-
22 percent in 1950 to 50 percent in 2010. Many plemental Security Income, or SSI payments) are
social observers are concerned that Americans financed through general tax revenues and are
today are less likely to belong to clubs and orga- paid on a means-tested basis to individuals with
nizations, regularly attend religious services, and very low income and very few assets. Both sys-
engage in other formal activities that provide easy tems make payments connected with disability or
access to social ties. Others believe that social attainment of a qualifying age. Eligibility for cash
engagement is not declining, but that new ways of benefits often connects with health care benefits
interaction are evolving. For instance, the emer- under the Medicare or Medicaid programs. The
gence of online communities dedicated to sharing two systems are governed by a complex set of
the experiences of living with particular health statutes and regulations, which have changed and
problems has not only helped patients and fam- evolved through amendment and judicial inter-
ily members to access health information but has pretation during the past 75 years.
also created for some a sense of connection with a
broader community. Social Security (Title II) Benefits
and the Social Insurance Model
Katherine King The Social Security Act became law in 1935, part
Duke University of President Franklin Delano Roosevelt’s New
Deal. Financed through tax payments withheld
See Also: Life Skills; Marital Status; Neighborhood from workers’ wages and matched by employer
Quality; Peer Identification; Social Control; Stigma; contributions, the first monthly payments were
Stress; Women. issued to retired workers in 1940. In the years that
followed, Social Security’s Title II benefit categories
Further Readings expanded. In addition to retirement benefits, pay-
Berkman, L. F., Thomas Glass, Ian Brissettec, and ments became available to dependents of retired
Teresa E. Seeman. “From Social Integration to workers and survivors of deceased wage earners.
Health: Durkheim in the New Millennium.” Social In the 1950s, Social Security benefits became avail-
Science and Medicine, v.51/6 (2000). able to disabled workers and their dependents.
 Social Security 819

Social Security’s Title II benefit programs oper- provides cash benefits to people who are age 65
ate on a social insurance model, designed to meet or over, blind, or disabled, who have very limited
broad social objectives, yet maintain a sense of income and resources. Payments are also affected
dignity for benefit recipients. Because workers by the recipient’s living arrangement.
pay into the system, they are said to be entitled to In 2011, the maximum federal SSI payment for
benefits they paid for and are not receiving wel- an individual living alone was $698 per month.
fare or relief payments or any form of charity. Eli- Recipients living in another person’s household
gibility and payment are based on the amount of received a reduced payment of $465. People liv-
a worker’s covered earnings, without regard to a ing in certain Medicaid-paid institutional arrange-
person’s assets or income from pensions or invest- ments received only $30 per month. An individ-
ments. In some cases, a person’s earnings from ual’s SSI payment is computed by reducing the
work affect eligibility. maximum payment by the amount of the person’s
The connection to payroll tax contributions is other countable income. Resources (meaning
so strong that people sometimes think that they assets, or the things that people own) over certain
are paying into an individual account, whose set amounts may also make the person ineligible
investments fund benefits, but that is not the case. for SSI. If a person has countable assets totaling
The system is actually funded on a pay-as-you- over $2,000, the person will not be eligible for
go basis. Taxes from current workers pay for the SSI. For a couple, the resource limit is $3,000.
benefits to current retirees. Not every asset or payment counts against
To qualify for Social Security Disability Insur- a person for SSI purposes. Some payments or
ance (SSDI) benefits, a person must have worked asset types are excluded by law or regulation.
and paid payroll taxes long enough to be covered Friends and relatives can substantially improve
by Social Security. A substantial amount of the an SSI beneficiary’s situation by contributing
work must be close in time to the onset of disabil- in ways that do not affect a person’s payment.
ity. These earnings requirements vary with a per- Income and resource exclusions are set out in
son’s age, but most individuals must have worked administrative regulations or based on case law
for 10 years total, with five years of coverage and are reflected in SSA’s online Program Opera-
within the 10 years prior to onset of disability. tions Manual System. Eligibility for SSI benefits
The SSDI payment amount is based on a work- connects with eligibility for Medicaid, a health
er’s lifetime average earnings covered by Social insurance program jointly funded by the federal
Security. The average payment to a disabled government and the states.
worker in 2012 was $1,111 per month. If a dis-
abled worker has a qualifying spouse and chil- Disability Determinations
dren, the family can receive an additional 50 to Claimants must meet a strict definition of disabil-
80 percent of a worker’s benefit. These are aver- ity to qualify for SSDI or SSI benefits. Adult claim-
ages. The amount of an SSDI payment is generally ants must be unable to engage in any substantial
not affected by the amount of other income or work, based on a medical condition expected to
savings that a person has, although earnings from result in death or last more than a year. Children
employment affect benefits. under age 18 are considered disabled if they have
Eligibility for Social Security Title II benefits marked and severe functional limitations from a
connects with eligibility for Medicare, a federally health condition expected to result in death or last
funded health insurance program. more than a year. The SSA’s disability requirements
differ from those of other federal and state pro-
Supplemental Security Income (Title XVI) grams. The agency is not required to accept a diag-
Benefits and the Welfare Model nosis or evaluation from the claimant’s doctor or
SSI payments began in 1974, authorized by Title from any other agency. TheSSA uses a sequential
XVI of the Social Security Act. SSI is a welfare- evaluation process to decide if a person is disabled.
style, means-tested program. It is a federalized A person must not be working and must have a
version of three New Deal welfare programs severe condition that limits the person’s ability to
formerly administered by state governments. SSI do past work or other work in the U.S. economy.
820 Social Support

The SSA may require people with mental illness are afraid to try because of concern that their ben-
to show evidence of repeated lengthy episodes of efits might stop, especially their health insurance.
decompensation, or inability to function outside a
highly supportive living arrangement. Paul Komarek
SSA personnel assist claimants in securing exist- Independent Scholar
ing medical records and may schedule claimants
for supplemental medical examinations or test- See Also: Health Insurance; Medicare and Medicaid;
ing. Case reviewers in state-run Disability Deter- Policy: Federal Government; Welfare.
mination Service offices make decisions based on
the medical records on file. Further Readings
Claimants who are denied benefits may Drake, R. E., J. S. Skinner, G. R. Bond, and
appeal. There are several levels of appeal. The H. H. Goldman. “Social Security and Mental
first step is reconsideration of the ruling, which Illness: Reducing Disability With Supported
takes place within the office that made the initial Employment.” Health Affairs, v.28/3 (2009).
determination. Frank, Richard G., Howard H. Goldman, and
If the claim is still denied, claimants may Michael Hogan. “Medicaid and Mental Health: Be
request a hearing before an administrative law Careful What You Ask For.” Health Affairs, v.22/1
judge. Because Social Security limits the discre- (2003).
tion of decision makers at initial and reconsidera- Social Security Administration. “Annual Statistical
tion levels, this hearing stage is where an unsuc- Report on the Social Security Disability Insurance
cessful claimant may first reach someone with the Program, 2011.” Washington, DC: Social Security
authority to render a favorable decision. This level Administration, 2011.
is especially important for persons with multiple
impairments whose effects should be considered
together. The hearing is also the point at which
many attorneys make their first appearance in the
SSA’s process. If a claim is denied at hearing, a Social Support
claimant may ask for a review by Social Security’s
appeals council, and, if still unsuccessful, may People do not live in isolation from one another;
bring a civil suit in federal court. instead, people are shaped by and shape their
Claimants who believe that they have a valid social environments. These social environments
claim for benefits should continue to pursue affect both mental and physical health, and one
appeals in a timely fashion. Claimants may have key aspect of social transactions are instances of
an attorney or other person represent them in giving and receiving social support. The idea that
claims for benefits. The amount of fees an attor- social relationships may be good for health is not
ney can charge is regulated by the SSA. new; strains of it flow from the book of Gene-
Some people who receive SSI or SSDI benefits sis when the Lord says, “It is not good that man
are not able to safely manage their finances. In should be alone; I will make him a helper compara-
those cases, the Social Security office may appoint ble to him,” to the writings of influential thinkers
a friend, relative, or other person to handle the SSI such as Aristotle, Émile Durkheim, Martin Buber,
or SSDI benefits. Some people prefer to have their and Sigmund Freud. Social scientific research on
representative payee be someone who works for a the association between social relationships and
local social service organization. Payees must be health proliferated in the 1970s, and the topic
able to account for how they handled funds. continues to be widely studied. Social relation-
People who have been certified eligible for ships have been found to be important predictors
SSI or SSDI are allowed to work (within certain of both mental and physical health outcomes, and
limits) without losing benefits. However, if they in fact, having poor social relationships decreases
exceed the earnings limit, they could lose their SSI survival likelihoods as much as traditional health
or SSDI income and Medicaid or Medicare. Many risk behaviors (e.g., smoking, physical activity,
people with disabilities would like to work but and obesity) and indicators (blood pressure). This
 Social Support 821

research suggests that positive relationships are whether one or the other is a better predictor of
good for both mental and physical health. mental health outcomes. Thus, each type of social
When specifically focusing on the relation- support is separately summarized for clarity.
ship between social support and mental health,
the research literature suffers from disagree- Receiving Social Support
ments about definitions, and also tends to focus The earliest form of received support stems from
on received social support when definitions con- parental caregiving. Parents help to shape infants’
verge. However, the day-to-day experiences of perceptions and beliefs about the availability and
social relationships involve both receiving social reliability of social partners in providing for their
support and giving it. Thus, social support can needs. These perceptions and beliefs are the basis
be defined as believing that others will provide of infants’ attachment styles, which have later
practical (e.g., money, errands, and childcare) implications for their ability to bond and form
and emotional support when needed (perceived close relationships. Attachment theorists posit that
support), receiving such support (received sup- infants who receive timely care that is matched to
port), and giving such support (given support). their level of need will develop secure attachments
In addition, structural support can be considered with their mothers (or other primary care givers),
the frame where such interactions take place (e.g., which in turn will be applied to other future rela-
number of relationships, frequency of contact, and tionships. Those who receive inconsistent care, or
strength and quality of bonds). Since both receiv- whose parents are distant and unavailable, will
ing and giving social support are confounded in develop insecure attachments (preoccupied and
the context of social relationships, it is unclear dismissing, respectively), which will negatively

With support from the United Kingdom’s Humanitarian Aid and Civil Protection department, Christian Aid and its partner,
Organisation for Eelam Refugees’ Rehabilitation, assist women in a Sri Lankan refugee camp in setting up social support and self-help
groups to address concerns such as gender violence. Counselors regularly provide psychosocial support to victims of gender violence.
Social relationships have been found to be important predictors of mental health outcomes.
822 Social Support

affect later relationships. Attachment styles func- However, these programs show remarkable effec-
tion like a lens through which children, and later tiveness because they address the social isolation
adults, view their social world such that even in and stigma that people experience while men-
the presence of actual social support, some indi- tally ill (e.g., the clubhouse model and Fountain
viduals may have trouble noticing or accepting it House).
because of formative developmental experiences. There is much research suggesting that simply
The bulk of research on the mental health subjectively perceiving the availability of social
effects of received support leans toward positive support is related to good mental health. For
effects. However, these studies are often cross- example, people who believe that others would
sectional (correlational) or prospective (longitu- be there for them if needed are better at coping
dinal), and thus it is difficult to know whether with stress and illnesses. However, it is unclear
and how recipient need plays a role. For example, whether mentally and physically healthier people
people who are at risk for mental health issues create better social networks, whether they are
(e.g., have just experienced a significant loss or better at believing that they have social support
trauma) may be more likely to receive social sup- (i.e., they are more optimistic), or whether such
port because their need is obvious. In these cases, beliefs actually cause better mental and physical
studies might find that the presence of received functioning.
social support is “bad” for one’s mental health, In terms of actually receiving social support,
but this might be explained by the fact that people the research literature is mixed. Some studies have
who need more support to begin with may actually found that people who have much available social
receive more support. Issues of status and power support feel more depressed, guilty, and depen-
also complicate the relationship between received dent. Some research even finds that those who
support and mental health, such that relatively receive more social support are more likely to
lower-status people (e.g., low socioeconomic sta- die several years later, even when controlling for
tus) may be seen as needing more social support baseline demographic and health variables. So the
by higher-status people, regardless of their actual receipt of social support is not always associated
needs. In those cases, offers of social support (or with better mental and physical health. However,
social services) might be spurned, or if they are many studies have found the opposite: being the
accepted, they may actually lead to poorer mental recipient of social support is associated with bet-
health in terms of a lower sense of independence, ter mental (e.g., depression) and physical health
self-esteem, and self-efficacy or mastery. (e.g., lower mortality risk).
In addition, people who are currently mentally Overall, meta-analytic integrations of the litera-
ill (e.g., depressed) might report not having much ture suggest that there are small benefits to receiv-
social support, which may lead to the conclusion ing social support, but that they depend on a num-
that low social support causes mental illness (e.g., ber of factors. Such benefits have even been found
depression). It may conversely lead to the conclu- in the presence of received social support via video
sion that the presence of social support protects messages. Because individuals do not always ben-
people from mental illness. For example, some efit from receiving social support, it is important
research finds that women who are not in com- for practitioners to consider such factors before
mitted relationships have over nine times the risk recommending that people receive more social
of depression than women in committed relation- support to alleviate their mental health issues. For
ships. However, it could be that people with men- example, gender norms must be taken into con-
tal illnesses, such as these women, have become sideration when predicting potential benefits of
alienated from their family members, partners, receiving social support. Males who hold gender-
and friends because of their illness, but otherwise stereotypical or traditionally masculine beliefs are
had strong social networks in the past. less likely to benefit, and may even be harmed by,
Psychosocial rehabilitation approaches to men- overt social support gestures. Other research has
tal illness cannot distinguish between giving and confirmed that more overt forms of providing
receiving social support because they involve support can be damaging because they undermine
community living and cooperative participation. recipients’ views of themselves as competent and
 Social Support 823

independent. Givers trying to maximize mental actual giving behaviors from other confounding
health benefits in recipients should be aware of contexts to best unpack potential mental health
these issues and provide more subtle supportive effects of giving. In the rare studies that have done
gestures. One other effective way for support giv- so, researchers have found that the more caregiv-
ers to minimize recipient harm is to be willing to ers actually help the recipient, the more positive
receive support in return and thus equalize the emotions they feel. But being on call at all times of
relationship dynamics. the day or night is especially toxic for caregivers.
Meta-analytic integrations of the caregiving lit-
Giving Social Support erature find that caregivers on average suffer from
Although social support is most often conceptual- increased physiological and psychological prob-
ized as received support, an emerging literature lems related to stress (e.g., high stress hormones).
examines the relationship between giving support However, there are some factors that seem to be
and mental health. One point to consider is that protective when it comes to caregiving. For exam-
people who are already mentally healthy might ple, male care givers function better than female
find it easier to give. So, it is important to con- ones, and this might be because they have lower
sider people’s initial mental health when examin- caregiving burdens and more financial resources.
ing the effects of giving support on later mental Similarly, Caucasians and younger caregivers suf-
health outcomes. As with receiving support, the fer fewer negative consequences from caregiving
literature on this topic is mixed. compared to ethnic minority groups and middle-
On one hand, many studies find that giving sup- aged caregivers.
port is linked with mental health benefits. People According to such meta-analyses, the fewer
who give social support are happier, have higher hours of care given, the fewer caregiving behav-
self-esteem, and are less lonely, results that are iors, the less impaired the recipient of care, and
found in both cross-sectional and prospective stud- the more financial resources available, the better
ies. In addition, studies that experimentally exam- the outcomes associated with caregiving. This is
ine the effects of giving support have found that it one situation when received social support makes
leads to higher well-being and lower depression. a positive difference. Overall, the best mental
However, in some circumstances, givers feel bur- health outcomes associated with caregiving occur
dened, frustrated, or exhausted, especially when when caregivers are able to experience some dis-
recipients make too many demands, have unsolv- tance from the recipients, whether this means
able or difficult problems, or do not give back. the ability to imagine the recipients’ experiences
Such negative responses to giving are best doc- without getting caught up in emotional distress
umented in two research literatures. First, the lit- or whether this means having time off to talk to
erature on caregiving (in older adults or disabled others or care for oneself.
children) generally finds negative effects associ- Research on people who give as part of their
ated with being primarily responsible for the daily full-time occupations (e.g., doctors, psychologists,
living activities (e.g., bathing, dressing, and eat- social workers, and corrections professionals) finds
ing) of spouses, children, or other family mem- parallel results. These individuals often experience
bers who have illnesses or functional limitations “compassion fatigue” while caring for others who
(e.g., because of a stroke, dementia, or develop- are in emotional or physical pain. Compassion
mental disability). Such caregiving behaviors are fatigue that is chronically experienced without
qualitatively distinct from other support-giving refueling can lead to depression, substance abuse,
behaviors because they involve seeing loved ones and post-traumatic stress disorder. Similar prin-
in distress, they are often nonvoluntary, and they ciples apply in the caregiving and the compassion
exist at a higher level of giving intensity in terms fatigue literature, with more intensity associated
of time, energy, and financial resources. In fact, with worse outcomes, and with the importance of
many situations involve 24-hour caregiving and caring for oneself apparent.
power-of-attorney over financial and medical
matters, both of which are difficult and stress- Sara Konrath
ful. Thus, researchers must attempt to tease apart University of Michigan
824 Sociopathic Disorders

See Also: Care, Sociology of; Family Support; of social and early learning experiences; this dis-
Integration, Social; Marital Status; Neighborhood suades the perspective that internal (such as psy-
Quality; Social Isolation; Stress. chological and biological) processes are involved.
“Antisocial personality” is a diagnostic label
Further Readings described in the American Psychological Associa-
Figley, C. Compassion Fatigue: Coping With tion’s fourth edition of the Diagnostic and Sta-
Secondary Traumatic Stress Disorder in Those tistical Manual of Mental Disorders (DSM-IV),
Who Treat the Traumatized. Philadelphia: which indicates a cluster of primarily behavioral
Brunner/Mazel, 1995. symptoms that reflect a pathological degree of
House, J., K. Landis, and D. Umberson. “Social social deviance. The term psychopathy indicates
Relationships and Health.” Science, v.241/4865 a group of affective/emotional, interpersonal, and
(1988). behavioral symptoms believed to be the result
Konrath, S. and S. L. Brown. The Effects of Giving of psychological, biological, and genetic factors.
on Givers. In Handbook of Health and Social The individual in question represents the psycho-
Relationships, N. Roberts and M. Newman, pathic personality and exemplifies the interaction
eds. Washington, DC: American Psychological between the internal and expressed components
Association, 2012. of psychopathy.
Post, S. G. Altruism and Health: Perspectives From
Empirical Research. New York: Oxford University Measuring Psychopathy
Press, 2007. A general understanding of the concept of psy-
Scheid, Teresa A. and Tony N. Brown. A Handbook chopathy is insufficient to ensure uniformity in
of the Sociology of Mental Health: Social Contexts, its definition. For instance, conceptualizations of
Theories, and Systems. Cambridge: Cambridge psychopathy in clinical or forensic settings may
University Press, 2009. vary considerably from empirical definitions used
for research purposes. In this way, current knowl-
edge of psychopathy as a construct and how it
relates to similar characteristics in different cul-
tures is limited by the consistency with which it
Sociopathic Disorders is measured.
The development of a variety of assessment
Picture an individual whose personality is char- tools aimed at identifying the psychopathy con-
acterized by selfishness, a coldness toward others, struct has assisted in standardizing a description
and deficient affective experience, which is reflec- of psychopathy. The Hare Psychopathy Checklist,
tive of a lack of remorse, shallow affect, lack of Revised (PCL-R) is a familiar tool among many
empathy, and failure to accept responsibility for researchers, clinicians, and forensic psychologists.
one’s own actions. This individual may present This 20-item instrument integrates information
with a superficial charm that they use to manipu- from a semistructured interview with collateral
late others for personal gain. This person is likely information, including a review of an individual’s
impulsive and might engage in reckless and even case history, for a comprehensive assessment of the
criminal behaviors. Such individuals can be very individual’s personality traits and related behav-
dangerous and are at high risk of causing pain to iors. Empirical studies of the PCL-R indicate that
those around them. ratings on these items load onto two related but
In the United States alone, many professional distinct factors: Factor 1 represents interpersonal/
terms have been coined to describe this human affective aspects of psychopathy, while Factor
condition, including sociopathy, antisocial per- 2 reflects social deviance.
sonality, and psychopathy. While sometimes used Other theoretical models have also been pro-
interchangeably, each of these terms may be used posed. For example, researchers D. J. Cooke,
to reflect notions regarding the etiology of such C. Michie, and S. D. Hart proposed that a three-
a personality. Use of the term sociopathy sug- factor model of psychopathy may be more appro-
gests that the individual’s behaviors are the result priate, with the three factors representing an
 Sociopathic Disorders 825

arrogant and deceitful interpersonal style, defi- and women. Similar to results identifying ethnic
cient affective experience, and impulsive and irre- differences in psychopathy, empirical evidence
sponsible behavioral style. suggests that greater gender differences exist in
the behavioral manifestations of psychopathic
Psychopathy Across Cultures personality, although it seems that the core fea-
An important aspect of understanding psychopa- tures of psychopathy may not differ.
thy as a construct involves assessing the influence It appears that the presence of psychopathy in
of cultural factors on how psychopathy is defined the United States may differ significantly from
both within and outside the United States. It that of other Western cultures and countries. For
should also be noted that culture is distinct from example, estimates of psychopathy in the United
race and ethnicity, although one’s culture is often States in prison samples range from 28 to 78 per-
assumed based on race, ethnicity, and/or country cent. Meanwhile, British estimates tend to range
of origin. The term race implies a biological basis; from 8 to 22 percent, suggesting the possibility of
ethnicity is based on identifiable characteristics, cultural influences. In addition to differences in
which suggests a certain cultural background; prevalence rates, the actual presentation of psy-
and culture refers more broadly to a common his- chopathy may differ between cultures. There are
tory or set of experiences. alternative explanations for such differences in
In the United States, professionals have prevalence rates, including divergent approaches
debated the extent to which the prevalence of in legal and incarceration policies, increasing
psychopathy and its measurement as a construct the likelihood of encountering psychopaths in
varies by different ethnic and racial groups. prisons.
For example, empirical examinations of PCL-R Significant cultural differences exist between
scores in African American and European Amer- the United States and Eastern countries. Ameri-
ican samples have yielded mixed results. While can culture is highly individualistic, with individ-
some have proposed that such differences are ual independence highly valued and temporary
biologically based and represent a racial differ- relationships and competitiveness considered
ence, others have contended that these differ- normative. On the other hand, many Eastern
ences are more likely due to environmental fac- countries tend to be collectivistic, emphasizing
tors such as socioeconomic status. The PCL-R social groups over the individual, acceptance of
has empirical support as a valid measure of psy- authority, and continuity of relationships. Given
chopathy for African Americans, with no sig- these distinctions, if cultural factors contrib-
nificant differences in factor structure between ute significantly to differences in psychopathy,
African American and Caucasian participants, one might expect to see such differences exem-
using a three-factor model. Furthermore, addi- plified in comparisons of psychopathy between
tional research suggests that certain main fea- the United States and Eastern countries such as
tures of psychopathy do not differ between Afri- China, Korea, and Japan.
can Americans and Caucasians. A meta-analysis Measures of psychopathy appear to generalize
of differences in PCL-R scores between these in their ability to assess psychopathy in Eastern
groups suggests no significant differences in the populations. For example, one study found cul-
core traits of psychopathy. This suggests that tural differences in scores on impulsivity, narcis-
differences found between the two groups may sism, and callous emotionality, with children in
be attributable to how individuals express these Hong Kong scoring higher on the callous emo-
traits behaviorally. tionality and narcissism factors and lower on
Empirical studies have also examined the impulsivity than children in the southeastern
extent to which cultural influences have impacted region of the United States. One hypothesized
gender differences in psychopathy. Within the reason for the difference in callous emotionality
United States, inconsistencies in results of epide- scores is the tradition of suppressing expression
miological studies have made it difficult to deter- of one’s emotions in China. Another recent study
mine whether there is a significant difference in observed cultural differences between a U.S.
prevalence rates of psychopathy between men sample and a Japanese sample in expressions of
826 Somatization of Distress

behavior associated with the three-factor model Somatization of Distress

of psychopathy. Psycholexical studies have
sought to identify how well definitions of psy- Somatization involves the manifestation of psy-
chopathy in the United States compare with sim- chological distress through physical symptoms.
ilar language used in other countries. One study Somatization of distress occurs when the response
comparing Korean definitions of psychopathic to acute or ongoing stressors involves physical
behavior to American definitions identified an symptoms that cannot be fully explained by envi-
honesty factor, which had a strong negative cor- ronmental factors or medical diagnosis. Somatiza-
relation with factors associated with antisocial tion may be more likely to occur when individuals
behavior. experience stress from culturally loaded or taboo
Evidence across European, North American, subjects, such as sexuality or trauma. Evidence of
African, and Asian samples suggests at least one somatization of distress is seen in populations all
key commonality of psychopathy in different cul- over the world. Cultural, environmental, biologi-
tures. This “pan-cultural core” has been identi- cal, and social factors may influence character-
fied as deficient affective experience. For example, istics of somatization, such as the expression of
samples in North America and the United King- symptoms and diagnostic patterns.
dom differed significantly on measures of interper- Common forms of somatization include gen-
sonal and behavioral but not affective symptoms. eral or localized pain or loss of function, including
Overall, the empirical data on measures of psy- chronic fatigue, loss of appetite, and gastrointesti-
chopathy in other countries indicate that culture nal or genitourinary complaints. Other common
has a significant influence over differences in how symptoms include difficulty breathing, dizziness,
psychopathy is defined and understood. Further- lack of balance or coordination, paralysis, spon-
more, there are also important similarities across taneous blindness or deafness, and hallucinations.
countries, including similarities in the central While symptoms related to somatization of
traits of psychopathy. distress may map onto known medical disor-
ders—especially disorders involving neurological
Virginia Elizabeth Klophaus impairment and diverse symptom profiles, such
Troy Ertelt as multiple sclerosis and Lyme disease—they do
University of North Dakota not correlate exactly with known disorders. Indi-
viduals suffering from somatization often report
See Also: Courts; Cultural Prevalence; more severe physical distress than what would
Dangerousness; Deviance; Grandiosity; Hospitals be commonly expected from known medical
for the Criminally Insane; Jails and Prisons; Law and disorders.
Mental Illness; Moral Insanity; Personality Disorders; Physician Paul Briquet described patients who
Race; Sadomasochism; Schizoaffective Disorder; appeared to exhibit somatization of distress
Violence. (physical symptoms without a known medical
explanation) in 1859. Late 19th- and early 20th-
Further Readings century accounts of hysteria, notably in the work
Cooke, D. J., C. Michie, and S. D. Hart. “Facets of neurologist Jean-Martin Charcot and Sigmund
of Clinical Psychopathy: Toward a Clearer Freud, the founder of psychoanalysis, also include
Measurement.” In Handbook of Psychopathy, reports of symptoms consistent with somatization.
C. Patrick, ed. New York: Guilford Press, 2006. Historical accounts of somatization help to
Hare, R. D. Without Conscience. New York: illustrate the extent to which it tends to reflect the
Guilford Press, 1993. historical and cultural milieu in which it occurs.
Millon, T., E. Simonsen, M. Birket-Smith, and There has been some controversy concerning
R. D. Davis. Psychopathy: Antisocial, Criminal, whether Briquet’s syndrome and hysteria should
and Violent Behavior. New York: Guilford Press, be viewed as separate disorders from somatiza-
1998. tion, unique to their historical context. The fourth
Patrick, C. J. Handbook of Psychopathy. New York: edition, text revision of the Diagnostic and Statis-
Guilford Press, 2006. tical Manual of Mental Disorders (DSM-IV-TR)
 Somatization of Distress 827

identifies both as interchangeable, historical terms as the “idiom of distress” hypothesis. Patients in
for somatoform disorders. areas where psychiatric care is less accessible may
When persistent somatoform symptoms cause be more likely to exhibit somatization of distress
ongoing distress, a patient may be diagnosed with because they must seek care in a setting that is
a somatoform disorder. Somatization is also fre- more prepared to treat physical than psychologi-
quently associated with anxiety disorders and cal ailments. In many cultures, seeking commu-
depression. It can be difficult for doctors to deter- nity support and medical treatment for a physical
mine whether patients are suffering from an undi- health concern may be more socially acceptable
agnosed medical disorder, rather than a somato- than seeking help for psychological distress, such
form disorder. Physicians frequently report as anxiety or depression.
somatization in difficult-to-diagnose diseases Women are more likely than men to exhibit
such as chronic fatigue syndrome, fibromyalgia, somatization in response to distress. It is pos-
and irritable bowel syndrome. Somatization has sible that women are also more likely to be diag-
also been related to disorders such as body dys- nosed with somatization than men because of
morphic disorder and anorexia. cultural norms that regulate women’s emotional
expression. The DSM-IV diagnostic criteria for
Cultural Characteristics somatoform disorders indicate that women are
Somatization of distress has been shown to take more likely to receive a diagnosis of somatoform
on characteristics reflective of pervasive cultural disorder. Additionally, the DSM-IV-TR indicates
norms or concerns. For example, in India, a that while 10–20 percent of first-degree biological
belief in dhat, or fear of semen loss, contributes female relatives of women with somatoform dis-
to a higher prevalence of somatization symptoms orders are likely to be diagnosed with the disease,
affecting the male reproductive organs than in male relatives are at an increased risk of being
communities that do not share this belief. In Asia, diagnosed with antisocial personality disorder and
shenjing shuairuo is a common disorder marked substance-related disorders. Recent studies have
by persistent fatigue or weakness that corre- suggested that men may be more likely to suppress
sponds to the DSM-IV-TR criteria for a diagnosis bodily symptoms and to be taken seriously by doc-
of undifferentiated somatoform disorder. tors when they report physical distress, leading to
Somatization of distress may be more common medical diagnoses for problems that might be seen
in members of marginalized groups, such as immi- as evidence of somatization in women.
grant populations, women, minorities, and persons
with disabilities. The pervasiveness of dominant, Kira Walsh
often Westernized cultural norms may result in Emory University
somatization being seen as a primitive or regressed
form of communication. Members of minority See Also: Anxiety, Chronic; Conduct, Unwanted;
populations might be more likely to be viewed as Diagnosis in Cross-National Context; Dissociative
somatizing, rather than experiencing a known dis- Disorders; Hysteria; Mind–Body Relationship.
order, because of prejudice and/or an inability to
recognize the symptom profiles of known diseases Further Readings
as they vary across culture and class lines, possibly Keyes, Corey L. M. and Carol D. Ryff. “Somatization
leading to inadequate or inappropriate treatment. and Mental Health: A Comparative Study of the
Culturally coded markers of distress may Idiom of Distress Hypothesis.” Social Science and
explain differences in the presentation of somatiza- Medicine, v.57 (2003).
tion across cultures. Physical expressions of emo- Kirmayer, Laurence J. and Allan Young. “Culture
tion consistent with somatization may alleviate and Somatization: Clinical, Epidemiological,
distress by providing an indirect way of express- and Ethnographic Perspectives.” Psychosomatic
ing emotion. In the literature on somatization of Medicine, v.60 (1998).
distress, the idea that the physical expression of Phillips, Katharine A., ed. Somatoform and Factitious
symptoms may reflect social norms, rather than Disorders. Washington, DC: American Psychiatric
the mental health of an individual, is referred to Publishing, 2001.
828 South Africa

South Africa Mental health services during South Afri-

ca’s apartheid era were inequitable and under
South Africa is a middle-income country, often resourced. In the postapartheid period, South
characterized by its history of apartheid, cultural Africa developed legislation, most notably the
diversity, socioeconomic inequality, and high levels 1997 White Paper on the Transformation of
of violence. The majority of South Africa’s approx- Health Care and the Mental Health Care Act (No.
imately 50 million population is black African 17 of 2002) that is designed to promote interna-
(79 percent), with various ethnic groups and sub- tional human rights standards and the decentral-
groups, followed by white (9.6 percent), colored ization and integration of mental health into pri-
(or mixed race, 8.9 percent), and Indian/Asian mary health care. However, mental health services
(2.5 percent). South Africa’s 11 official languages continue to vary considerably throughout South
reflect its cultural complexity. South Africa’s bur- Africa’s nine provinces and are underfunded, with
den of disease is almost double that of other devel- uneven adherence to policy guidelines.
oping countries, and is approximately four times Though prevalence rates vary across epide-
the disease burden of developed countries. Mental miological studies, approximately 16.5 percent
health disorders especially substance abuse, are a of South Africans report that they suffer from a
significant disease burden in South Africa, follow- mental health disorder in a given year, and 30.3
ing HIV/AIDS and other infectious diseases. percent experience a lifetime prevalence of chronic

Andrea Dondolo, a South African actress and activist, stands on Table Mountain in Cape Town, South Africa, to demonstrate her
support for One Billion Rising, a call to end violence against women and girls, February 14, 2013. For women, rape and domestic
abuse are significant risk factors for the development of post-traumatic stress disorder (PTSD) in South Africa. For men, political
violence, criminal assault, and childhood physical abuse are highly associated with the development of PTSD.
 South Africa 829

mental health disorders, including anxiety, mood, parents are deceased); the 1.9 million children in
impulse control, and substance abuse disorders. South Africa orphaned because of HIV/AIDS are
Adult anxiety, depression, substance abuse, and at an increased risk for developing PTSD, anxiety,
nonspecific psychological distress are more preva- depression, and conduct and delinquency prob-
lent among South African adults living in disad- lems because of HIV/AIDS-related stigma, bully-
vantaged communities. Food insufficiency poses ing, and food insecurity.
a significant physical and mental health burden Over one-third of South Africans have expe-
throughout South Africa; 38 percent of South rienced violence, and some reports suggest that
Africans report food insecurity, which is associ- South Africa has among the highest rates of vio-
ated with the development of anxiety disorder lence in the world. For men, political violence,
and substance abuse. criminal assault, and childhood physical abuse
While postapartheid South Africa has made leg- are highly associated with the development of
islative, policy, and social program improvements PTSD, whereas for women, rape and domestic
toward protecting its vulnerable populations, abuse are significant risk factors for the develop-
over 60 percent of children remain in severe pov- ment of PTSD.
erty. Food insecurity, inadequate housing, unsafe The ways in which mental illness are recognized
living conditions, low levels of education (typi- and treated vary according to culture throughout
cally from dropping out of school because of the South Africa. Indigenous conceptions of mental
cost of school fees or family commitments), and illness such as depression, anxiety, or schizophre-
exposure to violence pose risks to children’s men- nia include bewitchment, breach of social norms,
tal health, including the development of depres- or psychosocial stressors. Therefore, many
sion and insecure attachments. Adolescents liv- South Africans report seeking help from tradi-
ing in highly impoverished areas of South Africa tional healers, diviners, and/or herbalists, rather
(e.g., the Eastern Cape and Limpopo provinces) than seeking more formal, psychopharmaceuti-
are especially susceptible to substance abuse, cal interventions. Since South African integrated
high-risk sexual behavior, violent crime, and sub- mental health services are typically offered in the
sequent school dropout. Alcohol use during preg- language of those in power, communication may
nancy is also a problem throughout South Africa, be a barrier to indigenous speakers seeking treat-
and the Western Cape has among the highest rates ment. While South Africa’s legislation supporting
of fetal alcohol syndrome in the world. community and family-focused health care aims
South Africans face key risk factors for men- to reduce mental illness stigma, public stigmati-
tal health and substance abuse problems includ- zation of mental health and subsequent loss of
ing unemployment, low educational attainment, social support and/or employment pose barriers
poverty, urbanization, accidents (such as those to seeking and adhering to treatment.
related to automobiles, and burns), trauma asso- For psychiatric needs, South Africa provides
ciated with HIV/AIDS, and various forms of vio- 2.1 beds per 10,000 population within psychiat-
lence (e.g., criminal, political, sexual, and domes- ric and general hospitals; the availability of beds
tic abuse). compares well to other African countries, though it
South Africa has the highest number of people falls below European standards. Approximately 53
living with and dying from HIV/AIDS in the world; percent of general hospitals are equipped to pro-
18 percent of the South African adult population vide psychiatric emergency assessments for refer-
is living with HIV, as well as 330,000 infants and ral to specialized mental health institutions, and 80
children. The stigmatization and resulting social percent of the population have free access to psy-
rejection, discrimination, and verbal/physical chotropic drugs; however, access to counseling for
abuse experienced by many people living with more common mental disorders, rather than acute
HIV/AIDS are predictive of mental disorders such psychiatric care, remains limited. Of the facili-
as depression, substance abuse/dependence, and ties where data are available, an average of 1.4
post-traumatic stress disorder (PTSD). Approxi- percent of services are directed toward children/
mately 19.6 percent of all South African chil- adolescents, demonstrating a need for develop-
dren are orphans (i.e., the mother, father, or both ment. Treatment for mental illness is challenged by
830 South Korea

inadequate infrastructure (i.e., facilities in disrepair, be pegged to poor parenting, weak character, reli-
poor communication equipment, and lack of trans- gious providence, or a family curse. Even when
portation for home visitors), shortages of mental mental illness is understood as such, convention-
health professionals, few specialized services (e.g., ally it has been viewed as dishonorable and some-
for children/adolescents), and underdeveloped and thing to be endured quietly rather than addressed
underresourced community-based services. professionally. Many South Koreans feel that
mental illness will resolve on its own over time.
Ariane Schratter Until recently, anyone who sought counseling
Maryville College for a mental health issue would be officially clas-
sified as a mental patient under South Korean law.
See Also: International Comparisons; Post-Traumatic The designation imposes shame on the patient
Stress Disorder; Treatment. and his or her family. The stigma often results in
discrimination that makes it more difficult for the
Further Readings individual to get into a choice school, secure a
Khumalo, I., Q. M. Temane, and M. P. Wissing. desired job, and even apply for a driver’s license.
“Socio-Demographic Variables, General This system of prejudice has served largely to
Psychological Well-Being and the Mental Health perpetuate the cycle of insecurity and intoler-
Continuum in an African Context.” Social ance within South Korea’s culture—one that has
Indicators Research, v.105/3 (2012). become progressively more focused on competi-
Lund, Crick, Sharon Kleintjes, Ritsuko Kakuma, Alan tive rivalry and overt materialism.
J. Fisher, and the MHaPP Research Programme South Korea’s Ministry of Health and Welfare
Consortium. “Public Sector Mental Health Systems took action in 2012 and drafted a radical plan
in South Africa: Inter-Provincial Comparisons designed to improve the republic’s mental health
and Policy Implications.” Social Psychiatry and infrastructure, enhance public utilization, and
Psychiatric Epidemiology, v.45/3 (2010). ease the stigma associated with treatment.
South African Federation for Mental Health. http://
www.safmh.org.za (Accessed June 2012). Underlying Factors and Impact
In the span of approximately 50 years, South
Korea emerged from among the ranks of the poor-
est countries in the world based on gross domestic
product (GDP) per capita into the echelons of the
South Korea world’s wealthiest nations. The transformation
was propelled by intensive Westernization and a
South Korea is a modern republic built on concerted campaign among South Korea’s lead-
deeply held traditions. Contemporary demands ers to expand economic and political freedoms
and ambitions among citizens of this advancing throughout the country. South Korean traditions
nation exist in uneasy juxtaposition with ancient and social structures were unable to keep pace
society’s deep-rooted beliefs and values. The ever- with the country’s hurried evolution. Members
present dichotomy has taken a national toll on of a workforce accustomed to career security and
South Korea’s mental health. A lack of under- lifelong employment found themselves jockeying
standing and supportive infrastructure regarding for position to obtain and keep the country’s best
mental illness, together with unfavorable govern- jobs. Students faced similar situations regarding
ment policies and public perceptions, have con- academic admission and standing. Intense pres-
tributed to a meteoric rise over the past decade sure and antagonism quickly infiltrated every age
in the overall suicide rate among South Korea’s group and aspect of life in South Korea and have
increasingly stressed and depressed population. contributed to soaring rates of substance abuse,
Mental illness often is not recognized as an ill- divorce, and suicide.
ness at all in South Korea. Coping deficiencies, South Korea’s suicide rate rose 130 percent
psychiatric disorders, and even neurological med- from 2000 to 2012. It is estimated that every day
ical conditions such as autism are more likely to in South Korea, approximately 40 individuals put
 Spain 831

an end to their own lives, nearly triple the rate of in 2013. The mandated screenings are intended
other developed countries. Suicide is the fourth not only to help relieve mounting stress among
leading cause of death among all South Koreans the republic’s citizens but also to improve cultural
and is the most prevalent cause of death among perceptions about mental health issues and treat-
South Koreans between 20 and 30 years of age. ment. The ministry also revised the legal definition
The widely publicized suicide deaths of young of what constitutes a mental patient, narrowing
South Korean celebrities and public figures, includ- the scope from anyone who receives mental health
ing former President Roh Moo-hyun in May 2009, counseling to only those who are in serious psychi-
may reinforce the ongoing perceptions of suicide as atric need and require hospitalization. In addition,
a solution to depression and difficult times. the ministry partnered with the Korean Association
for Suicide Prevention to implement public aware-
Approaches to Mental Health Treatment ness campaigns and monitor the growing num-
South Koreans who do seek assistance for issues ber of suicide-discussion social media sites where
of mental illness tend not to enlist the aid of a individuals share plans, make pacts, and provide
psychiatrist or medical professional. Instead, they tips for suicide. On the policy side, South Korean
turn to family members or religious leaders who officials have introduced plans for assertive com-
generally have insufficient knowledge about men- munity treatment programs designed to improve
tal illness and carry the same negative perceptions social services and clinical outcomes.
about it as the society at-large.
Some South Koreans take alternative routes Shari Parsons Miller
to finding mental health support. These include Independent Scholar
fortune-tellers, social salons, and private clinics
where anonymity and cash payments mean there See Also: Business and Workplace Issues; Depression;
is no official record of a mental disorder to mar Family Support; Internet and Social Media; Mental
the person’s reputation. Those South Koreans Illness Defined: Sociological Perspectives; Public
who do seek out professional psychiatric help Education Campaigns; Stigma; Suicide.
for mental illness may find limited opportuni-
ties available. For example, the number of psy- Further Readings
chiatrists per capita in South Korea is among the Ito, Hiroto, Setoya Yutaro, and Suzuki Yuriko.
lowest of all countries within the Organisation “Lessons Learned in Developing Community
of Economic Co-operation and Development Mental Health Care in East and South East Asia.”
(OECD). In addition, mental health care spend- World Psychiatry, v.11/3 (2012).
ing as a proportion of GDP in South Korea has Kim, Myoung-Hee, et al. “Socioeconomic Inequalities
traditionally been near the bottom of all OECD in Suicidal Ideation, Parasuicides, and Completed
countries at roughly 2 percent of GDP. In 2010, Suicides in South Korea.” Social Science &
South Korea expended 1.13 trillion won in direct Medicine, v.70/8 (2010).
costs for mental illness infrastructure and treat- World Health Organization. “WHO-AIMS Report
ment while racking up an additional 22.39 tril- on Mental Health System in Republic of Korea”
lion won associated with indirect costs related to (2006). http://www.who.int/mental_health/evi
lost work time and other socioeconomic factors. dence/korea_who_aims_report.pdf (Accessed
A survey of South Koreans in 2010 found that January 2013).
only 15.3 percent of those who experienced mental
disorders utilized the country’s mental health ser-
vices, totaling less than half the rate of other OECD
countries. The low utilization, along with the
country’s rapidly escalating suicide rate, prompted Spain
South Korea’s Ministry of Health and Welfare to
implement a radical mental health policy requiring Spain is a high-income country with a social
all South Korea citizens to undergo regular mental income insurance system financed by tax rev-
health screenings throughout their lifetime starting enues and guaranteeing access to a basic package
832 Spain

of health services. However, service delivery is not study in psychology. Enrollment in psychology
entirely uniform because health and mental health programs increased from about 3,000 in 1970 to
care is organized by each autonomous region, about 59,000 in 1995 and 1996, and the number
rather than on a national basis. In addition, of tenured academic staff in psychology increased
Spain’s economy has been severely affected by the from 22 in 1977 to 1,295 in 1996. As of 2002,
eurozone economic crisis from 2008 onward, and the most common areas of practice were clini-
this has forced some cutbacks in services. cal psychology (68.4 percent, of whom 80 per-
Many historians trace the birth of psychology cent work in the public sector) and educational
in Spain to the work of 16th-century physician psychology (15.3 percent). Women constitute the
Huarte de San Juan, whose The Examination majority of psychologists (65 percent) in Spain.
of Men’s Wits discussed the physiological and The number of psychologists working in social
biological basis of psychology, as well as mat- services (e.g., with homeless people or substance
ters associated today with developmental and abusers) has increased steadily since the 1980s;
educational psychology. However, the develop- these services are generally provided in commu-
ment of scientific psychological thought in Spain nity-based models.
was suppressed by the Inquisition and was not Interest in psychoanalysis in Spain reaches back
resumed until the mid-19th century, when psy- almost to the origins of the field, and the first
chology became a mandatory subject in second- translations of Sigmund Freud’s works were pub-
ary schools. lished in Spanish as early as 1893. The Madrid
Luis Simarro, a psychiatrist and student of the author and philosopher Jose Ortega y Gasset pub-
French neurologist Jean-Martin Charcot, was lished a 1911 essay praising Freud’s works; and in
appointed in 1902 to the first chair of experi- 1922, Ruiz Castillo began publishing a series of
mental psychology in Spain, at the University of translations of all of Freud’s works. Completed in
Madrid. Simarro was the leader of one approach 1932, it was the first foreign translation of Freud’s
to psychology called the Madrid school, which complete writings. Although Freud’s ideas were
emphasized social reform and the use of psychol- well known to Spanish psychiatrists of the period,
ogy in educational counseling. A second approach psychoanalysis was criticized for its emphasis on
to psychology was seen in the Barcelona school, sexuality and for the subjective nature of Freud’s
led by the biologist Ramón Turró; this approach methods. The Spanish Civil War and subsequent
was more concerned with experimental and phys- dictatorship brought a temporary end to the pub-
iological research. Psychological research and lic discussion concerning psychoanalysis, as well
study was supported by the Second Republic in as its practice. In the late 1940s and early 1950s,
the 1920s and 1930s, and the first Spanish jour- a few Spanish physicians trained in psychoanal-
nal including psychology as a topic, Archivos de ysis in Germany and Switzerland, and in 1959,
Neurobiologia (Neurobiological Archives) was the International Psychoanalytical Association
founded in 1920 by Gonzalo Rodriguez Lafora, granted membership to the Grupo Luso-Español
Jose Ortega y Gasset, and Jose Miguel Sacristan. de Psicoanálysis (Portuguese-Spanish Group for
The Spanish Civil War (1936–39) dealt a blow Psychoanalysis). A second society, the Asociación
to psychology in Spain because many psycholo- de Psycoanalytica de Madrid (Madrid Psychoana-
gists were supporters of the Republic and fled the lytical Association) was recognized by the Inter-
country, and the Franco regime was conservative national Psychoanalytical Association in 1973;
and generally suspicious of psychology. The first and in 1990, the European School of Psychoanal-
Spanish journal devoted entirely to psychology, ysis was founded, and a branch school was estab-
Psicotecnia, was founded in 1939, the same year lished in Barcelona.
that the civil war ended.
Provision of Mental Health Services
Growth of Psychology in Spain Mental health services are organized by the coun-
Psychology became an official university subject try’s 17 autonomous regions and are financed pri-
in the 1960s, and by 2000, 23 Spanish univer- marily at the regional level. For this reason, there
sities offered undergraduate and/or graduate is no uniformity among the services guaranteed
 Spiritual Healing 833

or provided from one autonomous region to Further Readings

another. Recently the national government has Montes-Berges, Beatriz, Maria Aranda, and Maria
become more involved in the provision of men- del Rosario Castillo-Mayen. “Psychology in Spain:
tal health services, and since 2007, it has invested Its Historical and Cultural Roots, Instruction,
$11.7 million in mental health projects in differ- Research, and Future Prospects.” Psychology
ent provinces. The Spanish national government Teaching Review, v.17/2 (2011).
spends 9.7 percent of gross domestic product on Olivia-Moreno, Juan, Julio López-Bastida, Angel
health, and 5 percent of this total goes to mental Luis Montejo-Gonzalez, Rubén Osuna-Guerrero,
health services; neuropsychiatric illness contrib- and Beatriz Duque-González. “The Socioeconomic
utes an estimated 27.4 percent of the total burden Costs of Mental Illness in Spain.” European
of disease in Spain. In 2007, the 12-month preva- Journal of Health Economics, v.10 (2009).
lence for all mental health problems in Spain was World Health Organization (WHO) Regional Office
9 percent, with anxiety disorders the most com- for Europe. Policies and Practices for Mental
mon (6 percent). In 2007, 5 percent of the pop- Health in Europe: Meeting the Challenges.
ulation suffered from a mild disorder, 3 percent Copenhagen: WHO Regional Office for Europe,
from a moderate disorder, and 1 percent from a 2008.
severe disorder. The suicide rate in 2011 was 12
per 100,000 population for males, and 3.8 per
100,000 for females.
In 2011, Spain had 521 mental health outpa-
tient facilities, 115 day treatment facilities, and 88 Spiritual Healing
mental hospitals. For inpatient care, the country
had 14,831 beds in mental hospitals (32.7 beds Culture shapes the ways in which individuals
per 100,000 population) and 4,617 psychiatric within a society express, diagnose, and treat men-
beds in general hospitals (10.2 beds per 100,000 tal illness. Thus, culturally established emotional
population). The rate of admission to mental hos- and behavioral norms are utilized to label an indi-
pitals is 69.7 per 100,000 population, and the vidual as sick (as opposed to healthy). Although
rate of admission to psychiatric beds in general these norm violations can parallel Western con-
hospitals is 504.3 per 100,000. Spain has 8.6 psy- ceptualizations outlined in the Diagnostic and
chiatrists per 100,000 population (not counting Statistical Manual of Mental Disorders, people
those who are in private practice), and 6.6 nurses may interpret these concerns as having origins
per 100,000 working in the mental health sector. among unseen spiritual forces. As a result, inter-
Primary care physicians are allowed to prescribe ventions are designed to mitigate the underlying
psychotherapeutic medicines, treat common men- spiritual problem, thus alleviating the outward
tal health problems, and collaborate with mental manifestation of the symptoms.
health specialists to treat people with severe dis- Throughout the world, people are four times
orders; within the past five years, most Spanish more likely to seek out spiritual methods to
physicians have received official in-service train- address a Western-defined mental health problem
ing in the field of mental health. Expenditures for than to seek counseling. In the United States, this
psychotherapeutic medicines in 2011 totaled $4.6 is particularly true among people of color who
million, including $1.9 million for psychotic dis- experience similar levels of mental health con-
orders, $500,000 for general anxiety disorders, cerns as other Americans but have lower treat-
and $50,000 for bipolar disorders. ment utilization rates.
Researchers examining barriers to treatment
Sarah Boslaugh note that stigma, cultural mistrust, experiences of
Kennesaw State University racism, and culturally incongruent interventions
contribute to lower utilization and adherence
See Also: Business and Workplace Issues; rates. As a result, people of color rely on other
Psychoanalysis, History and Sociology of; Social healing modalities that include informal resources
Control. such as spiritual healers.
834 Spiritual Healing

Known by various names, including shamans, can include gazing into water, use of one’s hands,
root doctors, healers, or spiritual workers, this or special tools. Divining tools include food (corn,
group of healers historically enjoyed a privileged peanuts, coconuts, or sugarcane), currency, shells,
status within a community. Popularization of seeds, and a variety of items typically indigenous
Western biomedical interventions is one factor to the surroundings. A series of invocations open
that resulted in the denigration of the role of these the lines of communication between the healer
healers. More recently, there is increased interest and the spirit world. Then, exploration of the
in individuals who provide spiritual interven- origins of the problem occurs, the client’s ques-
tions to address Western-defined mental health tions are answered, and the appropriate remedy
problems. The training of these healers varies but is identified.
typically occurs within an apprenticeship model When mental health concerns arise, healers
over a period of several years. Part of the train- use a variety of interventions to treat the under-
ing process may include observation, hands-on lying spiritual issue, thus alleviating the physical
experience, and initiation into a secret society of symptoms. This is accomplished through a vari-
healers. ety of healing modalities including symbolic ritu-
als, purification regimens, verbal invocations, and
Diagnosis of Problems various types of bodywork.
Spiritual healers are consulted for a variety of
mental, physical, and spiritual health concerns. Symbolism
The categorical distinctions that exist in West- Symbolism and metaphors are integral parts of
ern biomedical approaches generally do not exist healing systems and include various types of tal-
among this group of practitioners. Diagnosis of a ismans/charms, rituals, and ceremonial sacrifice.
problem begins with a violation of cultural norms These symbols communicate messages of healing,
that disrupts social interactions between the indi- liberation, connection with community, and his-
vidual and his or her community. A healer is then tory of a people.
sought out to determine a prescriptive remedy. Talismans and charms are utilized by clients
This diagnostic process occurs through a combi- to ameliorate or guard against negative forces.
nation of methods including history taking, phys- These small medicinal items are specifically made
ical examination, and divination. for each individual. There are an infinite number
Understanding the progression of the problem of items used for these healing tools including
can be done by taking a client history so that the pouches, feathers, bells, animal body parts, and
healer can see the manifestation and course of metals. Some talismans are worn, whereas others
the illness. The healer may heavily rely on infor- are placed within the home. Healers who special-
mation from family members, elders, and others ize in making talismans have undergone addi-
within the community, denoting the interconnect- tional instruction to hone their craft.
edness between the client and community. Ritual is defined as collectively held ceremonial
Physical examination of the client takes a vari- activities, rites, or behaviors performed in a spe-
ety of forms and includes laying hands on or near cific manner. Certain elements exist in most heal-
the client. Physical examinations of the eyes or ing rituals, including community participation and
other body parts may also occur. In general, the opening, main, and closing activities. The structure
healer is identifying energy blockages, the pres- of a ritual will vary depending upon the healer,
ence of unseen spiritual forces, and the alteration intervention needed, and culture of the community.
or absence of expected physical characteristics. The act of sacrifice is defined as the forgoing
One of the most popular diagnostic tools is the of something in order to achieve positive gains in
healer’s use of divination. This process enables one’s life. This process is considered the essential
the practitioner to interact with unseen spiritual link between the physical and spiritual worlds.
forces in order to ascertain the cause of the prob- The process of sacrifice is believed to assist the
lem and appropriate intervention. The divination individual in gaining blessings from benevolent
process occurs differently depending on the cul- spirits while warding off or removing destructive
tural group and depth of the healer’s training. It malevolent forces. Sacrifices can include personal
 Spiritual Healing 835

commitments, plants, herbs, cooked foods, and to the extent that the religious beliefs of the cli-
livestock. ent (and healer) recognize the importance of such
The act of propitiation of one’s ancestors interventions.
includes an acknowledgment of deceased family Chanting or reciting sacred healing incanta-
members who are still considered spiritually con- tions is a healing modality practiced throughout
nected to the living. This can occur in a variety both indigenous healing systems and the major
of ways, including constructing sacred ancestral religions of Islam, Christianity, and Judaism. Sto-
spaces, conducting specific remembrance ceremo- ries, proverbs, and metaphors from sacred texts
nies, and telling stories to younger generations. are utilized as a therapeutic intervention. Beliefs
Some ailments are believed to be the result of vary regarding the actual medicinal properties
one’s failure to engage in adequate levels of pro- of the words that invoke change for the client.
pitiation of his or her ancestors, or the need to Some find healing in the lessons derived from the
perform a specific ritual on their behalf. symbolic meaning imbued within the text. Oth-
ers suggest that the actual words activate healing
Purification properties within the spiritual realm that posi-
The process of purification is designed to restore a tively alter the client’s overall well-being.
balanced state of well-being to a client experienc- Prayer can be defined as one’s process of talking
ing emotional distress. These types of rituals are to the supreme spiritual being, while meditation
designed to symbolically cleanse the individual is the process of listening to messages from that
through an interaction with spiritual forces. Puri- source. Depending upon one’s religious beliefs,
fication rituals can include consumption of herbal prayer and/or meditation are used to varying
remedies and participation in a sweat lodge. degrees. Studies suggest that prayers may provide
Herbal medicine is defined as prescriptions of beneficial curative effects for those engaged in
naturally occurring plants, flowers, seeds, and regular use of this healing modality. Additionally,
barks prepared to alleviate a specific client’s symp- there is an emerging body of literature suggesting
toms. This form of healing may occur in conjunc- that there are beneficial effects of meditation on
tion with the healer advising the client to make one’s physical and mental well-being.
additional dietary changes. The herbal prepara-
tion may be ingested, or may be used in a bath Bodywork/Movement
over a specified period of time. Similar to Western Bodywork and movement is defined as activities
pharmacological methods, clients are instructed that enable the individual to utilize one’s physical
in the use of the preparation, contraindications, body to interact with the unseen spiritual realm.
as well as dietary restrictions or additions. This can occur through a variety of activities,
Utilized for individual and community heal- including dancing, drumming, therapeutic touch,
ing, a sweat is a spiritual purification ritual uti- and other body movements. Within the United
lized by many indigenous communities through- States, there is growing popularity of activities in
out the United States and Canada. Although the this category.
specifics of the sweats vary depending upon to Cultural groups worldwide utilize dance and
the community, some components are similar, drumming for both entertainment purposes and
including use of a small enclosed space, heated as part of spiritual rituals. The healing properties
stones, a method for generating steam, and use of of the songs, dance movements, and drumming
medicinal herbs. The ceremony includes chant- rhythms may be associated with religious deities
ing, drumming, and singing relevant to the inten- or a particular ceremony. Drum and dance may
tion behind the sweat. be used as both a diagnostic tool and intervention
in which clients are actively engaged as the healer
Verbal Invocations watches and/or participates in the process. In con-
Verbal invocations are defined as activities that trast, therapeutic touch broadly includes activi-
enable the individual to interact with the spiritual ties designed to enable the healer to be a conduit
realm in the form of chanting, prayer, and medi- for positive spiritual energy that is absorbed by
tation. Each of these healing modalities is utilized the client. Some healing modalities that can be
836 State Budgets

included in this category are Reiki, the laying of State budgeting for mental health and sub-
hands, and massage. Bodywork that focuses on stance abuse or “behavioral health” services is
the individual harnessing vital energy occurs with complex because of the competing interests of
yoga, Qigong, and tai chi. These three exercise other state agencies’ budgetary requirements and
forms focus on maintaining or restoring optimum pressure applied by legislators, providers, con-
health by utilizing mind-body connectedness. sumers and their families, and the media and
other stakeholders to show that investments in
Ifetayo I. Ojelade behavioral health services are effective and effi-
A Healing Paradigm cient. Further, prescribed and often constrictive
state laws that govern agency budget making and
See Also: Diagnosis; Diagnosis in Cross-National contracting may limit the ability of SMHA direc-
Context; Hallucinations; Mind–Body Relationship; tors to communicate their needs to state budget
Racial Categorization; Religion; Religiously Based offices, reallocate funding among budget catego-
Therapies; Treatment. ries, and directly access legislators. Given these
circumstances, SMHAs have varying capacity to
Further Readings manage their budgets and establish priorities to
Gielen, Uwe, Jefferson Fish, and Juris Draguns, eds. the detriment of individuals and families dealing
Handbook of Culture, Therapy, and Healing. with mental illness and the communities where
Philadelphia: Erlbaum 2004. they reside.
Grills, Cheryl. African Psychology: Rejoinder the Evidence that services are achieving their
Search for Authenticity and Legitimacy. In Black intended outcomes is not always available, which
Psychology, R. L. Jones, ed. Hampton, VA: Cobb diminishes the SMHA’s ability to persuade state
& Henry, 2004. legislatures to allocate adequate funding to con-
Moodley, Roy and William West, eds. Integrating tinue services in the face of other state agencies
Traditional Healing Practices Into Counseling and that are competing for state funding. This is a
Psychotherapy. Thousand Oaks, CA: Sage, 2005. serious concern because virtually all states as
well as the federal government have drastically
slashed spending because of the downturn in
the nation’s economy since 2008 and—coupled
with mental health stigma and a prevalent but
State Budgets incorrect view that people with mental illness
are incapable of recovery and becoming useful
In the United States today, state mental health members of society—has led to behavioral health
authorities (SMHAs) oversee an almost $37 bil- funding being a low priority for state legislatures.
lion public mental health service system and serve Such reductions in behavioral health funding are
nearly 7 million consumers. SMHAs provide inconsistent with hard data that depicts a steady
community-based services, contracting directly and significant increase in demand for behavioral
with community-based, usually nonprofit, men- health services.
tal health agencies; paying city or county mental State budgeting for behavioral health systems
health authorities to contract with local mental is tied to mental health policy, which dictates
health agencies; and/or providing care directly state priorities for the prevention and treatment
using state employees in state-operated facilities. of mental disorders and the manner in which ser-
SMHAs provide funding for or directly operate vices are provided. Given dwindling resources for
nearly 20,000 community mental health and sub- behavioral health resources, however, SMHAs
stance abuse organizations and facilities, relying continually grapple with how to provide appro-
upon a mix of general state revenues and federal priate and adequate services for consumers.
grants. Historically, the financing of state behav- Given the current state of the nation’s economy,
ioral health systems has had a profound influence however, SMHAs are forced to make tough deci-
on the pattern of patient admissions to the differ- sions about which services and programs can be
ent kinds of state and local facilities. sacrificed without disrupting essential services.
 State Budgets 837

Governmental Roles in the Financing persons with mental illnesses. Out of concerns
of Behavioral Health Services that the mentally ill were not receiving humane
The responsibility for the care and treatment of care or treatment that would lead to recovery,
individuals with mental illnesses has been dis- state legislatures began assuming full responsi-
tributed between local, state, and federal govern- bility for the care and treatment of the mentally
ments, but the extent to which each entity has ill. Local government officials, however, used this
assumed responsibility has varied at different policy shift to further reduce their expenditures
points in time. State governments have tradi- by labeling their indigent elderly populations as
tionally provided communities with the funding mentally ill and transferring them to state men-
necessary to build and maintain mental hospitals tal hospitals when, in fact, they suffered merely
(also called asylums, in certain eras). However, from the normal consequences of old age. As a
until around the end of the 19th century, the result, local almshouses’ resident populations
financial burden for the poor, the indigent elderly, experienced rapid reductions between 1880 and
and mentally ill individuals was the responsibil- 1920. This action changed the nature of state
ity of local governments. Therefore, while mental mental hospitals as places that catered to the
hospitals existed, they were expensive, so local care and treatment of persons with severe mental
officials preferred to house their disabled indi- illnesses, to institutions tasked with the guard-
gent residents in almshouses that were less costly ianship of older patients with chronic somatic
to maintain. illnesses who would never leave; the censuses of
As the population of the United States grew state mental hospitals dramatically increased as a
rapidly in the 1800s, so did the numbers of consequence. By the late 1950s, almost one-third

Delaware Governor Jack A. Markell signs a bill modernizing Delaware’s mental health system, July 24, 2012. The state approved
funding for mental health reform initiatives in the governor’s 2014 budget, allocating $3.3 million for school mental health services
and $2.2 million for after-school and summer programs for youth. The bill also allowed a wider array of appropriate treatment
options. State budgeting for mental health services is complex because of a wide variety of competing stakeholders and pressures.
838 State Budgets

of all state mental hospital patients were over behavioral health research, training programs for
65 years of age. The addition of elderly patients behavioral health professionals, intensive treat-
also led to overcrowded conditions in state men- ments for individuals with mental illnesses in
tal hospitals. any venue, and additional services for individuals
The overcrowding of state mental hospitals, with less serious mental problems in community
combined with the economic downturn caused by outpatient clinics. World War II and a series of
the Great Depression and the recruitment of mental media exposés concerning appalling conditions
health professionals during World War II, resulted and overcrowding in mental hospitals (hospital
in significant deterioration in the care and treat- populations peaked at 559,000 by 1955) caused
ment of hospital residents and the maintenance of growing public support for federal action.
the physical plants. Beginning in the 1940s, psy- After President John F. Kennedy (1961–63) pre-
chiatrists also began to recognize that social and sented the first message concerning mental health
environmental conditions played some role in to Congress in 1963, Congress passed the Men-
mental disorders, and experimentation with com- tal Retardation Facilities and Community Mental
munity outpatient treatment during World War II Health Centers Construction Act of 1963 (Pub-
showed promise. These factors and others led the lic Law 88-164). This legislation provided $150
majority of state mental hospital psychiatrists to million from 1965 to 1967 to begin building and
leave what was largely custodial care of patients to staffing community mental health centers. The leg-
other caretakers, and to go into private practice or islation called for the establishment of 500 Com-
begin work in community outpatient clinics that munity Mental Health Centers by 1970, and 1,500
were then funded through state contracts. by 1980. Changes in 1965 permitted the provision
This movement was strengthened by the of funding to staff the centers, and expanded eligi-
National Mental Health Act of 1946, which pro- bility to include substance abuse treatment facili-
vided federal funding for states to build or main- ties and children’s services. The centers provided
tain community mental health outpatient clinics. inpatient and outpatient services, emergency ser-
Less than half of the states had any outpatient vices, day treatment, consultation, and education.
clinics prior to 1948, but almost all states had Services were provided regardless of the patient’s
one or more clinics only one year later. By the ability to pay. Since these centers were a collab-
late 1950s, more than 1,400 outpatient clinics orative effort of federal and local governments,
had been established, the vast majority of them SMHAs were sidestepped and lacked authority
supported by state funding, and were serving over the centers. The National Institute of Mental
over 500,000 consumers. Advocates of outpa- Health (NIMH), established in 1949, was charged
tient clinics argued that they were cost-effective with oversight of the centers.
because they facilitated early detection of mental
diseases and treatment, thus making hospitaliza- Medicaid and Medicare
tion less likely. Despite the federal initiative to enhance com-
The National Mental Health Act of 1946 sig- munity mental health treatment, the populations
naled a shift in the fiscal responsibility for the of state mental hospitals experienced only a 15
mentally ill from state governments to the fed- percent reduction between 1955 and 1965. How-
eral government. The passage of the Mental ever, a major change occurred in 1965 with the
Health Study Act of 1955 (Public Law 84-182) passage of Medicaid, which was established by
allowed for an investigation and second look at the Social Security Amendments of 1965 that
the human and monetary costs of mental health added Title XIX to the Social Security Act. Med-
and resulted in the formation of the Joint Com- icaid was founded as a federal-state health insur-
mission on Mental Illness and Health (JCMIH). ance program to assist states to provide medical
The JCMIH issued a report in 1961, “Action for treatment for low-income and other needy indi-
Mental Health,” which considered mental health viduals such as the blind, the aged, and the dis-
problems and resources needed nationwide to abled. The federal government pays states for a
better serve the needs of individuals with mental large percentage of program expenditures, which
illnesses. The report recommended the funding of vary by state. States administer their programs,
 State Budgets 839

determine qualified services, and establish pro- 65 and older, regardless of income or medical his-
vider payment rates, while the federal govern- tory. Before its establishment, almost half of older
ment determines essential service components, Americans carried no health insurance because
eligibility standards, and oversees the state-oper- it was too expensive or unavailable. While not
ated programs. States are required to fund their as flexible in the way states were able to use the
share of Medicaid expenditures through legisla- funding, Medicare also contributed to the dein-
tive appropriations to the state Medicaid agency, stitutionalization of elderly patients by enhancing
intergovernmental transfers (IGTs), certified pub- their ability to remain in their communities, either
lic expenditures (CPEs), and permissible taxes in their homes or in skilled nursing facilities. The
and provider donations. creation of Medicaid, Medicare, and other fed-
Congress never foresaw that Medicaid would eral funding sources for the mentally ill and the
become a major purchaser of behavioral health aged, as well as new state and federal laws affect-
care services when first created. Growing federal ing hospital admissions, public sentiment con-
fiscal support for states’ behavioral health services cerning the validity of community care, and the
and programs during the 1960s included not only development of new psychotropic medications,
the creation of Medicaid but also the creation of led to a sharp decrease in institutionalization. By
Medicare (Title XVIII of the Social Security Act, 1975, the censuses of state mental hospitals had
1965). Additionally, permanent legislative author- dropped by approximately 60 percent.
ity was granted to the food stamp program by the
passage of the Food Stamp Act of 1964 (Public Additional Resources
Law 88-525). The availability of these programs In the 1970s, there were a series of ups and downs
and others created during the 1970s made hos- in federal financial support for states’ behavioral
pitalization of the mentally ill less attractive to health services. It had become apparent to many
SMHAs because more resources were offered to Americans that the nation’s behavioral health
maintain and care for them in their communi- structure as a whole was confusing, and commu-
ties. Further, Medicaid was restructured during nity-based care for the mentally ill was not a uni-
the 1980s to better care for the mentally ill, such versal solution for the problems associated with
as providing options such as case management, institutionalization. Presidents Richard M. Nixon
financial coverage for mental health clinics under (1969–74) and Gerald R. Ford (1974–77) both
a clinic option, and improved access to rehabili- vetoed further financial support for community
tation. Medicaid does not, however, reimburse mental health centers; however, Congress subse-
states for the care and treatment of individuals quently voted to overrule their vetoes.
between the ages of 21 and 64 in state mental In contrast, because of concerns about dis-
hospitals, even though similar care offered in the parities between the states regarding disability
specialized psychiatric units of general hospitals standards and income requirements for state-
or in private psychiatric hospitals is reimbursable operated disability plans, the Nixon administra-
under Medicaid. States saw an opportunity to tion established Supplementary Security Income
shift a large portion of their costs for the aged, for the Aged, the Disabled, and the Blind (SSI) in
disabled, and mentally ill to the federal govern- 1972, which is administered by the Social Secu-
ment by transferring patients to nursing homes rity Administration, to create consistency across
or other facilities that were eligible for Medicaid states. In 1973, the NIMH, which had orches-
funding. In illustration, almost 220,000 mentally trated the national trend from mental hospitals to
ill patients, of whom 188,000 were over 65 years community-based treatment, experienced a num-
of age, were cared for by nursing homes in 1963. ber of organizational changes. It first joined with
In contrast, these numbers rose to 427,000 and the National Institutes of Health (NIH) and then
368,000, respectively, by the late 1960s. in 1974, accompanied by the National Institute on
Similarly, Medicare (Title XVIII of the Social Alcohol Abuse and Alcoholism (NIAAA) and the
Security Act) also provided substantial relief to National Institute on Drug Abuse (NIDA), NIMH
persons suffering from mental illnesses through combined to form the Alcohol, Drug Abuse, and
the provision of health insurance to people aged Mental Health Administration (ADAMHA).
840 State Budgets

In 1975, the Mental Retardation Facilities and by Congress, which obliged states to submit
Community Mental Health Centers Construction detailed service plans describing the needs of the
Act was bolstered through amendments. After seriously mentally ill to the Centers for Medi-
President Jimmy Carter (1977–81) took office care and Medicaid to remain eligible for block
in 1977, he founded a commission to investigate grant funding. The act also placed emphasis on
the behavioral health system and make recom- the funding of community-based services for the
mendations for its improvement. The commis- mentally ill, including case management.
sion completed its final report in 1978, which Today, there are two block grant programs, the
included over 100 recommendations concerning Community Mental Health Services Block Grant
the relationships of federal, state, and local gov- and the Substance Abuse Prevention and Treat-
ernment programs and services, including Medi- ment Block Grant, both administered by the Sub-
care and Medicaid. The report eventually led to stance Abuse and Mental Health Services Admin-
the establishment of the Mental Health Systems istration (SAMHSA). SAMHSA was established in
Act in 1980, which aspired to strengthen com- 1992, after Congress passed the ADAMHA Reor-
munity mental health centers and not only identi- ganization Act (Public Law 102-321), which elim-
fied services for people with severe and persistent inated the ADAMHA and realigned the research
mental illnesses but also noted the distinct needs functions of NIAAA, NIDA, and NIMH with the
of other groups such as children and adolescents, NIH. The lack of federal support for federal-local
older adults, rural inhabitants, and rape victims. community mental health centers diminished their
stature in ensuing years, and the creation of state
State Block Grants block grants shifted the responsibility for the care
President Ronald W. Reagan (1981–89) and his and treatment of the mentally ill back to SMHAs
administration created sweeping changes to fed- and local authorities. Currently, the role of the fed-
eral behavioral health policy, beginning with the eral government in behavioral health services has
immediate repeal of the Mental Health Systems changed to one of information sharing and techni-
Act through the passage of the 1981 Omnibus cal assistance to boost the capacity of SMHAs and
Budget Reconciliation Act. This act also stripped local behavioral health services providers.
the services funding from the ADAMHA’s treat-
ment programs and rehabilitation services, and Dwindling Resources and Cost Cutting
channeled the funding for behavioral health ser- Other attempts were made by the Reagan admin-
vices into one block grant for the states. However, istration to cut federal expenditures during the
the federal government reduced mental health and 1980s that would impact behavioral health ser-
substance abuse allocations by 25 percent when it vices. In an effort to curtail rising expenditures
created the block grant, which forced many states for SSI and SSDI, the Social Security Administra-
to make cuts in community-based programs. State tion was ordered to make reductions. However,
block grants do not have burdensome program- the agency’s approach to effecting the reductions
matic requirements, resulting in states having was to swap out prevailing, accepted definitions
greater flexibility in the management of behavioral of mental illness with other more narrow defini-
health services and programs. Block grant alloca- tions in order to deny the mentally ill benefits.
tions allow states to tailor programs and services The public’s reaction was harsh, however, caus-
to their distinct behavioral health needs and are ing the Social Security Administration to reverse
intended to provide for prevention, treatment, its decision. For a brief period in the late 1980s,
and recovery assistance to augment other services federal expenditures for behavioral health ser-
covered by Medicaid, Medicare, and private insur- vices increased somewhat due to pressure exerted
ance. States also use block grant funds to assist by advocacy groups; however, the increases were
people without insurance to access needed services carefully concealed by supporters in omnibus
and to provide care and treatment not covered by budget bills.
Medicaid and Medicare for indigent individuals. Since the 1990s, however, public- and private-
In 1986, the State Comprehensive Mental sector funding for behavioral health services and
Health Plan Act (Public Law 99-660) was passed programs has been on the wane. Consequently,
 State Budgets 841

Medicaid expenditures have consumed a greater highest levels of service use. The largest amount
share of state budgets, surpassing state appropri- of behavioral health services are used by com-
ations for behavioral health services. In illustra- paratively few consumers, many of whom move
tion, during federal fiscal year 2010, total Medic- repeatedly from state hospitals to the community
aid payments amounted to $383 billion, of which because a truly comprehensive network of com-
the federal share was $260 billion (68 percent) munity care has never been achieved.
and the states’ share was $123 billion (32 per-
cent). Concern over growing Medicaid expendi- Current Roles and Responsibilities of
tures and the recent economic recession has made State Mental Health Authorities
Medicaid a prime target for legislators seeking to Today, SMHAs still retain control of their bud-
trim state budgets. States pay for their share of gets by directing the spending of state allocations
Medicaid through appropriations of general rev- and federal block grants and seeking Medicaid
enues, levying special taxes on health care provid- and Medicare reimbursements. Approximately
ers, and voluntary donations from hospitals and 70 percent of state funds for behavioral health
other organizations. A desire to contain Medicaid are dedicated to community-based programs.
costs and health care/social welfare costs gener- The fact that the bulk of behavioral health ser-
ally (e.g., reductions in SSI, public housing, and vices are now delivered through community-
the food stamp program) has had serious reper- based agencies means that the role of the SMHA
cussions for the mentally ill and their ability to has changed to one of administration and over-
remain independent in their communities. These sight. SMHAs are responsible for contracting
reductions also diminished the achievements with local providers, setting standards and rates,
made earlier in behavioral health service design defining eligibility, licensing community pro-
and implementation made possible by the flexibil- grams, performing quality assurance, and evalu-
ity of Medicaid requirements. ating services and programs.
The costs of community-based behavioral State legislatures hold SMHAs accountable
health services are more susceptible to change for funded services, and SMHAs have a vested
than those of general medical services, caus- interest in ensuring high performance in an era
ing concern in both state and federal sectors. of reduced state spending and competition. They
Therefore, federal and state governments have may sanction programs that do not prove to be
explored different rationing methods for mental effective and efficient by imposing corrective
health services delivery, such as capitation and action plans, restricting agency licensure or pro-
other kinds of managed care structures, includ- fessional certifications, or discontinuing funding
ing prepaid group practice, limiting entitlements altogether. Because of state budget cuts, SMHAs
by diagnosis, or calculating the level of cost shar- must maximize the potential of state and federal
ing based on the kind of service provided. How- funding to build sustainable and comprehen-
ever, these alternative services delivery methods sive systems of care, which is quite a challenge.
are complicated, requiring governments to solve Strengthening community agencies that provide
problems related to their construction, financ- behavioral health services is of paramount con-
ing, and accountability. Behavioral health advo- cern because many are overly reliant on Med-
cates, furthermore, take the position that certain icaid for survival, and the future of Medicaid
managed care practices are unfair to consumers. and other sources of funding is always subject
For instance, a diagnosis may be an inadequate to change.
measure of service needs, and many consumers of
behavioral health services do not meet the diag- Julie L. Framingham
nostic thresholds established for certain mental Florida Department of Children and Families
disorders but are nevertheless seriously impaired
in their psychosocial functioning. See Also: Community Mental Health Centers; Costs
State legislators, eager to trim behavioral health of Mental Illness; Deinstitutionalization; Economics;
costs, have the greatest ability to reduce expen- Mental Institutions, History of; Policy: Federal
ditures by targeting those consumers with the Government; Policy: State Government.
842 Stereotypes

Further Readings that are socially and culturally constructed. Most

Grob, Gerald N. “Mental Health Policy in the seriously, socially imposed stereotypes are read-
Liberal State: The Example of the United States.” ily internalized, creating destructive forms of self-
International Journal of Law and Psychiatry, v.31 stereotyping that reduce an individual’s sense of
(2008). distinctiveness and agency, and as a consequence,
Mazade, Noel A. and Robert W. Glover. “State clinical depression can follow. The incidence of
Mental Health Policy: Critical Priorities stereotyping within the field of mental health
Confronting State Mental Health Agencies.” provides a further illustration of the fact that the
Psychiatric Services, v.58/3 (2007). imposition of normative categories does not nec-
Mechanic, David and Richard C. Surles. essarily correlate with more obvious attitudinal
“Challenges in State Mental Health Policy and evidence of “prejudice” as understood in racial or
Administration.” Health Affairs, v.11/3 (1992). gendered terms. There is ample evidence for the
Rochefort, David A. From Poorhouses to tendency for health care providers to develop cat-
Homelessness: Policy Analysis and Mental Health egorical expectations of patients that calcify into
Care. 2nd ed. Westport, CT: Auburn House, 1997. stereotypical assumptions. Furthermore, more
Rosenheck, R. A. “Principles for Priority Setting in hostile and prejudicial stereotyping by class, gen-
Mental Health Services and Their Implications for der, or ethnicity may lead to hasty diagnosis (or
the Least Well Off.” Psychiatric Services, v.50/5 pigeonholing) of patients, particularly in terms
(1999). of socially or culturally informed diseases such as
depression or alcoholism. Harnessing knowledge
of differing stereotype content toward clusters of
mental illnesses may improve the efficacy of inter-
ventions to counteract public stigma.
Stereotypes
Creation of Categories
Stereotypes are generally conceived of in nega- However, this negative tradition of usage is chal-
tive terms—the organization of hostile over- lenged by a tradition within social psychology that
generations in order to overdetermine certain regards stereotyping as an essential way of build-
communities in pejorative terms. Studies of ste- ing conceptual categories. Stereotyping can serve
reotyping easily overlap into studies of prejudice cognitive functions on an interpersonal level and
and stigma. Of particular theoretical concern performs a necessary social function on an inter-
has been the stereotyping associated with men- group level. Stereotypes can, therefore, help make
tal illness and the practical deleterious effects sense of the world. They provide a form of cat-
of such typologies upon health care policy and egorization that helps to simplify and systematize
practice. Social psychologists have argued that information so that it becomes easier to identify,
stereotypes allow people to simplify their social recall, predict, and react to. Stereotypes, defined
world and may be essential to the way in which in this technical, value-free sense, are merely cat-
people make sense of the world. This simplifica- egories of objects or people. Between stereotypes,
tion may well have reductive prejudicial conse- objects or people are as different to each other as
quences, but simplifications are essential to the possible. Within stereotypes, objects or people are
construction of cognitive categories. Stereotypes as similar to each other as possible.
are part of the process of defining in-group and The ubiquity of stereotyping provokes the ques-
out-group dynamics. Determining who belongs tion as to why humans prefer to encounter infor-
within a group is inextricably linked with the mation in terms of categories. In 1954, Gordon
question of who should (or should not) be Allport argued that categories facilitate responses
excluded from a group. to unfamiliar objects. Within a group or category,
Stereotyping affects different forms of mental the distinctiveness of individual objects may be
illness in different ways, resulting in a variety highlighted. Moreover, people can readily describe
of ways in which human distinctiveness can be things within a category because objects within
tram-lined, according to predictive expectations the same category have distinct characteristics.
 Stereotypes 843

Allport acknowledges that a category may be an Sociologists from an interactionist background

arbitrary formulation, although it can be useful consider stereotyping in terms of detailed interac-
for the purposes of characteristic recognition. tions between people and groups, examining the
From an ergonomic point of view, stereotypes myriad of small ways in which individuals “size
may have a role in efficient deliberations, allow- one another up” while negotiating and socializing,
ing people to reach conclusions with less expen- both formally and informally. Stereotypes, preju-
diture of time and mental energy. The primary dice, and discrimination are understood as related,
motivation behind stereotyping is not some unjust but different concepts. Stereotypes are regarded
emotional aversion but rather a rational desire to as the most cognitive component, prejudice as
construct a social world that is less cognitively the affective, and discrimination as the behavioral
demanding. The study of stereotypes therefore component of prejudicial reactions. In this tripar-
collides with the theorization of in-groups and tite view of intergroup attitudes, stereotypes reflect
out-groups, familiar concepts within any tradi- expectations and beliefs about the characteristics
tion of trying to make sense of societal identity. of members of groups perceived as different from
Self-affirmation requires social affirmation, which one’s own, prejudice represents the emotional
in turn demands a differential logic. A positive response, and discrimination refers to actions.
sense of in-group membership is reinforced by the Despite these academic explanations, it is still
stereotyping of out-group exclusionary criteria. difficult to disentangle the habitual understand-
Stereotyping also provides a way of making ing of stereotyping from habits of oversimplifica-
consistent sense of presumed facts. For example, tion that fail to do justice to the complexity of
according to Henri Tajfel, Europeans stereo- human identities and experiences. Movies and
typed various non-European peoples in terms of media representations actively use stereotypes to
an inherent incapacity for independent develop- quickly convey desired emotions and meaning,
ment. This stereotype was used to justify Euro- and this is particularly true for the portrayal of
pean colonialism, but the stereotyping neither mental illness. Within the field of cultural stud-
preceded nor caused the colonial activities, func- ies, however, a more value-neutral definition of
tioning instead as a widely disseminated rational- stereotyping coexists with this pejorative under-
ization of policies that were already well estab- standing. Many narratives, whether literary, dra-
lished. Such stereotyping represents not so much matic, or filmed, make extensive use of “stock
cynical propaganda as an internalized “comfort- characters” who may be choreographed in ways
able doctrine.” that alternately flatter and challenge a reader or
a viewer’s expectations. In addition, a popular
Sociological Perspective stereotype such as the 19th century “stage Irish-
A less extreme way of considering stereotyping man,” although originally imposed from outside
within the context of in-groups and out-groups Ireland, may end up being enjoyed, appropriated,
insists upon the essentially differential nature of and perpetuated by Irish people.
identity. Logically, the characteristics that are
imposed upon an out-group are more descrip- Tanya M. Cassidy
tive of the needs, fears, and aspirations of the in- University of Windsor
group than of the group to whom they are tradi-
tionally and repeatedly applied. Furthermore, not See Also: Alcoholism; Emotions and Rationality;
all stereotypes are necessarily negative (e.g., Italy Labeling; Marginalization; Movies and Madness;
is stereotypically associated with sexual charisma, Popular Conceptions; Sex Differences; Social
delicious food, and artistic genius). Nor are ste- Isolation; Stigma; Stigma: Patient’s View.
reotypes always imposed from outside the group
that is defined. The concept of the “self-fulfilling Further Readings
prophecy” is familiar within studies of education, Jost, John T. and David L. Hamilton. “Stereotypes in
whereby students who are labeled low achievers Our Culture.” In On the Nature of Prejudice: Fifty
become unmotivated and used to a low level of Years After Allport, J. F. Dovidio, P. G. Glick, and
academic attainment. L. Rudman, eds. Oxford, UK: Blackwell, 2006.
844 Sterilization

Oakes, P. J., S. A. Haslam, and J. C. Turner. to such a degree that any means can be justified.
Stereotyping and Social Reality. Oxford: Persons of otherwise good sense and moral sensi-
Blackwell, 1994. tivity are thereby taken in, acting out of character
Sadler M. S., E. L. Meagor, and K. E. Kaye. in pursuit of the greater good.
“Stereotypes of Mental Disorders Differ in Like many other atrocities, compulsory steril-
Competence and Warmth.” Social Science and ization was born of ideology. The work of a pair
Medicine, v.74/6 (2012). of cousins—Charles Darwin by publishing On
Tajfel, H. Human Groups and Social Categories. the Origin of Species and Francis Galton by pub-
Cambridge: Cambridge University Press, 1981. lishing Hereditary Genius—provided the ideolog-
ical seeds of the eugenics movement, a program
of selective human breeding designed to better
the human race. By the end of the 19th century,
the scientific theory of Darwin and the statisti-
Sterilization cal speculations of Galton were being applied in
England. While eugenics remained in England, its
The idea of forcibly sterilizing American citizens doctrines were largely confined to advocacy by
is unthinkable to those with modern humanis- individuals and nongovernmental organizations.
tic sensibilities. If openly voiced by a politician, Thereafter, eugenic ideas crossed the Atlantic and
publicly defended by an intellectual, or even pri- grew more vigorously in American soil, transi-
vately maintained by a citizen, the idea would tioning from passive promotion by individuals to
be roundly condemned. Yet, in American his- active coercion by government.
tory, thousands were sterilized. These steriliza- Symbolizing the power of eugenic ideology,
tions were sanctioned by the culture at-large, distinguished U.S. Supreme Court Justice Oliver
authorized by politicians, condoned by intel- Wendell Holmes, Jr., while trying Buck v. Bell in
lectuals, and favored by many average citizens. 1927, authoritatively declared, “three generations
Today, the very act of sterilizing the mentally ill of imbeciles are enough!” Under this judgment
and the morally weak would cause posterity to from a justice presiding over the highest court,
question the mental health and moral character Carrie Buck, thought capable of bringing forth
of the perpetrators. But despite the severity of only defective progeny, was forcibly sterilized and
their transgressions, the eugenicists who sup- denied the natural right of reproduction.
ported these sterilizations were not crazed or Eugenically inspired forced sterilization legis-
psychopathic; they were swayed by the ideology lation was first passed at the state level in Indiana
of eugenic racial hygiene and its promise of elim- in 1907, which was the first step in legitimizing
inating inferiority, illness, and immorality from the sterilization surgeries that were being per-
the species. formed on select members of the prison and psy-
chiatric population. Under the combined impetus
From Ideology to Eugenics: of grassroots support and elite leadership, state
Racial and Mental Hygiene after state followed Indiana’s path. According to
Within the pages of the correspondence between a North Carolina government task force, between
Thomas Jefferson and John Adams, who carried 1929 and 1974, fully 7,600 men, women, and
on a philosophical correspondence from 1811 children were declared unfit to reproduce and
until their deaths in 1826, is a discussion about a thereafter sterilized by authority of the state’s
word created within the throes of the French Rev- eugenics board. Under the Racial Integrity Act of
olution: ideology. Adams, condemning the condi- 1924, nearly as many were sterilized in the state
tions out of which the term grew, understood the of Virginia. Other states less committed to racial
concept of ideology to sanction mad excesses that hygiene sterilized not thousands, but hundreds;
elicit evils. The true danger of ideology is in its for instance, Washington, Vermont, Utah, South
seductive trappings, in which it can craftily adorn Dakota, Pennsylvania, and South Carolina.
evil in the most ornamental of good intentions. Others, such as Wyoming and Tennessee, never
Ideology sanctions atrocities by exalting an end passed eugenic sterilization laws.
 Stigma 845

Perverse and misguided though it now science, full of the dross of ideology, value judg-
appears to contemporary persons, eugenics was ments, and tyranny.
an attempt to apply Darwinian insights toward Freed from the myopia of the times, later gen-
a human breeding program meant to better erations reconciled the folly of the eugenics exper-
mankind. Just as dog breeders select for certain iment with the wisdom of the American experi-
traits by controlling which dogs reproduce, so ment. Aspiring to some inchoate, ideal human
elites of all stripes sought to select for certain monoculture, eugenicists undervalued the diver-
traits by controlling which humans reproduced. sity of types and talents that form the foundation
Leonard Darwin, the son of Charles Darwin, of all societies. It is suggested that for a human
participated in the eugenics movement along population to be fully human, it must celebrate
with many other notable leaders, intellectuals, such diversity and protect, rather than persecute,
and politicians of the time: Winston Churchill, its “weak.”
Alexander Graham Bell, Thomas Hunt Morgan,
George Bernard Shaw, H. G. Wells, and Theo- Steven C. Hertler
dore Roosevelt. Imported from England, matur- College of New Rochelle
ing in America, and thereafter transferred to
Germany in its most virulent form, eugenics— See Also: Disability; Ethical Issues; Eugenics;
like other ideologies—justified abominable acts Genetics; Germany; Human Rights; Inequality;
with utopian hopes. Indoctrination, segregation, Intelligence; Kraepelin, Emil; Malaria Therapy; Nazi
and incarceration were mainstays in the eugeni- Extermination Policies; Policy: Federal Government;
cist arsenal, but sterilization was its irreparable Policy: Medical; Policy: State Government.
weapon of mass destruction. In an effort to pre-
clude the feeble-minded, promiscuous, epileptic, Further Readings
and insane from reproducing, thousands were Black, Edwin. War Against the Weak: Eugenics and
sterilized with the hope that future generations America’s Campaign to Create a Master Race.
would become ever more intelligent, chaste, New York: Four Walls Eight Windows, 2003.
healthy, and sane. Chesterton, G. K. Eugenics and Other Evils. Seattle,
This mission only came to an end after World WA: Inkling Books, 2000.
War II when the veneer of legitimacy fell away Kevles, Daniel. In the Name of Eugenics: Genetics
and the horror of German genocide was revealed. and the Uses of Human Heredity. New York:
Nevertheless, many state laws remained in force, Alfred A. Knopf, 1998.
and Buck v. Bell was never overturned. Instead Lombardo, Paul A. Three Generations, No Imbeciles:
of being decisively checked, compulsory steriliza- Eugenics, the Supreme Court, and Buck v. Bell.
tion withered away. As human rights violations Baltimore, MD: Johns Hopkins University Press,
mounted, public opinion changed and eugenic 2008.
sterilization slowed along with it. Sterilization
only fully ceased in the 1970s. All levels of gov-
ernment are still dealing with the ramifications
of forced sterilization. For instance, as recently
as 2011, North Carolina issued a public apology Stigma
and paid reparations to its victimized residents.
The history of eugenics, like so many other his- Those with mental illness have been stigmatized
torical epochs, serves as a testament to human from the earliest times. In more modern times,
hubris. Eugenicists came to believe they could even the notion of noncommunicable disease still
judge between the moral and immoral, the sane evokes stigmatizing behaviors. Labeling theory
and insane, and the intelligent and unintelligent. focuses on the tendency of society to label those
The trappings of science gave eugenicists an seen as deviant from accepted cultural norms.
implicit faith in the morality, psychiatry, and mea- Individuals attempting to hide their stigma may
surement of the day, which in turn gave eugeni- experience psychological damage, whereas oth-
cists the confidence to act. Yet it was alloyed ers who are able to challenge the obstacles of
846 Stigma

stigmatization may gain respect for themselves

and others.

Historical Stigma
Stigma is a Greek word that originally referred
to a type of marking that was cut or burned into
the skin of criminals, slaves, or traitors in order
to visibly identify them as blemished or morally
damaged persons. These individuals were to be
avoided or shunned, particularly in public places.
In the Hebrew scriptures, God declared that
Cain, the firstborn son of Adam and Eve, be cursed
for murdering his brother. A mark was placed on
him to warn others that killing Cain would pro-
voke the vengeance of God, that if someone did
something to harm Cain, the damage would come
back sevenfold. Thus, although marked as a dam-
aged—or stigmatized—person, those who would
cause harm to him would also be harmed.
Throughout history, slaves have been branded During a “Stomp the Stigma” mental illness awareness tour,
and disfigured in multiple ways. The nature of the actor Joe Pantoliano of The Sopranos and The Matrix fame
branding might be more visible for different types shares his own history of mental illness with U.S. Army soldiers
of offensives or to signify different functions. For at Division Chapel in Baghdad, Iraq, September 4, 2009.
example, a slave who stole might have a hand cut
off, but a beautiful slave intended for sexual per-
formance might be identified with only a discreet
mark or tattoo. Once the mark was known to more modern times that the mechanism by which
others, the individual’s status and place in society leprosy is transmitted from one person to another
was also known. through close contact is understood, and yet even
In the ancient world, families would often though this disease can be treated, the notion of
either lock a mentally ill person away from public leprosy still evokes stigmatizing behaviors.
view or send them away so as to prevent shame The idea of “stigma” does not just apply to
and preserve the family’s honor. Having a men- disabled people but also to those with certain ill-
tally ill family member, which could be viewed as nesses such as HIV/AIDS or cancer. Individuals
evidence of a damaged bloodline, might taint sib- with HIV or AIDS have long been stigmatized
lings and their potential marriage arrangements because the disease continues to most profoundly
and/or opportunities. In some cultures, the men- affect gay men, even though many cases do occur
tally ill were left to wander the streets, surviving among heterosexual men and women. The stigma
only by begging. Their behavior, rather than any associated with cancer is possibly related to the
distinguishing mark, was what identified them as fear of death, as there is no evidence it is trans-
stigmatized. mittable from person to person. In some cul-
tures, people believe that cancer is brought on
Social Stigma by something the person did and thus they are
Social stigma is an important concept in help- shunned and shamed. Those with mental illness
ing understand how people with disabilities are may or may not look different than others, but
excluded from social activities. In some cases, the their thinking and behavior may identify them as
stigma might be justified by society, as in the case damaged or dangerous, which results in stigmati-
of lepers in ancient society, who lived in colonies zation by others.
away from healthy individuals because of fear of Émile Durkheim (1858–1917) may have been
the illness and a lack of treatment. It is only in the first sociologist to discuss stigma. In The Rules
 Stigma 847

of Sociological Method (1895), he described soci- Individuals undergoing chemotherapy may wear
ety as having the ability to judge and punish acts wigs to disguise the effects of their medication,
that it believes to be deviant. Thus, deviance is a for example. While prostheses may be functional,
social construct that is defined by society, which many people employ them to look “normal.”
may choose how to treat those identified as such. Thus, a person with a missing leg may choose to
In Asylums: Essays on the Social Situation of use different artificial limbs if wearing shorts or
Mental Patients and Other Inmates (1961), Erv- long pants. Individuals with mental illness may
ing Goffman (1922–82) explored the process take medications and employ other strategies to
by which individuals in mental institutions are function normally in society and hide their illness.
socialized into their roles as mental patients and In these situations, the person with the potentially
come to accept their stigmatized identities. The discreditable stigma may find it difficult to act
term social stigma was first used by Goffman in normally in case they are exposed.
Stigma: Notes on the Management of Spoiled According to Goffman, when the discrediting
Identity (1965). He suggested that certain groups or discreditable status becomes the predominant
of people are defined as discredited because of way in which one is viewed by others, it becomes
characteristics that are seen as negative by soci- the stigmatized person’s “master status.” The
ety, and this “spoils normal identity.” He identi- stigma completely dominates the way the per-
fied three forms of social stigma categorized by son is treated, and any other attributes are seen
overt or external deformations, deviations in per- as less important. Their whole identity is tied to
sonal traits, and tribal stigmas related to mem- the stigma. The person who has mental illness is
bership in a stigmatized ethnic, cultural, national, only seen as someone who is “crazy” and not as a
or religious group. Mental illness, drug addiction, funny, smart, or thoughtful, person or as a caring
alcoholism, gay lifestyle, promiscuous behavior, father, husband, and/or worker. Goffman writes
pedophilia, and other behaviors are all perceived that the individuals themselves may accept this
as deviations that lead to stigmatization. William master status and come to see themselves solely in
Jopling (1911–97), who treated and worked with terms of their stigmatized status.
individuals afflicted with leprosy, used Goffman’s In research published in 1986, Graham Scam-
framework identifying three sources of stigma bler and Anthony Hopkins studied the impact of
among individuals with leprosy: physical defor- stigma upon the lives of epileptics with a focus on
mities causes by the illness, damaged character coping strategies developed in the family and at
from living in a leper colony, and membership in work. While epilepsy itself is not a mental illness,
a poor social class. it may predispose individuals or co-occur with
Goffman suggested that there are two types of various psychiatric disorders. Scambler and Hop-
stigma. The obvious types of stigma, such as being kins made distinctions between “enacted” and
in a wheelchair, missing a limb, odd behaviors, “felt” stigma. Enacted stigma refers to instances
or being morbidly overweight, were called “dis- of discrimination against people with epilepsy on
crediting stigma.” People may find it awkward to the basis of perceived unacceptability or inferior-
have normal social relations with those who are ity. This did not include episodes of what might
discredited. They may be confused, awkward, or be called “fair” or “legitimate” discrimination,
embarrassed; avoid eye contact; or ignore the vis- for example, banning epileptics from driving,
ible disability. operating industrial machinery, or serving in the
Discreditable stigmas are not necessarily as military. Felt stigma is the individual’s manifesta-
easily identified. This stigma is one of poten- tion of the fear of enacted stigma and also encom-
tial, dependent on whether other people find out passes a feeling of shame associated with being
about the discreditable status. Examples include epileptic.
HIV status, mental illness, or epilepsy. Individu- Scambler and Hopkins identified different tac-
als in this category may try to hide their discred- tics that individuals and their families might use to
itable characteristics by trying to “pass.” Light- manage their stigma. If the stigmatizing condition
skinned blacks, gay men and lesbian women, and is not visible, the person may use “selective con-
the mentally ill have attempted these strategies. cealment” and only tell a few friends. In “covering
848 Stigma

up,” the person tells no one. If the person is unable In order to reduce the stigma of negative
to hide the condition, they may prefer “medical- labels, unwanted categorizations may be rejected
izing the behavior” and thereby emphasize the on the basis that they are merely “labels,” often
medical aspects using the “sick role,” possibly with attempts to adopt a more socially accept-
to gain sympathy. Finally, the ill individual may able language. For example, “Physical disabil-
“condemn the condemners.” In this situation, the ity” becomes “differently abled” and “mentally
people with the stigmatizing condition challenge retarded” becomes “developmentally delayed.”
those stigmatizing them through the use of pub- Using this perspective, a stigma is defined as a
lic media to shame opponents, legal measures to powerfully negative label that changes a person’s
ensure rights, and other political actions. self-concept and social identity. In some situa-
tions, particularly among a group of individuals
Labeling and Stigma who have been stigmatized because of their mem-
Labeling theory is a sociological perspective that bership, the group creates a more powerful label
proposes that deviance is not inherent to an act but that is attached to a positive identity. Lesbian
focuses on the tendency of society to label those seen women and gay men reject the label homosexual
as deviant from accepted cultural norms. Different with its psychological, diagnostic implications.
cultures may interpret the same behavior in differ- Even psychiatric diagnostic categories may adapt
ent ways, which may or may not result in stigma. less negatively perceived labels. Autism becomes
Thus, a psychotic individual may be seen as either autism spectrum disorder, which may offer par-
mentally ill or a messenger from the gods. Label- ents the hope of different levels of potential func-
ing theory is concerned with how the self-identity tioning of their children.
and behavior of individuals may be determined or
influenced by the terms used to describe or classify Conclusion
them. Medical and psychiatric diagnoses have this Throughout history, individuals have been stigma-
effect on people. Once they have been labeled as tized for a variety of reasons. Because of stigma,
having an illness, people behave as if they are that many have tried to control who knew about their
illness. Their entire identity may become that of difference, managed behaviors in order to be
being a person with a specific malady. accepted in society, or challenged the prevailing
A child identified as having attention deficit views. Those who try to hide their stigma may be
hyperactivity disorder (ADHD) may believe they subjected to additional psychological damage as
are not able to learn and therefore may stop try- they try to deny who they are and/or when their
ing to learn, and as a result do poorly in school. stigma becomes known. Others who are able to
This exemplifies the concept of the self-fulfilling challenge a stigmatizing society may face great
prophecy, as developed by Robert Merton (1910– obstacles but may also gain respect for themselves
2003), an American sociologist. In a self-fulfilling and others. Individuals with mental and physical
prophecy, a belief or an expectation (correct or illness and other stigmatizing conditions chal-
incorrect) about the way a person or a group will lenge people to think about their internalization
behave effects the eventual outcome of a situa- of stigma and the effects it has on others and soci-
tion. The response is, “See, I told you this would ety at large.
happen,” when in actuality, it is the person’s belief
that the event would happen that caused them to Adele Weiner
behave as if it would—and eventually makes it so. Metropolitan College of New York
Others can also participate in this phenomenon: Kim Lorber
a wife who calls her husband a lazy drunk, par- Ramapo College of New Jersey
ents who conclude why their child cannot do well
in school and place few expectations on her to See Also: Dangerousness; Identity; Labeling; Mental
succeed academically, and a father who calls his Illness Defined: Historical Perspectives; Mental
son clumsy and does not allow him to participate Illness Defined: Sociological Perspectives; “Normal”:
in sports or other activities he has identified as Definitions and Controversies; Patient Activism;
impossible for his child. Popular Conceptions; Stigma: Patient’s View.
 Stigma: Patient’s View 849

Further Readings have developed successful alternatives, often based

Goffman, Erving. Asylums: Essays on the Social on creative methods and personal narratives.
Situation of Mental Patients and Other Inmates. The term stigma derives from the ancient
Garden City, NY: Anchor Books, 1961. Greek word for a bodily mark signifying that the
Goffman, Erving. Stigma: Notes on the Management bearer is morally corrupt or inadequate and con-
of Spoiled Identity. Englewood Cliffs, NJ: Prentice- sequently should be shunned. Thus, to be seen as
Hall, 1963. possessing a stigmatized attribute is to be mor-
Medscape Reference. “Psychiatric Disorders ally and socially discredited. The attributes that
Associated With Epilepsy.” http://emedicine.med are considered discrediting are particular to social
scape.com/article/1186336-overview (Accessed contexts, rather than universal. Mental illness/
February 2013). distress is an example of an attribute that is cur-
PBS News Hour. “In Many Countries, Cancer rently stigmatized, typically causing the bearer to
Patients Face Stigma, Misperceptions” (June 15, be rejected by those who are considered, or who
2011). http://www.pbs.org/newshour/updates/ consider themselves to be, mentally healthy.
health/jan-june11/cancerstigma_06-15.html Much of the research and thinking on the soci-
(Accessed February 2013). ology of stigma stems from Erving Goffman’s sem-
Scambler G. “Re-Framing Stigma: Felt and Enacted inal work, Stigma: Notes on the Management of
Stigma and Challenges to the Sociology of Chronic Spoiled Identity. Goffman identified three catego-
and Disabling Conditions.” Social Theory & ries of stigma, based on physical disfigurements;
Health, v.2/1 (2004). tribal groupings such as race; and character blem-
Scambler, G. and A. Hopkins. “Being Epileptic: ishes such as weak will, unnatural passions, and
Coming to Terms With Stigma.” Sociology of dishonesty. Mental illness and distress falls into
Health & Illness, v.8/1 (1986). http://onlinelibrary this last category, meaning that it tends to be stig-
.wiley.com/doi/10.1111/14679566.ep11346455/ matized as a defect of an individual’s character.
abstract?globalMessage=0 (Accessed December Writing in a contemporary context, Bruce Link
2012). and Jo Phelan argue that stigma arises when four
converging concepts are present: first, human
differences are identified and labeled; second,
labeled people are linked to undesirable charac-
teristics or negative stereotypes through domi-
Stigma: Patient’s View nant cultural beliefs; third, people are placed into
stigmatized categories creating an “us and them”
The stigmatization of people who experience separation; and fourth, being placed into stigma-
mental distress has been of sociological interest tized categories causes status loss, discrimination,
since the 1960s, with understanding of the con- and unequal outcomes. Link and Phelan assert
cept extended by Jo Link and Bruce Phelan in the that processes of stigmatization can only occur
2000s and beyond. However, some consumers/sur- when dominant groups possess social, economic,
vivors have argued that discrimination is a more and political power, enabling them to identify and
relevant concept because it describes macro-level label difference, associate it with negative stereo-
social and economic exclusion. Stigma and dis- types, and exercise rejection and discrimination
crimination are experienced by consumers/survi- against the out group.
vors across the globe and in numerous social con- While the term stigma tends to be used in the
texts. Stigma can be internalized, and consumers/ mental health arena, Link, Phelan, and colleagues
survivors can develop strategies to resist negative argue that it is synonymous with the term preju-
stereotyping and discrimination. Although societ- dice, which is used to describe negative attitudes
ies around the globe have developed national-level and behavior toward people who belong to par-
antistigma campaigns, these have been criticized by ticular sociodemographic categories. In contem-
some consumers/survivors for medicalizing human porary society, one rarely discusses the stigma of
emotions and responses to poor social conditions. being black, gay, or female. Instead, one thinks
Instead, people who experience mental distress in terms of racism, homophobia, and sexism.
850 Stigma: Patient’s View

Similarly, mental health survivor Liz Sayce has resources and their chances of living in poverty.
argued that the term stigma is best reserved for Historically, and in some contemporary contexts,
how individuals perceive themselves and engage people who experience mental distress are subject
in social relations at a micro level, yet what is of to human rights abuses, including caged beds and
greatest concern is the macro-level consequence of forced sterilization. Workers across health and
stigma: discrimination. Thus, rather than think- social care services typically hold more negative
ing about stigma in the context of an individual’s attitudes toward people diagnosed with mental
attitudes, by shifting the focus to the macro level, illnesses than the general population. This means
one is forced to acknowledge social and economic that people who use psychiatric, health, and social
exclusion and the need for structural change. care services are sometimes exposed to disrespect-
ful, unfair, or abusive care.
Mental Illness Stigma
Empirical research, which typically uses survey Responses to Stigma
methodology, has found that the stigmatization Like workers in mental health services, people
of and discrimination against people who expe- who experience mental distress may share and
rience mental distress is a global phenomenon: extend dominant cultural beliefs about mental
it has been identified on every continent and in illness. As a consequence, they are vulnerable
high-, middle-, and low-income countries. Some to internalized stigma or self-stigma. Internaliz-
studies report an increase in global stigma. Inter- ing stigma involves a process of being exposed
nation research into the attitudes of the general to culturally shared stereotypes about mental ill-
public has found that negative attitudes consist ness; failing to critically appraise or reject these
of false, and often contradictory, beliefs. These negative stereotypes, leading to the adoption of
include that people who experience acute mental these beliefs; identification as a member of the
distress are incompetent, dangerous, responsible stigmatized group through personal experiences
for their problems, and unlikely to recover. As a of mental distress; and application of dominant
consequence, the general public typically desires negative stereotypes to oneself. This can lead to
social distance from those they see as mentally ill. a sense of shame or embarrassment, alienation
This impacts the extent, quality, and number of from “normal” society, lowered self-esteem, dis-
relationships that people who experience mental empowerment, and social withdrawal. However,
distress may have. Moreover, false negative ste- the concept of self-stigma has been criticized by
reotyping and the public’s desire for social dis- consumers/survivors because it fails to acknowl-
tance have been found to affect the mental health edge the rejection, discrimination, and prejudice
and quality of life of consumers/survivors. that they routinely experience. Similarly, the con-
Stigma and discrimination operate in numerous cept of internalized racism no longer has currency.
social contexts, with each carrying consequences People who experience mental distress have
for people with mental distress. Structural stigma adopted various strategies to resist the negative
includes discriminatory laws and the underfund- stereotyping, prejudice, and discrimination they
ing of mental health services. Negative media face. These include hiding mental distress and
representation of people experiencing mental dis- psychiatric service use from friends, families,
tress, typically the dangerous lunatic stereotype, neighbors, and employers so as to avoid being
confirms the public’s misconception that the men- labeled mentally ill. A further tactic is to try to
tally ill pose a threat, compounding their desire “act normal,” either by concealing thoughts and
for social distance. This exacerbates the margin- emotions that could identify one as belonging to
alization of people experiencing mental distress. the stigmatized group or by adopting dominant
When consumers/survivors become parents, negative cultural beliefs about the mentally ill.
they are exposed to particular discrimination, Yet others embrace the social status conferred
such as being seen as an unfit parent. Stigma and on them by their experiences of mental distress,
discrimination in the workplace stops people rejecting dominant cultural beliefs and embrac-
from attaining and keeping jobs and hinders pro- ing the concept of mad pride and mad culture.
motion. This impacts people’s access to economic These tactics need to be seen within their broader
 Stress 851

cultural context, with stigma and discrimination Rose, Diana, et al. “Reported Stigma and
enforced by dominant cultures, making labeling a Discrimination by People With a Diagnosis of
social, rather than individual, problem. Schizophrenia.” Epidemiology and Psychiatric
Around the globe, societies have attempted to Sciences, v.20 (2011).
implement macro-level solutions to stigma and Sayce, Liz. “Stigma, Discrimination and Social
discrimination. These typically revolve around Exclusion: What’s in a Word?” Journal of Mental
coordinated mass media campaigns to educate Health, v.7/4 (1998).
the public about mental health, challenge negative
stereotypes, and reduce discrimination. Examples
of such programs include the World Psychiatric
Association’s Global Programme Against Stigma
and Discrimination, Beyond Blue in New Zea- Stress
land, Time to Change in England, the National
Anti Stigma Campaign in the United States, and Stress is a complex phenomenon involving both
the PSYKE-Campaign in Sweden. Evaluations of psychological and physiological components.
these programs suggest that they have enjoyed When under stress, individuals are often aware
some success. However, the programs tend to of their own subjective, psychological experi-
be based on a medical model of mental distress, ence, reporting that they feel “stressed.” Many
which assumes that the “sufferer” is experiencing people may not be aware, however, that dramatic
an illness akin to heart disease or cancer, which physiological responses are also occurring. These
could strike anyone. This medical model is rejected responses are termed the “stress response” or the
by some consumers/survivors, who believe that it “fight-or-flight response.” The stress response is
stigmatizes them further by medicalizing human designed to save an individual’s life in an emer-
emotions and responses to social conditions such gency, but it may also cause harm to both the
as inequality, abuse, and poverty. Furthermore, the body and one’s psychological well-being if not
campaigns have been seen by some as an attempt managed properly. A wide variety of stress man-
to destigmatize psychiatry and its treatments, agement techniques are available. An industry
rather than reducing prejudice against people who has formed around stress management, involv-
experience mental distress. Consequently, psychi- ing the marketing and sale of physical and mental
atric consumers/survivors have developed methods techniques and substances that are ingested (for
for tackling discrimination. These include sharing instance, herbal supplements).
personal testimonies, narratives, and creative chal-
lenges to discrimination such as art and drama. The Stress Response and Disease
These methods are now recognized as among the The stress response occurs following the presence
most effective to tackle stigma and discrimina- of one or more threatening or challenging situ-
tion and have been incorporated into many main- ations called “stressors.” The stress response is
stream antistigma programs. an all-body response. A number of the physical
changes that occur during the stress response are
Angela Sweeney increased heart rate and blood pressure; increased
University College London blood flow to large muscles; release of stress
Sarah Clement hormones, including epinephrine (adrenaline)
King’s College London and cortisol; mobilization of energy stores (for
instance, glucose in the liver); and a slowing of
See Also: Consumer-Survivor Movement; Patient digestion. These body changes prepare the indi-
Accounts of Illness; Patient Activism; Patient Rights; vidual to fight the stressor or flee from it.
Stigma. This response can damage the body, contrib-
uting to both physical and psychological ill-
Further Readings ness. Researchers have discussed the relation-
Link, Jo and Bruce Phelan. “Conceptualizing ship between the stress response and disease
Stigma.” Annual Review of Sociology, v.27 (2001). states, such as neuroscientist Bruce McEwen and
852 Stress

Elizabeth Lasley in their book The End of Stress This epidemiological trend suggests that the
as We Know It and biologist Robert Sapolsky in stresses associated with low socioeconomic status
his work Why Zebras Don’t Get Ulcers. As McE- may contribute to these psychiatric conditions.
wen and Sapolsky describe, it is clear that stress However, other explanations are possible. For
plays a role in the development of heart disease. instance, individuals who suffer from these dis-
When the hormones adrenaline and cortisol orders may have genetic relatives (including par-
are released during stress, they mobilize fats as ents and more distant ancestors) with deficits that
sources of energy. Those fats that are not utilized make it relatively more difficult to acquire high-
as energy during the stress response may remain paying employment or even hold a job; thus, the
circulating in the blood, attaching to the interior characteristics of the psychiatric condition may
of blood vessels. This condition, called athero- cause lower socioeconomic status rather than the
sclerosis, decreases the circumference of the blood other way around.
vessels. The heart responds by increasing blood Scholars have discussed a number of additional
pressure, which may further damage blood ves- types of stress as playing potential causal roles in
sels and place one at risk for a heart attack or schizophrenia. Schizophrenia is a serious psychi-
stroke. This is one example of the many ways that atric condition involving deterioration of cogni-
stress may contribute to heart disease. tive functioning and abnormal emotional reac-
Stress also affects the immune system. Immune tions. It is a psychotic disorder, meaning that the
suppression may occur, increasing one’s risk of sufferer has lost contact with reality. Schizophre-
contracting infectious diseases, both bacterial and nia has been associated with family stress. Par-
viral. Stress may also contribute to an overactive ents of people with schizophrenia often are more
immune system, which can increase allergies, con- critical of and intrusive with their children and
tribute to asthma, or contribute to autoimmune have inferior communication with their children
conditions, a state in which the immune system compared to other parents.
attacks one’s own body tissues. Examples of auto- Some scholars, such as John Modrow, argue
immune conditions include rheumatoid arthritis, that social labeling contributes to the severity of
type I diabetes, the skin condition psoriasis, and schizophrenia. According to Modrow, in many
lupus. In research on stress and immune suppres- societies, the label schizophrenic is applied to
sion, there is substantial evidence that the immune people who do not conform to particular societal
suppression resulting from stress increases the norms of proper behavior. Once the label occurs,
probability that a person will come down with he says, it is dramatically stigmatizing, creating
symptoms of the common cold when they are a self-fulfilling prophecy. The nonconforming
exposed to the virus. Researchers are currently “schizophrenic” behaviors become reinforced and
investigating connections between stress-related exaggerated, and the individual appears increas-
immune suppression and the contraction of other ingly more “crazy” to others while, in turn, react-
infectious diseases. Additionally, the research on ing to the reactions of others, feels “crazy” him-
ways in which stress affects the immune system self or herself.
continues to shed light on the precise mecha- Even in cases where stress is not associated
nisms by which stress plays a role in autoimmune with a diagnosable physical or psychiatric illness,
conditions. stress can negatively affect well-being. Because the
stress response is energy consuming, stress causes
Stress, Psychiatric Illness, and Well-Being fatigue, diminishing quality of life. Stress may
Social stress is also related to psychiatric illness. also cause many types of discomfort, including
In the United States, people from lower socioeco- muscle pains, gastrointestinal upset, headaches,
nomic backgrounds are more likely to be diag- and sleep difficulties. These symptoms may affect
nosed with a number of psychiatric disorders, work performance and disrupt recreational activ-
including schizophrenia, phobias, generalized ities. These symptoms may also cause irritability,
anxiety disorder, panic disorder, and obsessive- which may affect interpersonal relationships. In
compulsive disorder, than are individuals from short, stress is related to physical illness, mental
middle or higher socioeconomic backgrounds. illness, and general dysfunction.
 Stress 853

Stress Management accepted health care practices in Eastern cultures

A wide variety of stress-management techniques for centuries. Stress-management techniques are
may prevent or decrease the negative impacts of now also part of mainstream medicine in Western
the stress response. In their 2007 book The Prae- cultures, as evidenced by many prominent West-
ger Handbook on Stress and Coping, psycholo- ern hospitals and medical establishments such as
gist Alan Monat and colleagues divide stress the Mayo Clinic, the National Institutes of Health,
management techniques into three broad catego- and university medical centers. These institutions
ries: (1) a change in one’s environment or life- include extensive sections on what stress is, how
style, for instance, eating nutritious food, exercis- to identify its presence, and instructions on how
ing regularly, and avoiding stressors; (2) a change to utilize stress management techniques.
in one’s attitude or perception, such as taking As stress and stress management have become
assertiveness training, working to reduce feelings well-known concepts in the West, a market has
of hostility toward others, and using one’s sense been created for stress-management products.
of humor; and (3) a modification of the physio- Television, radio, and the Internet advertise
logical effects of stress, including deep breathing, stress management techniques such as yoga and
autogenics (imagining oneself heavy and warm), tai chi DVDs and CDs providing guided medita-
and meditation. A number of books provide tions. Additionally, ingestive substances related to
instructions on relaxation techniques, such as stress management are advertised. For instance,
The Relaxation and Stress Reduction Workbook a number of herbal dietary supplements are sold
by Martha Davis, Elizabeth Eshelman, and Mat- for relaxation and stress-related appetite control,
thew McKay. such as Relora, which is presumed to affect the
Many of the modern stress management hormone cortisol. Forskolin is also used to treat
techniques such as exercise, meditation, mas- many medical conditions, including colon cancer,
sage, yoga, tai chi, and visual imagery have been glaucoma, and heart problems, and is sold as a

Employees at the National Aeronautics and Space Administration’s Marshall Space Flight Center take some time to relax at a Yoga
for Anxiety class during the 2012 Safety, Health, and Environmental Day, May 2, 2012. Many modern stress management techniques
such as meditation, massage, yoga, tai chi, and visual imagery have been used in eastern cultures for centuries.
854 Sudan

weight loss aid despite the fact that there is limited conducted have been limited by geographical area
evidence for its effectiveness. Such is the case for or subject of focus.
many stress-management products on the market. The wide distribution of the Sudanese popu-
lation and the conflicts that have ravaged the
Gretchen M. Reevy country make a centralized mental health system
California State University, East Bay impossible in the near future, and any system that
will serve the populace will need to be decen-
See Also: Anxiety, Chronic; Depression; Life Skills; tralized. There is little support at present for the
Mind–Body Relationship; Post-Traumatic Stress severely mentally ill, including psychotics, depres-
Disorder; Role Strains; Schizophrenia; Self-Help. sives, those with pronounced anxiety disorders,
epileptics, and the severely retarded.
Further Readings While South Sudan seceded with the peace-
Comer, Ronald J. Abnormal Psychology. New York: ful agreement of the Sudanese government after
Worth, 2010. a referendum, it followed a 25-year civil conflict
Davis, Martha, Elizabeth R. Eshelman, and Matthew between the north and south, and has been fol-
McKay. The Relaxation and Stress Reduction lowed by continued border skirmishes. Many
Workbook. Oakland, CA: New Harbinger, 2008. people, not only in the south, but also in border
Mayo Clinic. “Stress Basics.” http://www.mayoclinic communities, have been repeatedly displaced. As
.com/health/stress-management/MY00435 a result, post-traumatic stress disorder (PTSD)
(Accessed August 2012). and depression are widespread in the country. A
McEwen, Bruce and Elizabeth Norton Lasley. The 2007 study of Juba, in what is now South Sudan,
End of Stress as We Know It. Washington, DC: found that one-third of respondents were likely
Joseph Henry Press, 2002. candidates for PTSD, while one-half had suffered
Modrow, John. How to Become a Schizophrenic: The from depression at some point in the previous
Case Against Biological Psychiatry. Lincoln, NE: year. Men were more likely to suffer from either
Writers Club Press, 2003. mental illness.
Monat, Alan, Richard S. Lazarus, and Gretchen The Sudan Household Health Survey was con-
Reevy, eds. The Praeger Handbook on Stress and ducted in 2006, the first comprehensive baseline
Coping. Westport, CT: Praeger, 2007. health and nutrition study of all of Sudan’s 25
Sapolsky, Robert. Why Zebras Don’t Get Ulcers. states since the 1980s. In addition to other issues,
New York: Henry Holt, 2004. the results of the survey revealed a number of
issues that have a negative impact on children’s
health, and likely contribute to developmental
disorders and other problems. Only a little more
than half of the population have access to clean
Sudan water, while only 31 percent of the population use
appropriate sanitation facilities. Only 31 percent
The Republic of Sudan, sometimes called North of children less than 5 years old had been immu-
Sudan since the secession of South Sudan in nized, and 31 percent of the same age group expe-
2011, is a north African Arab state. Most of the rienced moderate to severe malnutrition.
Christian population was in the southern region, Sudan’s children are at great risk for child-
so Sudan’s population is now overwhelmingly hood health problems that could lead to neuro-
Muslim. logical, developmental, or cognitive disorders in
Sudan’s mental health programs are minimal. their adulthood, even apart from their exposure
There are no mental health services provided to trauma and stress. Further, only 11 percent of
for people displaced by the country’s internal the population consume iodized salt, necessary
conflicts; they have nowhere to turn except to a to prevent mental retardation in babies (among
few nongovernmental organizations with low other health concerns). Subsequent technical
resources. There have not been sufficient mental papers issued as follow-ups to the survey focused
health assessments, and the studies that have been on ways that the plight of Sudanese children could
 Suicide 855

be improved, including better access to iodized Studies of Sudanese refugees in Western countries
salt, alternative family care, and schooling. found similar results—a high rate of exposure to
Further, these are national averages. In some trauma, albeit generally lower than in the Ugan-
states, the number of children who had received dan study, perhaps because of the longer passage
all their vaccinations was lower than 10 percent; of time before reaching non-neighboring countries.
and in Jonglei, 66 percent of children had received Standardized surveys about mental health ask
no vaccination at all. There were strong correla- respondents to answer questions about what they
tions throughout the country between the likeli- have experienced in a specific period of time, such
hood of vaccination and the mother’s education, as the week or year preceding the survey.
as well as the family’s wealth. Overall, the south
was worse off. Care-seeking behavior was also Bill Kte’pi
examined, and it was found that only 15 percent Independent Scholar
of women knew the danger signs for pneumonia,
making children much more vulnerable to that See Also: Children; Post-Traumatic Stress Disorder;
disease than in most countries. Social Isolation; Stress; Trauma, Psychology of;
Almost three-quarters of Sudanese households Uganda; Violence; War; Women.
rely on solid fuels (wood and charcoal) for cook-
ing, which expose adults and developing children Further Readings
to unhealthy levels of carbon monoxide, sulfur Cockett, Richard. Sudan: Darfur and the Failure of
dioxide, and hydrocarbons, increasing the risk an African State. New Haven, CT: Yale University
of low birth weight and a host of respiratory Press, 2010.
diseases. Collins, Robert O. A History of Modern Sudan. New
An International Medical Corps study exam- York: Cambridge University Press, 2010.
ined the questions of basic needs, mental health, Jok, Jok Madut. Sudan: Race, Religion, and Violence.
and women’s health among displaced persons in London: Oneworld Publications, 2007.
Darfur, the war-torn region in western Sudan. Kim, Glen, Rabih Torbay, and Lynn Lawry. “Basic
With no significant differences by age, marital sta- Health, Women’s Health, and Mental Health
tus, ethnicity, or the period of time that they had Among Internally Displaced Persons in Nyala
been displaced, 31 percent of respondents suffered Province, South Darfur, Sudan.” American Journal
from major depressive disorder, while 63 percent of Public Health, v.97/2 (2007).
reported depression symptoms. Suicidal ideation Natsios, Andrew S. Sudan, South Sudan, and Darfur:
was found in 5 percent of respondents, and sui- What Everyone Needs to Know. New York:
cide attempts in 2 percent. The same percentage Oxford University Press, 2012.
of respondents had a household member who had
committed suicide in the previous year. Though
alarmingly high relative to the general worldwide
population, the suicide statistics were still lower
than those found in many other conflict-affected Suicide
populations. PTSD and mental disability were
also common. Cultural influences underlying suicidal behav-
A 2007 study of Sudanese refugees displaced ior are often like icebergs: deep and powerfully
to Uganda found that nearly all (94 percent) had influential, but often out of visible awareness.
been exposed to serious trauma, including forced Culture profoundly shapes human responses and
isolation, forced separation from family, and lack manifests as broad variances in suicidal behavior
of food and water, as well as violence witnessed, among cultural groups. Cultural scripts determine
experienced, or perpetrated. One-third of the adults who dies by suicide, when they die, and how. Cul-
in the camp suffered from PTSD, as did 20 per- tural scripts can place barriers in between those
cent of children. Every ex-soldier in the camp was most vulnerable for suicide and lifesaving treat-
found to suffer from depression. Only 20 percent ment. Evidence for suicidal behavior variations
of patients seeking care did so for mental illness. among several cultural groups exists; therefore,
856 Suicide

broadening the traditional mental health frame- • Time orientation to past, present, and
work to a more sociocultural framework for future and how time is linked together
understanding suicide would be beneficial. • Focus on relationships and ideas of
Originally developed by organizational devel- “selfishness”
opment scholars, the iceberg model of culture • Burdensomeness and duty as they relate
has been largely applied to cross-cultural analy- to suicide
sis among ethnicities and races, yet the concept • Views of conflict and willingness to con-
is equally powerful because of its implication for front aberrant behavior
mental health and suicide. According to this the-
ory, observable behavior is only a 10 percent indi- Men complete suicide more often than women.
cation of what is actually happening to a person to White men have the highest rates. The trend
drive that behavior at any given point in time. For occurs as they are entering the workforce, and
instance, at the surface of culture, one can witness then starts to peak again as they leave the work-
help-seeking behavior, access to mental health force. The highest raw numbers for suicide are for
services, policies, and everyday conversation white men in the working years. Native Alaskan
about mental health and suicide, but these exter- and American Indian rates are highest among
nal cues only give a glimpse into the complex con- their young male population, and taper off over
ditioning underneath. In fact, the most effective time. This pattern is seen in indigenous commu-
treatments exist, and they can be free and easily nities around the world. Black women have the
accessible; however, if the deep culture mandates lowest rates throughout the life span. Young adult
nondisclosure for emotional distress, most follow men appear to be increasing in suicide risk over
this unconscious set of rules. Many are not even the last two decades (suicide is the second lead-
able to identify what these rules are because they ing cause of death for men ages 25–34), while the
have been conditioned through ancestors’ history, female rate is falling. In particular, young African
norms of geography, and other powerful cultural American males’ rates have significantly increased
forces such as religion and media. Like the ice- over the past 20 years; however, suicide is the only
berg, these cultural impressions shift very slowly means of death for which black males have lower
and have tremendous impact on core beliefs, the mortality rates than European American males.
inner values that help construct worldviews.
These cultural constructions shape the reality Working-Age Men
of suicide and suicidal behavior across the follow- According to the Centers for Disease Control and
ing factors: Prevention (CDC), the following suicide statistics
are true for men:
• Definitions of sanity and insanity and
their relationship to suicidal behavior • Suicide is the eighth leading cause of
• Tolerance of emotional pain and accept- death for all U.S. men
able patterns of emotional expression • Males are four times more likely to die
• Concept of “self” and the relationship to from suicide than females
community, or the sense of individualism • Suicide rates are highest among European
and collectivism and what this means to Americans and Native Americans
the suicidal person
• Work ethic and problem-solving capacity Consistently, over different ages, nationalities,
to solve the suicidal distress and ethnic and racial backgrounds, men seek help
• Biological, psychological, sociological, less frequently than women and die by suicide at
and spiritual views of mental illness and much higher rates. This trend is partly because of
suicide men’s socialization by their culture. Some argue
• Locus of control, or the belief in fate that because of socialized gender roles, men are
versus the ability to shape destiny and its less likely to identify symptoms of depression and
impact on hopelessness within the sui- seek appropriate help. Men often wait until their
cidal person mental health symptoms are debilitating before
 Suicide 857

entering the health care system, which makes early every adult to own one, and the majority
identification and intervention for suicide risk a of these are owned by men; when com-
challenge. This critical difference is often cited as pared to women, men tend to use much
the main reason for the gender gap in suicide. more lethal means in suicidal behavior,
Cultural codes of achievement, aggression, and this difference is believed to be partly
competitiveness, and emotional isolation are con- because of differences in acquired capac-
sistent with the masculine stereotype; symptoms ity from more exposure to guns, physi-
of depression are not. Cultural ideals of rugged cal fights, and violent sports; in Western
individualism, a commonly held masculine ideal industrialized countries, it is considered
in the United States, lead to social fragmentation unmasculine to survive a suicide attempt
and fewer coping alternatives, compounding the • Sense of isolation—research indicates
suicide risk. In fact, when examining gender roles, that women are more likely to have
a double jeopardy for suicide emerges. Men who larger social networks and rely on them
are the most at risk for suicide are often the least more as a strategy to cope with life
able to access mental health services, usually for stressors as compared to men; social
cultural reasons. Men who adhere to rigid ste- networks have shrunk dramatically in the
reotypes of masculinity are associated with both last 20 years, and young, white, educated
increased likelihood of depressive symptoms and men seem to have lost more confidants
more negative attitudes toward seeking help. than any other population
Often, men do not report experiencing suicidal • Stigma associated with help-seeking
distress because they equate this with weakness behavior
or a sense of failure. Because of this shame, men
often cope with their suicidal experiences with Native Americans and Alaska Natives
male norm-congruent vices, which make the In the United States, the suicide rate among Amer-
problem much worse. These vices, such as sub- ican Indians ages 15 to 34 is 1.9 times higher than
stance abuse, sexual acting out, and compulsive the national average. Suicide death rates for Native
video game playing or gambling, are often dis- American populations spike just before and during
missed because it is “what men do”; however, the time of life when they would be transitioning
these behaviors can lead to an escalating cycle of into adulthood. Many attribute these spikes to the
dysfunction, depression, and increased risk-tak- influence of historical trauma and lost connections
ing. In particular, there is a strong link between to cultural traditions and roles.
alcohol dependence and suicide risk in men, and Outside the United States, others have noticed
impairment from substances often makes the dif- the connection between indigenous populations
ference between a suicide thought and an attempt. and increases in young male suicide risk. For
There are many risk factors for suicide, and the example, indigenous populations from around
following particularly apply to men: the world show the same pattern: a spike in
male adolescent suicide deaths and an absence
• Alcohol and other substance abuse dis- of a similar spike among the elderly that is com-
orders—the lifetime prevalence rate for monly seen in European American males. Many
alcohol dependence is more than twice researchers have speculated that this pattern
as high in men as it is for women, and in has more to do with the legacy of colonialism
developed countries, approximately one and historical trauma than with mental illness.
in five men and one in 12 women develop Researchers studying Native Hawai‘ians point
alcohol dependence during their lives out that since their first contact with Europe-
• Impulsive and/or aggressive tendencies ans, native peoples have suffered great loss from
• Job or financial loss—men report more infectious disease, the taking of land, violations
work-related stressful life events that of sovereignty rights, and assaults on traditional
women cultural and healing systems. These same authors,
• Easy access to lethal means—America has trying to understand the surge in adolescent male
at least 200 million firearms, enough for suicides, note that these rates started to climb in
858 Suicide

the 1960s, when the first postwar generation’s do not consider themselves gay or bisexual. There
breakdown of village cohesion and intergenera- are others who feel attracted to the same sex, but
tional families occurred. never engage in sexual behavior and live a hetero-
Researchers speculate that the coming-of-age sexual life. All of these complications play a part
process, when a young adolescent starts to take in the complexities of studying the suicidal risk of
on responsibilities of the family, changed dramati- these very diverse populations.
cally in the last century, and with these changes Furthermore, most death certificates and hos-
the traditional rituals lost their social-cultural pital records do not collect information on sexual
significance, leaving these young men with much orientation. Even when the data are collected, they
role confusion. The authors suggest that behav- are not compiled by the National Violent Death
ioral and mental health disparities within indige- Reporting System in a way that helps researchers
nous populations result from the discord between look for trends across large numbers of people.
their internalized ideal cultural identity and their Therefore, most of the research has been done
expressed cultural self. This same pattern of sui- with gay, lesbian, or bisexual people who have
cide rates and hypothesized cause is attributed to experienced suicidal ideation or prior attempts,
the trends in adolescent male suicides in the native and from that one can hypothesize about the sui-
youth of North America, the Maori of New Zea- cide risk. The following are some of the most cur-
land, the aboriginal people of Australia, Cana- rent findings:
dian First Peoples, and the indigenous people of
the Arctic, Brazil, and other regions. • Nonheterosexual college students were
Those studying these trends suggest that using 2.56 times more likely than heterosexual
a mental illness paradigm to explain suicide risk students to have seriously considered
may be limited as an effective tool with these attempting suicide
populations. Research in India, for example, • Lesbian, gay, and bisexual (LGB) youth
suggests that suicides are often more related to are one to seven times more likely to
socioeconomic circumstances, especially the have attempted suicide than heterosexual
adverse economic conditions affecting farmers. youth
These researchers acknowledge that distress sec- • LGB youth suicide attempts have higher
ondary to life circumstances can be understood intent to die and higher lethality than
through the lens of a medical model of depres- those of their heterosexual peers
sion, but the understanding would be limited. In
addition, treating mental illness alone will not There are many unique risk and protective fac-
have a major effect on reducing suicide of these tors that young sexual minority and gender non-
populations because of the sociocultural drivers conforming people experience. On the risk side,
of the distress. the coming out process can be a particularly rough
time when young people are facing rejection and
Gay, Lesbian, Bisexual and hostility from their families, friends, schools, and
Transgender People and Suicide faith communities. In addition, many young peo-
There are many complexities in understanding ple have great internal conflict about their sexual
the true levels of risk of these very diverse cul- orientation that they often cannot discuss freely
tural groups. First, some groups that are often with the people who are closest to them. When
associated with sexual orientation diversity (i.e., they know of other young adults who struggle
intersex, transgender, questioning, and “queer”) and take their lives, they become at risk for con-
have not been extensively studied to fully under- tagion. On the protection side, young adults who
stand their true risk of suicide; however, many are working through sexual orientation or gender
anecdotal reports exist that give evidence for con- identity development benefit greatly from caring
cern. Second, within each of these groups, there mentors who can model for them a way through
are many differences and there is still no consen- the process. When supportive groups and wel-
sus on defining the groups. For instance, many coming environments emerge, their many visible
people who engage in same-sex sexual behavior and vocal cues of acceptance also add protection.
 Suicide: Patient’s View 859

Veterans just mental illness drive suicide behavior. In popu-

The Veterans Administration estimates that each lations such as indigenous groups, men of work-
year, 6,500 veterans die by suicide. While veter- ing age, LGB people, and veterans, many other
ans make up only 13 percent of the U.S. popula- sociocultural factors are evident. Thus, for suicide
tion, they comprise approximately 20 percent of prevention to be comprehensive and effective,
the people who die by suicide. additional prevention practices beyond treatment
Suicide among male veterans is more than dou- for mental illness are needed.
ble the suicide rate among civilian peers, and vet-
erans with post-traumatic stress disorder (PTSD) Sally Spencer-Thomas
are more than three times as likely to die by sui- Carson J. Spencer Foundation
cide as the general population.
Many cultural reasons for these concern- See Also: Cross-National Prevalence Estimates;
ing trends exist. First, upon transition back into Depression; Gender; Suicide: Patient’s View; War.
civilian life, many veterans discover that war
survival skills do not easily translate into non- Further Readings
military roles. For example, communication pat- Biddle, Lucy, et al. “Factors Influencing Help-Seeking
terns are extremely different and concerns about in Mentally Distressed Young Adults: A Cross-
safety and trust may also get in the way of war- Sectional Survey.” British Journal of General
riors successfully integrating into general society. Practice, v.54 (2004).
In war, hypervigilance saves lives, and trust must Canetto, Silvia. “Love and Achievement Motives in
be earned because everyone could be a poten- Women’s and Men’s Suicide Notes.” Journal of
tial enemy. Warriors are routinely recognized for Psychology, v.136/5 (2002).
being courageous and strong—attributes that go Leach, Mark. Cultural Diversity and Suicide: Ethnic,
against the behavior of help seeking. Religious, Gender, and Sexual Orientation
For those who have been deployed to war, many Perspectives. New York: Routledge, 2006.
other complications may put service members at Mahalik, James and Aaron Rochlen. “Men’s Likely
greater risk for suicide. PTSD and traumatic brain Responses to Clinical Depression: What Are They
injuries are the invisible wounds of war, yet they and Do Masculinity Norms Predict Them?” Sex
leave deep scars in the psyches of their sufferers. Roles, v.55 (2006).
Those who have experienced the ugliness of Moller-Leimkuhler, Anne Maria. “The Gender Gap
war usually have their worldviews altered in a in Suicide and Premature Death or: Why Are Men
way that civilians can never appreciate. Few seem So Vulnerable?” European Archives of Psychiatry
to understand what they have been through, and and Clinical Neuroscience, v.253 (2003).
they are now separated from the people who
could relate to their experiences the most, their
battle buddies. If they have lost close friends in
combat, they may be experiencing survivor guilt
that exacerbates their ruminative state. The Suicide: Patient’s View
adrenaline rush of war cannot be duplicated, but
many unconsciously try to recapture those feel- Suicide is a mysterious enigma that challenges
ings through high-risk behavior such as reckless most people on many levels. One of the biggest
driving, bar fights, and substance abuse. aspects of the challenge is that one can never
If there is a possibility that they might be ask the person who died, “why?” One can only
deployed again, many actively resist the reintegra- infer from notes left behind, snippets of last con-
tion process and are unable to purposefully plan versations, and changes in behavior. Emerging
for the future. All of these dynamics put obstacles research asks both people who have survived
between wounded warriors and traditional meth- significant suicide attempts and those who have
ods of helping. been bereaved by suicide about their experiences.
By exploring the deeper cultural issues behind Through this new knowledge, suicidologists are
suicide, one learns that many other factors beyond developing better models of risk and prevention.
860 Suicide: Patient’s View

The question of “why” often haunts the minds

of those bereaved by suicide. While one can never
really know all the reasons why people die of sui-
cide, there are some explanations that can help
elucidate how individuals might find themselves
in such a state of despair. Most people who kill
themselves believe that suicide is the only solu-
tion to their unbearable situation. Sometimes,
the analogy of what happened in New York City
on 9/11 gives people a framework for empathy.
When one remembers 9/11, images are etched in
memories such as the pictures of people jumping
out of the World Trade Center. These people did
not want to die. They were leaping to escape the
flames at their back. In a similar manner, people
who contemplate suicide are trying to escape
some type of peril in their lives or unbelievable
pain in their souls. Most find it difficult to truly
appreciate the flames that consume the minds of
people who contemplate suicide.
Ed Shneidman, a founder of the field of sui-
cidology, coined the term psychache to describe
the excruciating psychological pain that suicidal
people experience, which often blocks the abil-
ity to see other potential solutions to problems.
Psychache torments individuals who often do not
want to die, they just cannot escape. Even though
a pervasive sense of hopelessness stifles the ability
for many to seek help, most suicidal people are
very ambivalent about taking their lives.
William Styron, the Pulitzer Prize–winning Wide receiver Kenny McKinley of the Denver Broncos warms
author of Sophie’s Choice, wrote about his up on game day against the New England Patriots, October 11,
psychache in his 1990 book, Darkness Visible: A 2009. McKinley committed suicide on September 20, 2010, at age
Memoir of Madness: “tomorrow, when the pain 23. In addition to being on the injury roster, it was revealed that
descended once more . . . I would be forced to he had a gambling problem and was deep in debt at the time.
judge that life was not worth living and thereby
answer, for myself at least, the fundamental ques-
tion of philosophy.”
that may or may not have empirical support. To
What Are Risk and Protective Factors? differentiate, risk factors offer longer-term risk,
According to the Suicide Prevention Resource while warning signs are signals of proximal risk
Center, “Risk factors may be thought of as lead- for suicide. Many risk factors are static and endur-
ing to or being associated with suicide; that is, ing, while warning signs are episodic and vari-
people ‘possessing’ the risk factor are at greater able. Promoting awareness about risk factors and
potential for suicidal behavior. Protective factors, warning signs enables the lay public to identify
on the other hand, reduce the likelihood of sui- and refer people at risk earlier in the evolution of
cide. They enhance resilience and may serve to the suicide risk. After convening a working group
counterbalance risk factors.” to review the risk factor and warning signs litera-
Risk factors and warning signs are often con- ture, the leading experts in the field developed a
fused and appear on multiple lists on the Internet consensus two-tiered approach to warning signs.
 Suicide: Patient’s View 861

The first set of warning signs is accompanied self-preservation. This theory goes beyond pre-
by an agitated depressive state, then the risk is vious theories of suicide that were adequate in
even graver. That is, when a person is highly anx- describing psychological risk factors but did little
ious, which may be indicated by pacing, rapid to explain why some people with those risk fac-
thoughts, tremors, and insomnia while they are tors died by suicide and others did not.
also despondent and are verbalizing suicide intent, The theory states that wanting death is com-
they should be taken very seriously. People who prised of two psychological experiences. The first
are in danger of taking their lives may try to reach is a perception of being a burden to others (per-
out to others, sometimes directly, sometimes indi- ceived burdensomeness). According to Joiner,
rectly. Rarely will at-risk individuals immediately when people are in this state, they feel that their
volunteer the information that they are thinking death is worth more to the people who love them
of harming themselves. Instead, they might ver- than their life. The word perceived is empha-
balize their suicidal thinking with vague threats sized because frequently these thoughts are sig-
such as the following: nificantly distorted by depression or other mental
disorders.
• “I wish I were dead” The second is a social disconnection to some-
• “People would be better off if I were not thing larger than oneself (thwarted belonging-
around” ness). People are hardwired to be in relationship
• “Soon you won’t have to worry about with others. For some people, this means just a
me” couple of very intense relationships; for others, it
• “I just can’t take it anymore. I am done” means vast social networks. When people lose key
• “I wish I could go to sleep and never relationships with partners, children, colleagues,
wake up” and friends through death, divorce, separation,
moves, layoffs, or conflict, they can experience
While much focus has been on the proximal profound distress that can lead to a desire to die.
warning signs for suicide, efforts are now also Marked social withdrawal is not temperamental
focusing on how to identify more distal risk shyness. Rather, it’s a marked change: the per-
factors. When the course of these risk factors son used to be engaged with friends and family,
is altered early, the developmental progression and now they withdraw into a bedroom or into
of mental health issues over the life span is also their own head, and what you see is what Joiner
changed. In heart disease prevention, efforts try calls “an inward gaze of bemused resignation and
to change children’s diets early to prevent heart resolution.”
disease later. Likewise, when efforts prevent By themselves, however, neither of these states
depression, drug and alcohol abuse, family con- is enough to move a person to act on the desire
flict, child abuse, and conduct disorders, suicide for death. For this, the person needs an acquired
is prevented. For example, in the 1980s, preven- capacity for suicide. A person must have the know-
tion initiatives targeted aggressive behavior in the how and must be habituated to both the pain and
classroom, and 15 years later, researchers found fear associated with lethal self-harm before he or
that the kids who were in the intervention group she is a high risk for suicide. Three things build an
had a significantly lower probability of reporting acquired capacity for suicide: a temperament of
a suicide attempt. fearlessness, provocative and painful experiences,
and access to and knowledge of lethal means.
Model of Suicide Risk Some people come out of the womb as risk tak-
In his book Why People Die by Suicide, Dr. ers. They do not seem to be afraid of anything.
Thomas Joiner brings together several theories Natural risk-takers in society include law enforce-
of suicide that have emerged over the past two ment personnel and military, sky divers and adven-
centuries in developing his model of suicide risk. ture explorers, race car drivers and emergency
In his theory, Joiner claims that those who kill room doctors. These people are not at risk for sui-
themselves not only have a desire to die, they cide unless they have a desire for suicide. Should
have also learned to overcome the instinct for that desire ever develop, however, they have less
862 Suicide: Patient’s View

distance to cross to self-harm because the fear of ifs.” When loved ones die from a prolonged ill-
death or pain is not as great as in other people. ness, by contrast, there is time to prepare for
Repeated exposure to physically painful and their absence.
psychologically provocative experiences is the sec- Deaths that involve suffering or extreme pain
ond way that people can acquire the capacity for may cause horrifying traumatic imagery and
suicide. For some people, this means a history of intrusive thoughts, whether or not the bereaved
physical or sexual abuse. For others, it is chronic actually witnessed the death or the body. If the
injuries or illnesses that require adapting to high death occurred in a familiar or personal space of
levels of pain. For still others, it may be repeated the bereaved, that space will most likely continue
suicidal thoughts or attempts. When Denver to trigger traumatic reactions.
Bronco Kenny McKinley died by suicide, his death The randomness of such a loss can trigger a
sent shock waves through the nation. However, in greater sense of vulnerability and anxiety. This is
the NFL, there are a number of stories of suicide often the case when there were no apparent warn-
attempts and death, especially for retired players. ing signs before the person died.
Professional football players are national heroes. In addition to the primary loss of the person,
They have it all: fame, money, and talent. But secondary losses may include loss of income,
they also have fearlessness, and usually a history loss of a home, or loss of all things familiar. The
of powering through intense pain and debilitating resulting disorganization can strain the family
injuries. The vast majority do not experience sui- and social system.
cidal crises, but when they do, they have a shorter Sometimes, the reactions of first responders,
distance to go to reach a place of considering sui- who need to rule out homicide in every suicide
cide because they are not afraid of pain. case, can increase confusion and distress among
The last acquired-capacity method is familiar- those bereaved. If the events surrounding the
ity with and access to lethal means. The more death were newsworthy, the bereaved may also
comfortable a person is with the lethal means of be dealing with the intrusion of the media.
suicide, the more likely he or she will choose that Trauma reactions and grief work are often at
method, should they find themselves wanting to odds with each other. On one hand, the trauma
die by suicide. experience leads to continual intrusion of the
So, in Joiner’s theory, both conditions must death event. Survivors of suicide loss can’t stop
exist to have increased risk for suicide. A desire thinking about the death scene (even when they
for suicide is necessary but not sufficient. Suicidal are dreaming), and disturbing images may flash
thoughts are relatively common experiences, but before the mind’s eye when they least expect it.
suicide death is much less so. This is because most The horror can be overwhelming, and the natu-
people who have suicidal thoughts do not have ral impulse is to stay away from anything that
the acquired capacity for lethal self-harm. reminds them of the trauma. Sometimes, sur-
vivors develop post-traumatic stress disorder
After a Suicide: The Paradox (PTSD) in the aftermath of a violent or unex-
of Traumatic Grieving pected death.
In the aftermath of an unexpected death, espe- As researchers pose questions to those most
cially suicide, traumatic grief is a common reac- directly affected by the crisis of suicide, both the
tion. When this occurs, both trauma and grief suicidal and those left behind, the mystery of sui-
reactions are experienced together, and elements cide becomes less of an enigma and more of a sig-
of this combined level of psychological distress nificant preventable public health problem.
are often debilitating and complex.
A number of circumstances about a suicide Sally Spencer-Thomas
death may influence traumatic grief reactions. Carson J. Spencer Foundation
The unexpected death offers no opportunity
for good-byes, unfinished business, resolution See Also: Art and Artists; Depression; Patient
of conflict, or answers to questions. Often, the Accounts of Illness; Self-Help; Self-Injury; Trauma:
bereaved are left with endless “whys” and “what Patient’s View.
 Szasz, Thomas 863

Further Readings illness. Instead, Szasz contended that these were

Joiner, Thomas. Why People Die by Suicide. meaningless and without scientific validity. Szasz
Cambridge, MA: Harvard University Press, 2006. believed strongly that mental illness does not exist
Stapleton, Arnie and P. Solomon Banda. “Kenny in the way that it has been defined by the psychi-
McKinley Gambling Problem: Broncos Receiver atric profession. He further argued that treating
Was Deep In Debt Before Suicide” (December 1, this behavior medically therefore represents both
2010). http://www.huffingtonpost.com/2010/12/01/ coercive practice and the exercise of control by
kenny-mckinley-gambling-p_n_790699.html the psychiatric community.
(Accessed June 2013). Szasz described mental illness as a myth, and
Styron, William. Darkness Visible: A Memoir of at best merely a metaphor. He saw the context
Madness. New York: Vintage, 1992. of behavior as crucial in defining mental illness,
Suicide Prevention Resource Center. “Risk and stating that “If you talk to God, you are praying;
Protective Factors for Suicide.” http://www.sprc if God talks to you, you have schizophrenia.” He
.org/sites/sprc.org/files/library/srisk.pdf (Accessed outlined his theories in 1961, with the publication
August 2012). of The Myth of Mental Illness. This book was
published during a time of some crisis for psy-
chiatry generally, with the emergence of the anti-
psychiatry movement. Szasz argued that mental
illness was a pseudoscientific term. He contended
Szasz, Thomas that illness or disease must be related to the body,
not the mind, and that mental illness can there-
Thomas Szasz was born on April 15, 1920, in fore only exist as a metaphor.
Budapest, Hungary. He moved to the United He argued that the popular approach to men-
States with his family in 1938, where he studied tal illness as disease, while understandable given
at the University of Cincinnati, and subsequently some of the similarities, is flawed. Given that the
graduated as valedictorian with a medical degree term mental illness generally refers to undesirable
in 1944. He spent his career as a psychiatrist, thoughts, feelings, and behaviors, he contended
writer, and academic. Szasz authored 35 books that mental illnesses are problems with living, as
that have been translated into many languages, as opposed to the result of any observable pathol-
well as hundreds of journal articles. ogy. Szasz attacked psychiatry for categorizing
Szasz worked briefly at Cincinnati General such behaviors and suggested that this process
Hospital before moving to the Chicago Institute of categorization and the labeling of patients
for Psychoanalysis, where he gained his diploma as diseased was an attempt to exert control. He
and then worked for the next five years. During thus saw the medicalization of behavior as an
this time, Szasz also spent two years in military exhibition of power that removed free will and
service with the U.S. Navy. He joined the State responsibility from people. Szasz further argued
University of New York (SUNY) faculty, where he that the true nature of disease is manifested in
gained tenure in 1962, and remained there until pathology at the cellular or molecular level. His
his retirement in 1990. Szasz continued to pub- position was that if one cannot measure or test
lish prolifically after retirement, until his death on something in a scientific way, as he contended was
September 8, 2012, aged 92. the case with mental illness, then it should not be
Szasz has frequently been associated with the labeled as disease. Szasz advocated a libertarian
antipsychiatry movement; however, he did not view of freedom and suggested that human free-
accept this and was negative toward both the dom should only be restricted by a criminal act.
label and those most closely associated with it, He saw human beings as free agents and, as such,
for example, R. D. Laing. Szasz believed in the fully responsible for their actions.
validity of noncoercive psychiatric practice, but Szasz felt that individual competence should be
he opposed involuntary psychiatric interventions. a matter for the legal system to decide. He argued
In addition, he argued against the categories that against the assumption that medical professionals,
psychiatrists had developed with regard to mental and mental health workers more generally, possess
864 Szasz, Thomas

the ability to determine the correct course of action on practices that restricted freedoms, questioning
for someone exhibiting behaviors seen as undesir- the legitimacy of such approaches. This concern
able. He therefore suggested that in legal settings, and his unwavering defense of personal freedom
expert witnesses should not be allowed to testify and responsibility led the American Humanist
regarding the mental state of an accused individ- Association to honor him as Humanist of the
ual, for example, in support of an insanity defense. Year in 1973. His championing of individual
Szasz’s views were criticized by many of his rights against the power of medical authority has
peers. It was suggested that his theories could do influenced some current psychiatric practice, such
damage to people who were suffering. Critics sug- as user-led approaches.
gested that people are not always in a position
to take responsibility for their actions because of James Edward Houston
what they are experiencing. However, at the core of Nottingham Trent University
Szasz’s arguments was a genuine concern for those
who were suffering. His pro-psychiatry stance can See Also: American Psychiatric Association;
be overlooked, with his theories misrepresented Antipsychiatry; Biological Psychiatry; Medicalization,
as anti-intervention, rather than anticoercion over History of; Medicalization, Sociology of.
antimedicalization. Szasz’s critics further suggest
that mental illnesses can and are now approached Further Readings
and measured in a scientific way, thereby rejecting Szasz, Thomas. “Debunking Antipsychiatry: Laing,
Szasz’s main argument that mental illness is a myth Law, and Largactil.” Existential Analysis, v.19
and cannot be considered as disease. These critics (2008).
include the American Medical Association (AMA) Szasz, Thomas. The Myth of Mental Illness:
and the American Psychiatric Association (APA). Foundations of a Theory of Personal Conduct.
Szasz is recognized as one of the foremost crit- New York: Paul B. Hoeber, 1961.
ics of psychiatry, coercion, and medical treatments Szasz. Thomas. The Second Sin. Garden City, NY:
for behavior. His criticisms of psychiatry focused Doubleday, 1973.
 T
Tanzania number of mental health care units at other hos-
pitals throughout the country.
The United Republic of Tanzania is an east Afri- There is no formal mental health care available
can country on the Indian Ocean, including the outside of the large hospitals, so it is out of reach
former country of Tanganyika on the mainland of the rural population. No regional, district, or
and the semiautonomous islands of Zanzibar, community organization allocates money to treat
which united in 1964. The country is diverse, mental illnesses. There are only six psychiatrists
with roughly equal number of Christians, Mus- working in the public sector, few in the private
lims, and followers of indigenous religions. The sector, a limited number of psychiatric nurses,
mainland also includes significant populations of and an estimated 2.5 million mentally ill; the
Buddhists and Hindus. overwhelming majority will never receive profes-
Half of the leading causes of disability in Tan- sional care.
zania are mental illnesses and neurological dis- Mental illness carries a strong stigma, strong
orders, and suicide is the tenth leading cause of enough not only to shame the mentally ill and
death. Tanzania is one of the poorest countries their families and discourage the revelation of a
in the world, and health care access is extremely condition required in order to receive care, but
limited, explaining the popularity of traditional also to discourage medical professionals from
healers, who are cheaper and more widely dis- entering the psychiatric field. The belief that men-
tributed. Traditional healers often use herbs or tal illness is contagious is prevalent, even among
spiritual techniques to serve their patients. Men- medical students, as is the belief that mental ill-
tal health care is even less common than physi- ness is spiritual in origin and inaccessible to medi-
cal health care. About 80 percent of the popula- cine. In many cases, mentally ill relatives (some-
tion live in rural areas, away from the centralized times parents or older siblings) are cared for by
health care system, and one-third of the central- children. Many of the seriously mentally ill are
ized live below the poverty line. In a country of 40 homeless or squatters, living off donations.
million people, there are a total of 900 psychiatric The stigma affects the quality of care, likeli-
beds (spaces in hospitals for psychiatric patients), hood of seeking care, attitude of relatives toward
600 of which are in the single, government-run the afflicted, possibility of reentering society after
mental health hospital, the Psychiatric Referral recovering from a mental illness, and formulation
Hospital Mirembe in Dodoma. There are a small of policy. The mentally ill typically have difficulty

865
866 Tardive Dyskinesia

obtaining skills to hold a job, as well as diffi- See Also: Religiously Based Therapies; Spiritual
culty interacting in the social world, and so, even Healing; Stigma: Patient’s View.
with treatment, they may face obstacles. In many
cases, the mental illness stigma also attaches to Further Readings
neurological conditions. The mentally ill may be Jenkins, Rachel, Joseph Mbatia, Nicola Singleton, and
shunned because their presence may be seen as Bethany White. “Common Mental Disorders and
cursing the community or drawing the ire of a Risk Factors in Urban Tanzania.” International
witch. The family of a mentally ill person may Journal of Environmental Research and Public
also be shunned. Blaming the patient for their Health, v.7/6 (2010).
condition is extraordinarily common, even among Mbatia, Joseph and Rachel Jenkins. “Development
medical professionals. of a Mental Health Policy and System in Tanzania:
As in much of the developing world, there is An Integrated Approach to Achieve Equity.”
a serious supply problem with medication. Much Psychiatric Services, v.61/10 (2010).
psychiatric medication is priced out of reach of Ngoma, Mdimu Charua and Martin Prince.
patients in Tanzania, but even so, it is simply not “Common Mental Disorders Among Those
consistently available. Because the government Attending Primary Health Centers and Traditional
and most medical institutions do not prioritize Healers in Urban Tanzania.” British Journal of
mental illness, budgets do not allow for the pur- Psychiatry, v.183 (2003).
chase of psychiatric medications in significant
quantity, and often the drugs that are purchased
are out of date with modern practices. Because
the country is so decentralized, patients have to
travel great distances to receive their medications, Tardive Dyskinesia
and medicating a chronic condition is prohibi-
tively difficult for many. Tardive dyskinesia is a neurological disorder
HIV/AIDS is an epidemic in Tanzania, with a associated with the use of antipsychotics and
prevalence of about 5.6 percent of the adult popu- some drugs used to treat gastrointestinal disor-
lation. There is a strong correlation between HIV/ ders. After prolonged use of these drugs that act
AIDS and mental illness because of the trauma as dopamine antagonists, often in high doses,
and stress of the disease. patients may develop tardive dyskinesia. It is
In many parts of the country, traditional Afri- characterized by repetitive, involuntary, tic-like
can religion is the dominant faith, and it has an movements.
important cultural impact, even among adher- The word tardive refers to a late-appearing
ents of Christianity and Islam. Key elements of condition. Dyskinesia relates to involuntary mus-
traditional African religion include the belief in cle movements or problems controlling voluntary
a divine creator, a holistic view of the world, muscle movements. These movements often occur
and the belief in a spirit world that can influence in the facial muscles (particularly the mouth,
the physical world and does so regularly. This tongue, cheeks, and jaw) but can also happen in
spirit world was traditionally seen as the cause the arms, legs, fingers, toes, hips, and abdomen.
of many mental and physical ailments. Christians The mouth may move up and down or side to
are less likely to visit traditional healers but do side. The tongue may stick out and move around,
not eschew them entirely. In much of the country, the cheeks may puff out, and the person may dis-
traditional healers provide an accessible health play lip smacking or pursing. Another facial phe-
service for both physical and mental ailments. A nomenon is extensive eye blinking. The fingers
2003 study found that mental illness was twice as can seem to flutter or have impaired mobility. The
prevalent among the patients of traditional heal- toes may tap or legs move up and down.
ers as among the patients of health care centers. In more extreme situations, walking can become
impossible. Grunting and difficulty breathing
Bill Kte’pi are possible because of impairment of respira-
Independent Scholar tory muscles; however, they are not common
 Tardive Dyskinesia 867

symptoms. These involuntary movements are Maxolon, is a drug used to treat gastrointestinal
more likely to occur when a person tries to relax and digestive disorders. It can cause tardive dys-
these voluntary muscle groups, though they can kinesia as a side effect. This drug was developed
be absent during sleep. Emotional arousal can in Europe in the 1960s, found widespread use in
lead to a decrease in these movements, though the 1980s, and it was not until 2009 that the U.S.
stressful events can increase the severity of symp- Food and Drug Administration publicly warned
toms. Afflicted persons may be socially inhibited. that metoclopramide was the most common cause
Severity of the disorder is related to the frequency of drug-related movement disorders, a fact that
of the involuntary movements and is often mea- was backed by empirical studies.
sured using the abnormal involuntary movement While tardive dyskinesia is connected to the use
scale (AIMS). of certain drugs, the effect of these drugs on the
dopamine system in the body leads to the condi-
Difficult Diagnosis tion. Dopamine is a neurotransmitter involved in
Tardive dyskinesia has symptoms that are simi- many functions of the body, such as the regula-
lar to a number of other disorders that can make tion of mood and movement. Though the exact
diagnosis difficult. The tic-like movements are mechanism is unclear, it is likely that the extended
often similar to those of people diagnosed with blocking of dopamine D2 receptors, on which
Tourette syndrome. Other movement disorders antipsychotics act, increases the amount of D2
that can be mistaken for tardive dyskinesia are receptors in an area of the brain responsible for
tardive dystonia, myoclonis, tardive tourettism, coordinating muscle movement. This could lead
and akathisia. Unlike these disorders, tardive to increased, random muscle movements.
dykinesia displays slow movements, rather than People taking antipsychotics are likely to
rapid and jerky movements. Those with tardive develop tardive dyskinesia at some point if they
dyskinesia have difficulty not moving, compared take the drugs long enough. This is even more
to those with Parkinson’s disease who have dif- likely for patients who are older, diabetic, sub-
ficulty initiating movement. The use of antipsy- stance abusers, have experienced traumatic brain
chotic drugs can sometimes mask the symptoms injury, are alcohol and tobacco users, and have
of tardive dyskinesia, and it will not be apparent mental retardation. Postmenopausal women have
that a person has it until they discontinue use of an increased risk because of lowered estrogen lev-
the drugs. els. Even upon discontinued use of the medica-
Tardive dyskinesia is often associated with tion, the symptoms can still develop and remain
mental illness because of the high number of peo- for an extended period of time.
ple developing the condition from the intake of The best method to deal with tardive dyskinesia
antipsychotics. It was first classified as a disorder is to prevent its onset. Using another drug or limit-
in 1964. Around this time, about 30 percent of ing the dosage will help in this regard. This is not
people taking antipsychotics displayed symptoms always entirely possible, such as in treating those
of this disorder. Current estimates are that 20 with schizophrenia. Clozapine is an antipsychotic
percent of individuals taking dopamine antago- drug used to treat schizophrenia that appears to
nists develop tardive dyskinesia. Some psycho- have a lower incidence of developing tardive dys-
active drugs that work to increase the effects of kinesia. If a person develops tardive dyskinesia
dopamine can cause tardive dyskinesia, espe- there is no cure, and it may last for months or
cially with extended use, often over four years. years or may not disappear at all. Some medica-
First-generation antipsychotics, such as haloperi- tions that work to lower dopamine levels in the
dol, have been strongly linked to the disease. It is body can help reduce symptoms. These drugs
not clear how much of a reduced risk for tardive include those used to treat Parkinson’s disease (a
dyskinesia exists with the newer generation anti- disease marked by heightened levels of dopamine)
psychotics, if any. such as Miraplex, Tarvil, Zofran, and Aricept.
Also connected to the onset of tardive dyskine- Botox can be used in treating minor symptoms.
sia is the use of metoclopramide. Metoclopramide, Benzodiazepines can be used as a treatment; how-
sold under the brand names Reglan, Deglan, and ever, they can also cause tremors. Tetrabenzine
868 Television

is approved for treating tardive dyskinesia and mental illness. The recent increase in depictions
works by diminishing dopamine. Best practices of lesser-known mental illnesses in television pro-
dictate prevention of the disorder, rather than grams has the potential to alter the perception of
intervention. individuals diagnosed with mental illnesses, both
positively and negatively, depending on the accu-
Alishia Huntoon racy and empathetic nature of these character
Oregon Institute of Technology portrayals.

See Also: Atypical Antipsychotics; Clozapine; Depictions of Mental Illness in Television

Dopamine; Drug Treatments, Early; Schizophrenia; Depictions of mental illness in television can be
Thorazine and First-Generation Antipsychotics. divided into two groups: traditional series and
reality shows. Traditional television series on
Further Readings major networks have begun to incorporate a wider
Aia, Pratibha, Gonzalo Revuelta, Leslie Cloud, and range of mental illnesses into their story lines by
Stewart Factor. “Movement Disorders: Tardive way of affected characters or plotline twists. Per-
Dyskinesia.” Current Treatment Options in ception is a TNT drama that features Dr. Daniel
Neurology, v.13/3 (2011). Pierce, a university neuroscience professor who
Barnes, Thomas R. E., ed. Antipsychotic Drugs and solves cases for the FBI. He lives with schizophre-
Their Side-Effects. Waltham, MA: Elsevier Science nia and has opted not to take his medication. In
& Technology, 1994. the Emmy-winning Homeland, the primary char-
Llorca, Pierre-Michel, Isabelle Chereau, Frank- acter, Carrie Madison, grapples with bipolar dis-
Jean Bayle, and Christophe Lancon. “Tardive order in her fast-paced job in the CIA. The United
Dyskinesias and Antipsychotics: A Review.” States of Tara, a series that began in 2009, is the
European Psychiatry, v.17/3 (2002). first show to highlight dissociative identity disor-
der, which is still a hotly debated mental illness
among clinical psychologists in terms of diagno-
sis and treatment. Additionally, autism spectrum
disorders have appeared in the series Parenthood
Television and The Big Bang Theory, which has brought
new understanding about the nature of the disor-
Historically, depictions of mental illness in tele- der to television audiences.
vision programming have been scarce. However, Perhaps more notable is the depiction of men-
portrayals of characters with psychiatric disor- tal illness in reality television, an increasingly
ders have been increasing in frequency within the popular type of programming. The reflection
past decade, both in traditional programming and hypothesis states that cultural artifacts such as
in reality television. There has been a continuous literature, television, and film are in some way
effort among research scholars across the fields interconnected to the social order, mirroring
of sociology, psychology, and communications, what is occurring in a given society. Recent real-
beginning in the 1950s, to examine how these ity television depictions of mental illness may
depictions affect public perceptions of mental ill- be considered more directly driven by societal
ness. Such social science literature has explored demand because the content of those shows is
the implications of these depictions on attitudes determined by the most immediate social climate.
and perceptions of mental illness in society as a Those who ascribe to this theory might argue that
whole. Television is one of the greatest communi- this climate consists of individuals who are com-
cation mediums in the United States and is a pow- pelled to learn about the lifestyles of others who
erful outlet; it affects how the public perceives possess interesting backgrounds or experiences
both mental illness and its treatment. Television deemed unique by society. This desire would then
depictions of characters with various psychiatric explain the growing demand for programming
disorders have contributed to society’s negative that would not have been of interest in earlier
stereotypes and stigmatization of individuals with time periods. The reality trend has glamorized
 Television 869

wealthy housewives, partying youths, competi- cleaning solutions consumed. Eating disorders
tions for love, and cop–criminal interactions. are the main focus of What’s Eating You?, where
There are opposing views to this theory; some symptoms consistent with body dysmorphic dis-
sociologists do not agree that there is a mutual order are highlighted. Animal Hoarding features
cultural reflection but rather a product such as a a variety of psychiatric symptoms, all of which
film or novel that then impacts society, shaping cause perceived behavioral deviance in the show’s
its views. That latter perspective can be described characters.
as made of socialization theories.
As much as the significance of the reality televi- Historical Consideration of Depictions
sion genre is downplayed, reality television yields The recent increased prevalence of mental ill-
a significant amount of influence in how society ness depictions in both the traditional and real-
views the individuals participating in these series. ity genres has not yet undergone a comprehensive
This idea is evidenced in a 2006 study of real- review by the academic community. The earliest
ity television and mental illness conducted by sociological study to examine this topic was con-
sociologist Phillip Chong Ho Shon, in which he ducted in 1957 by psychologist Jim Nunnally and
examines the reality television series COPS. He demonstrated that public opinion of mental illness
demonstrates how the rhetoric used by police offi- varied greatly from that of the health community.
cers dealing with criminals with mental illnesses, In the following decades, numerous studies were
along with the hidden-camera style of filming, conducted, all of which came to the conclusion
manipulates the real events to the audience in a that the portrayal of individuals with psychologi-
problematic manner. Within the past two years, cal disorders was unequivocally negative.
a more expansive reality trend has arisen, where A more recent review of television’s role in
mental illnesses are featured in other capacities shaping attitudes regarding psychological dis-
beyond programming related solely to criminal orders can be seen in Darcy Granello’s 1999
activity. research. A Community Attitudes Toward the
In 2010 alone, the Oprah Winfrey Network Mentally Ill (CAMI) questionnaire was given to
(OWN), Animal Planet, TLC, and E! Entertain- 183 college undergraduates to measure their tol-
ment all picked up reality shows featuring men- erance toward individuals with mental illnesses.
tal illness. On My Strange Addiction, audiences Of the 183 participants, 53 students selected
across the country watch as women consume television as their predominant communication
soap and laundry detergent and view their per- medium. Granello demonstrated with this study
sonal cleanliness as dependent on the amount of that this group of 53 undergraduates, who were
categorized as watching from 11 to 20 hours of
television per week, had significantly lower toler-
ance levels toward individuals with mental illness
than their counterparts. Granello further demon-
strated the negative association between media
portrayals of characters with mental disorders
and public perception of those disorders.
Sociological research outside the specific con-
fines of television supports these assertions with
alternative research methods (e.g., surveys, inter-
views, and observation). Virginia Hiday, in her
1995 study on the social context of mental illness
and violence, effectively demonstrated that the
general public held a negative stereotype of those
Jim Parsons (left), who plays Sheldon on CBS’s comedy The Big suffering from mental disorders. Many of the par-
Bang Theory, talks at Comic-Con with costar Johnny Galecki ticipants in this specific study associated mental
(right), July 24, 2009. Sheldon’s flat tone, gawkiness, and rigidity illness with instability, where one might act in an
seem to suggest symptoms of an autism spectrum disorder. irrational or violent manner. This theme was also
870 Television

mentioned in a number of the television-specific humanity do so primarily because of the vari-

research studies. ous psychiatric disorders from which they suffer.
In 2002, Monk was the earliest American tele- Substance abuse is another area of concern for
vision show that centered on a mentally ill charac- conflict theorists because public opinion gener-
ter with obsessive-compulsive disorder. Since that ally views the cause of their conditions to stem
time, the number of television shows with some from moral and character flaws, as opposed to
apparent aspect of mental illness has swelled con- biological predisposition. Television series such as
siderably. These examples in contemporary media Rehab With Dr. Drew have popularized this con-
have yet to be fully explored, demonstrated by the cept because they do not equally address the bio-
lack of literature utilizing the most recent exam- logical and behavioral aspects of mental disorders
ples of programming that predominantly feature that contribute to substance abuse and addiction.
characters with psychological disorders. Reality television may also be of concern to
conflict theorists. The term reality often causes
Sociological Perspectives on audiences to assume that they are watching a
Mental Illness in Television documentary-type of program that is true and
Depictions of mental illness in television can be accurate. However, as demonstrated by Shon in
considered through three main theoretical lenses his 2006 study, this is a problematic assumption
that shape sociological inquiry: functionalism, because the events portrayed on these types of
conflict theory, and symbolic interactionism. programs are under the authority of the produc-
When viewed through a functionalist lens, the ers, whose personal bias or commercial interests
creation of television characters that accurately may interfere with an honest depiction of events.
portray the real-life experiences of individu- Shon further demonstrated that the combination
als suffering from psychological disorders has of entertainment and reality utilizes interchanging
increased awareness for those diagnosed with elements of fiction and nonfiction, which often
mental illnesses and the public at-large. For indi- causes misleading representations of the subject
viduals who have never experienced mental illness matter.
in either themselves or in family members, their From a symbolic-interactionist perspective, the
favorite shows that feature them can be a teach- trend of more frequent television depictions is sig-
ing tool. These shows address the symptoms of nificant because it is changing the way in which
certain disorders and their accompanying behav- society defines mental illness. Where the defini-
iors, along with available treatment options. Indi- tion may have previously only included substance
viduals connect with the characters on the show and alcohol abuse, depression, or anxiety disor-
and can draw comparisons between their lives ders, these new and popular television shows are
and the fictional lives. This may also contribute to exposing the public to lesser-known forms of men-
a perception of knowing individuals with mental tal illness, such as dissociative and psychotic dis-
illness, which could translate into shifting views orders. The connotation of mental illness is also
toward individuals with mental illness. changing, where today it as viewed as a disease,
With all of the power and influence that tele- caused by biological or trauma-related factors,
vision yields in society, conflict theorists might rather than as an abnormality. Although televi-
be alarmed by the inaccuracy of mental illness sion cannot be given credit in full for this new
depictions in these series. A false portrayal or a trend, there are prominent examples reaffirming
consistently negative one could cause disastrous these views. The popular medical drama Grey’s
consequences in solidifying stereotypes and stig- Anatomy links Dr. Owen Hunt’s post-traumatic
mas against the mentally ill. Sociologists ascribing stress disorder to his service in Iraq. One scene
to this school of thought may find problematic in particular depicts Hunt drifting off to sleep
series such as Criminal Minds, whereby the title beneath a ceiling fan that resembles the propellers
links psychological disorders to erratic and vio- of a helicopter, whereupon he has a nightmare
lent behavior. The show perpetuates the violent about his deployment and chokes his girlfriend
image consistent with Hiday’s study, where the lying next to him. Connecting his reaction to his
characters that commit atrocious crimes against nightmare serves to communicate to the viewer
 Television 871

that his acting violently against his girlfriend is both the behavioral depictions and individual
because of a traumatic experience. These cause- reactions.
and-effect linkages aid the public in understand- By viewing the symptoms presented in televi-
ing that there is a cause for mental illness, just sion, one may inaccurately assume that he or she
as there is a cause for physical diseases such as suffers from a mental illness, simply because of
cancer, diabetes, and heart disease. shared behaviors. If the symptoms are at all dis-
torted or do not portray the larger picture, this
Implications for Society might lead to unnecessary psychological distress
Television has the potential to impact the way in an individual. Conversely, based on television
that society perceives social behavior, including depictions, an individual would learn to recognize
mental illness. A diagnosis of a mental illness is context-specific symptoms of the psychological
only made after an individual, or someone close disorders presented in the television shows and
to the individual, recognizes changes in behav- then use that knowledge to identify disorders in
ior and seeks help. Moreover, this recognition of themselves or in others. This heightened aware-
symptoms only comes with a basic understanding ness would lead to greater percentages of the pop-
of numerous psychological disorders. If a broad ulation seeking and receiving treatment.
range of all disorders across the spectrum are not It is not only the depictions of mental illness
fully represented in popular television shows, that matter but of the treatment and societal
then individuals may never gain enough exposure response to mental illness. Many television depic-
to recognize symptoms of mental illness in them- tions show individuals who are ostracized for
selves or in others. their illness, and are treated harshly within the
According to the fourth edition, text revision mental health care system and broader medical
of the Diagnostic and Statistical Manual of Men- system. If one feels that he or she will be judged
tal Disorders (DSM-IV-TR), there are 13 different harshly or stigmatized because of a diagnosis,
categories of psychological disorders: adjustment, then that may prevent them from seeking help
anxiety, dissociative, eating, impulse-control, and necessary treatment. If the trend of a higher
mood, sexual, sexual dysfunction, sleep, somato- prevalence of the depiction of both mental illness
form, substance, personality, and psychotic disor- and mental health care in television were to per-
ders. Currently, eight of these classes of disorders sist, the medical community in America, and spe-
have prominent roles in television series airing on cifically the mental health sector, would be greatly
major networks, and two others have been briefly impacted. Mental health services may be valued
referenced or at least alluded to within the past more heavily if larger segments of the population
five years. This is a major accomplishment, one feel that they need them, partly because of tele-
that the academic community surrounding psy- vision exposure of various disorders. This might
chological disorders needs to further examine. expand insurance coverage and medical resources
Television series that depict various behaviors to additional sectors of the population that oth-
of the mentally ill may assist individuals with- erwise would not have access to them. However,
out exposure to such disorders in understand- this could also have widespread economic and
ing and empathizing with others. After watching legal implications for the medical community.
Parenthood and seeing the challenges that Max, Until further research is conducted, it is unclear
a child suffering from Asperger’s syndrome, has how this medium will affect societal percep-
after being forced to take off a pirate costume, tion, despite the recent trend regarding televi-
one might be less inclined to judge a parent whose sion’s depictions of mental illness within the past
child is throwing a similar tantrum in reality. decade. With its far-reaching influence, television
Conversely, if an individual finds the behaviors has the potential to facilitate or inhibit stigmati-
in the show disturbing, they might be inclined zation of psychological disorders, depending on
to avoid those with similar disorders altogether. the authenticity of the depiction and accuracy
The behaviors could foster a unifying sense or a of character portrayals. Past studies have dem-
dividing sense between mentally ill populations onstrated that television traditionally has fos-
and those without mental illness, depending on tered negative views of individuals with mental
872 Thailand

illnesses, associating them with increased violence apparitions. In the mid-1680s, King Narai was
or erratic behavior. With the recent inclusion of very ill, and this was thought to affect him men-
lesser-known disorders, this trend may change. tally. His illness led to a potential succession cri-
sis, the Siamese Revolution of 1688. More recent
Alexis T. Franzese historians have ascribed his actions to stress and
Kelsey Price court politics.
Elon University After the sacking of the Thai capital of Ayut-
thaya by the Burmese, a prominent general man-
See Also: Asylums; Dangerousness; Lay Conceptions aged to regain most of the Thai territory, and
of Illness; Mass Media; Movies and Madness; Popular he took the name of Taksin the Great. Initially
Conceptions; Psychoanalysis and Popular Culture; a very successful military commander, by 1781,
Public Education Campaigns; Stereotypes. he started to exhibit severe mental problems,
including making unusual decisions such as the
Further Readings execution of people for little or no reason. He
Collins, Paul. “Is the World Ready for an Asperger’s was overthrown and killed by one of his generals,
Sitcom?” (February 6, 2009). http://www.slate who became King Rama I, the first of the Chakri
.com/articles/arts/television/2009/02/mustgeek dynasty, which rules Thailand to this day.
_tv.html (Accessed June 2013). Most care of the mentally ill was provided
Diefenbach, D. “The Portrayal of Mental Illness on either by pagodas or (in most cases) by individual
Prime-Time Television.” Journal of Community families until the mid-19th century. The mentally
Psychology, v.25/3 (1998). ill were cared for by extended family members,
Granello, D. “Relationship of the Media to Attitudes while others had the solace of help from monks
Toward People With Mental Illness.” Journal and nuns. In villages and small towns, this system
of Humanistic Counseling, Education, and was effective. However, with the growing size of
Development, v.38/2 (1999). cities, the scale of the problem increased.
Phelan, J., B. Link, A. Stueve, and B. Pescosolido. Moves in psychiatric care in the West started to
“Public Conceptions of Mental Illness in 1950 affect thinking in Siam (now Thailand), and fol-
and 1996: What Is Mental Illness and Is It to Be lowing developments in Singapore, an asylum was
Feared?” Journal of Health and Social Behavior, established on Klong Sarn, at Thonburi, to the
v.41/2 (2000). west of Bangkok. It opened on November 1, 1889,
Ritterfeld, U. and S. Jin. “Addressing Media Stigma in a building that had been owned by a nobleman,
for People Experiencing Mental Illness Using an and initially there were only 30 patients. The insti-
Entertainment-Education Strategy.” Journal of tution soon grew to accommodate people from all
Health Psychology, v.11/2 (2006). over Siam, not just from the capital; and by 1908,
Shon, P. C. Ho and B. Arrigo. “Reality-Based it had the capacity of coping with 200 men and 50
Television and Police–Citizen Encounters.” women, including rooms for people deemed crimi-
Punishment and Society, v.8/1 (2006). nally insane. Many patients were ill-treated there,
with some chained up in small rooms resembling
prison cells, and some treated with holy water, but
there are also reliable accounts of violence seen as
therapy and punishment.
Thailand It was not long before the resources of this asy-
lum became overstretched, and a new asylum was
In common with neighboring Burma (Myanmar), constructed, also in Thonburi. Originally called
there are references to insanity in chronicles from the Mental Hospital, this new institution was
the early modern period, when rulers and advis- designed by a British architect and supervised by
ers were portrayed as having mental illnesses. a British physician, Dr. Morden Carthew, who
In traditional society in Thailand, there was a had gained his medical qualifications from the
view that suffering from mental problems was University of Edinburgh, Scotland. Dr. Carthew
caused through the influence of devils or ghostly (later given the title Phya Ayuraved Vichakshana)
 Theater 873

was not actually a trained psychiatrist, but he Association of Thailand; and after the 2004 Box-
managed to introduce some of the methods used ing Day tsunami, foreign psychiatrists came to
elsewhere in the world at that time. He ensured Thailand to help treat some of the survivors. In
that there were quiet surroundings, with many spite of a major investment in psychiatric care,
patients able to walk in gardens. This institu- more than half of all asylum beds are located in
tion was located on 18 acres of land, which the Bangkok, and with three-quarters of psychiatrists
Thai government had purchased from the Som- working for the government, around 60 percent
dej Chao Phraya family. There was still a secure work in the capital.
facility, where those deemed criminally insane
could be held. These included not only locals, but Justin Corfield
also some foreigners such as Danish resident Mr. Independent Scholar
Fabricius, who was sent there after having been
found guilty of killing a Siamese official in 1916 See Also: Burma (Myanmar); Globalization; Mental
while suffering from insanity. In his case, the Dan- Institutions, History of.
ish government was able to intervene successfully
on his behalf. Further Readings
Luang Vichien Patayakom was appointed Lebra, William P. Transcultural Research in Mental
director in 1925, and in 1926, he went to Health. Manoa: University of Hawai‘i at Manoa,
the United States to study practices there. He Social Science Research Institute, 1972.
renamed the asylum The Mental Hospital, and Ratanakorn, Prasop. Studies of Mental Illness in
with three new buildings, it could cope with 580 Thailand. Phra Nakhon, Bangkok, Thailand:
patients by 1929. In 1942, Luang Vichien Pata- Ronghim Phakdi Pradit, 1957.
yakom was succeeded as director by Phon Sang- Silpakit, Chatchawan. A Study of Common Mental
singkeo. However, there was a stigma associated Disorders in Primary Care in Thailand. Ph.D. diss.,
with the name, and the facility was later renamed University of London, 1998.
the Somdej Chaopraya Mental Hospital after
the family who donated much of the land. It has
established a reputation as a place for teaching
and training.
After World War II, with increasing prosperity Theater
in Thailand, there was more recognition of men-
tal illnesses in the country. In 1955, the Prasart Theater has served as both a mirror and a micro-
Neurological Hospital was established in Bang- scope of the experience of mental illness through-
kok. The Mental Health Association of Thailand out the history of theater and psychology. Austrian
was formed in 1959, and two years later, the Pan- neurologist Sigmund Freud formed his theory of
ya On Training School and Hospital was opened psychosexual development in part by reading and
with 50 beds and the responsibility of looking interpreting the Greek drama Oedipus Rex. This
after 50 children between 7 and 18 years. By theory became a pivotal and influential abstrac-
1962, there were 2,391 patients at the Somdej tion of the structure of human personality and
Chaopraya Mental Hospital, with hospitals and was used to explain the development of both
care facilities elsewhere in the country. In 1966, normative and pathological psychological coping
Phon Sangsingkeo’s pioneering work was rec- mechanisms. Also, the forum in which Freud and
ognized by his receipt of the Ramon Magsaysay his contemporaries learned about psychosomatic
Award for government service. illness while training in Jean-Martin Charcot’s
The expansion of psychiatric services in Thai- Paris salon may be thought of as theatrical; female
land has made it possible for many people to patients were brought into a rotunda lecture hall
receive treatment for trauma in recent years. By (stage), and under direction of the lecturing phy-
1993, there were some 400 psychiatrists registered sician (director), they were prodded to provide
with the Psychiatrists’ Association of Thailand, depictions of their symptoms (perform), ranging
which publishes the Journal of the Psychiatric from uncontrolled laughter, fainting, paralysis,
874 Theater

blindness, and excited speech. These symptoms lead to untruthful behaviors on stage and can be
were labeled as evidence of their “hysteria.” emotionally dangerous for the actor. An example
The relationship between the theatrical and of a performer being unaware of the unconscious
mental illness has been bidirectional, not only desires driving their performance and not being
informing the understanding of mental illness but emotionally strong enough to withstand the con-
also exposing ways in which emotion can be used sequences is Natalie Portman’s character in the
to influence theatrical performance. In more con- 2010 movie Black Swan. Her character is seen
temporary times, the idea that actors can become as fragile and malleable, and as she starts to give
mentally ill by tackling an insane character has over to the id of her personality, her mental health
been used to explain the untimely death in 2008 breaks down.
of actor Heath Ledger. Theater, rather than help-
ing to turn a stable mind unstable, has been found Theatrical Examples of Mental Illness
effective when used to heal communities that have Long before there were officially sanctioned terms
experienced a natural disaster or conflict. And to describe mental illness, plays presented char-
while mental illness topics and symptoms have acters whose experiences can be understood as
made for riveting drama, psychological terms and driven by illnesses such as depression, anxiety,
approaches developed to understand or address psychosis, paraphilias, and addiction. Since peo-
mental illness within actual patients have also ple in crisis make for great drama, there are many
been useful in deepening the veracity of an actor’s examples of playwrights dramatizing mental ill-
portrayal within a work of drama. ness for the stage.
American playwright Tennessee Williams used
Sense Memory and Mental Health facts from his life, including his beloved sister
While Konstantin Stanislavsky, the father of mod- Rose’s forced lobotomy and his foray into psy-
ern acting training, advocated some emotional choanalysis, when writing the 1958 play Sud-
memory work in his seminal book The Actor Pre- denly, Last Summer. The story was popularized
pares, American acting teacher Lee Strasberg took by the 1959 film of the same name starring Eliz-
those ideas and subverted them into the sense abeth Taylor, Montgomery Clift, and Kather-
memory training that most acting students go ine Hepburn. The plot centers around a young
through today. This training began at the Actors’ woman, Catherine, who is scheduled to receive a
Studio in New York City during the 1950s and lobotomy because she witnessed her cousin’s mur-
has become popularized as “the method.” Emo- der and cannibalization but cannot bring herself
tional memory is defined as a memory of feelings. to fully verbalize what she saw. The memory is
What an actor is trained to do is to use an event locked in her mind, and the doctor wishes to use
from his or her life to conjure up the feelings asso- discursive therapy to unlock Catherine’s block.
ciated with that event, and then use them in the However, in Williams’s play, the older generation
playing of a scene. is trying to silence the younger generation, specifi-
While for Stanislavsky this was one tool of many cally any references to the cousin’s homosexual-
in an actor’s arsenal, Strasberg felt that this was ity, which in the late 1950s would have been clas-
the key to a performance. He would lead actors sified as a mental illness. Williams, through his
through a series of questions and exercises so that theatrical work, shows how power and bigotry
they could fully relive the heightened moment in can be used to create mental illness within those
their lives, feel the emotion fully, and then substi- who are disenfranchised.
tute that personal memory at the moment in the In 1963, playwright Peter Weiss published the
script that required the same emotional outburst. groundbreaking look at a group of inmates in an
Strasberg cautioned that not every actor is able insane asylum performing a play for visitors after
to stay in control of their feelings, and if an actor the French Revolution. It was titled The Perse-
gets caught up in the emotion, then they kill the cution and Assassination of Jean-Paul Marat as
character they are supposed to be playing. Performed by the Inmates of the Asylum of Cha-
Actors are urged to make every character renton Under the Direction of the Marquis de
choice conscious because unconscious desires can Sade, but is commonly referred to as Marat/Sade.
 Theater 875

The Marquis de Sade’s imprisonment in Charen- practitioners have utilized drama to intervene
ton was also dramatized in Doug Wright’s play after the effects of traumatic events. Within clini-
Quills, which garnered actor Geoffrey Rush an cal practice, the discipline of psychodrama has
Oscar nomination when it was adapted as a film developed as a way of enabling patients to exer-
in 2000. The psychological condition of sadism cise their emotions in the safety of a therapeutic
takes its name from the behavior of the Marquis theatrical experience. Psychodrama is useful in
de Sade. Playwright Weiss uses the conceit of the improving the empathy skills of those who par-
play within the play to have Charenton inmates ticipate.
perform a play for French nobility. Under the Within theater practitioners, drama has been
direction of Peter Brook, the 1965 Broadway pro- used to create an altered narrative of hope and
duction of Marat/Sade endeavored to keep the real resilience in the wake of traumatic events, and is
audience as unsettled as the fictional audience in helpful in rejuvenating a community post-trauma.
the play. A sense of danger was established, where Following the lead of Augusto Boal, who believed
it was felt that at any moment an insane actor that the audience should be spectactors, take part
could cross the footlights of the stage and attack. in performances and be spurred to action, many
This theatrical concept of theater of cruelty comes theater practitioners have turned to devised or
from the writings of Antoine Artaud, who advo- collaborative work in communities to illuminate
cated theater as therapy, using shock tactics and a social issue or assist trauma survivors. Devised
theatrical tricks to cause the audience to under- theater is the process of collaborative creation,
stand their obsessions and feelings. and the opportunity to present a survivor’s story,
Examples of mental illness in theater include without fear of reprisal, represents unique oppor-
William Shakespeare’s Hamlet. Soon after Ham- tunities for survivors and artists to transform
let’s father, the king of Denmark, dies, his ghost a trauma narrative for a community or for an
appears to Hamlet and tells him that he was mur- individual.
dered by his brother, Hamlet’s uncle, who now Cornerstone Theater Company in Los Angeles
wears the crown and who has married Hamlet’s is one such theater company that goes into the
mother. Hamlet feels that he needs proof of this community to work with people who often feel
murder in order to enact revenge, and so he begins powerless, and creates plays with them so that
to act irrationally in his quest to cause his uncle to their voices can be heard. In one such project,
reveal the truth. While Hamlet famously asks the titled Rooted: The Greensburg Odyssey, the resi-
question “To be or not to be,” the actor portray- dents of Greensburg, Kansas, worked with actors
ing Hamlet must decide if he is truly insane, or and writers to tell the story of their town after a
just pretending to be. tornado almost completely destroyed it. The Free-
Hamlet is musing over suicide, a decision that a dom Theater operates in Palestine, and its origi-
mental health clinician would characterize as the nal mission was to conduct drama therapy with
act of a mentally ill patient. Hamlet can no lon- the children who live under occupation. The the-
ger take the injustices of life and wants to go to ater also works to be a safe haven, where issues
sleep and not wake up. However, he then worries of discrimination can be illuminated through
about what dreams he might have, and if those drama. The narrative of conflict and resolution is
dreams might not be worse than the uncertainty used in devised theater to gain an understanding
of the life he is currently living. Many actors and of how artistic expression can be an instrumen-
directors point to the fact that Hamlet is alone on tal part of the healing process of trauma recovery.
stage when he delivers this speech to support the Theater and mental illness have a long and inter-
claim that he is truly mentally ill and not feigning twined relationship, where one is understood and
insanity. explored through the other.

Using Theater as Psychological Intervention Suzanne Delle

Psychology has long identified the importance Salve Regina University
of narrative coherence in the process of trauma Loretta L. C. Brady
recovery. Both theater practitioners and clinical Saint Anselm College
876 Therapeutics, History of

See Also: American Psychiatric Association; Art and be executed for subversion, leading to a partial
Artists; Creativity; Movies and Madness; Visual Arts. remission of the illness.
Moral treatment became the dominant thera-
Further Readings peutic mode in the state hospitals and private
Becker, Ernest. “Socialization, Command of asylums of the 19th century in Europe and the
Performance, and Mental Illness.” American United States; however, as these institutions
Journal of Sociology, v.67/5 (1962). became more crowded with the chronically ill,
Boal, Augusto. The Rainbow of Desire: The Boal particularly those suffering from tertiary syphi-
Method of Theatre and Therapy. New York: lis and senile dementia, overworked staff placed
Routledge, 1995. more and more emphasis on controlling behav-
Gordon, Mel. Stanislavsky in America: An Actor’s ior. The introduction of germ theory in the 1880s
Workbook. New York: Routledge, 2010. and the development of a clearer understanding
Styan, J. L. Modern Drama in Theory and Practice. of the physiology and pathologies of the nervous
Cambridge: Cambridge University Press, system by physicians such as Jean-Martin Char-
1998. cot (1825–93) and researchers such as David Fer-
Zucker, Marla, Joseph Spinazzola, Amie Alley Pollack, rier (1843–1928) meanwhile encouraged a new
Lauren Pepe, Stephanie Barry, Lynda Zhang, and interest in somatic origins of mental illness. Physi-
Bessel van der Kolk. “Getting Teachers in on the cians developed and employed a wide spectrum of
Act: Evaluation of a Theater- and Classroom-Based somatic treatments, including a number of drugs,
Youth Violence Prevention Program.” Journal of to treat mental illness and to control behavior in
School Violence, v.9/2 (2010). the psychiatric hospitals of the late 19th and early
to mid-20th centuries.

Somatic Treatments
One of the oldest somatic approaches, hydrother-
Therapeutics, History of apy or the water cure, became highly popular in
the United States from the 1840s for many types
Therapeutic approaches to mental illness through- of nervous and chronic disorders. Psychiatrists of
out history have reflected medical and cultural the early 1900s disdained such earlier approaches
ideas of causation. In the premodern era, those as simply plunging the patient headfirst into a tub
who exhibited bizarre or violent behaviors were of water in favor of more scientifically endorsed
often considered to be experiencing angelic or methods—the wet sheet pack and the continuous
demonic possession; the individual might receive bath, both of which immobilized the patient for
tolerant care, prayers, exorcism rituals, or chain- periods of hours to days and allowed the atten-
ing and abuse. Physicians might offer treatments, dants to control and monitor body temperature,
such as bleeding or purging, to those suffer- pulse rate, and other parameters. These treat-
ing from melancholia, diagnosed as a humoral ments, according to published research, aided in
imbalance. In the 18th century, physicians such the cure of mental illness by slowing blood flow
as Francis Willis (1718–1807) and Philippe Pinel and relieving cerebral congestion or by stimulat-
(1745–1826) and social reformers like William ing kidney functions and helping to clear toxic
Tuke (1732–1822) recharacterized madness as substances from the body.
illness of the mind requiring humane, or moral, Drugs used during this period included chloral
treatment—a healthy regimen and useful occupa- hydrate, hyoscine, paraldehyde, sulfonal, barbi-
tions in an ordered, tranquil environment under turates, bromides, and some narcotics. Although
kind but very firm supervision to enforce nor- some writers had described these as treatments,
mal thought and behaviors. Pinel argued that a physicians by the 1890s acknowledged that they
rational approach to a patient’s delusions could, were in fact sedatives, administered to control
in some but not all cases, restore sanity. In one disruptive behaviors and relieve patient agitation.
famous example, he staged a mock trial and The major risks for patients were dependency or
acquittal of a man who believed he was about to overdose. In the 1920s, Jakob Kläsi in Zurich
 Therapeutics, History of 877

used barbiturates to induce prolonged sleep for of Italy. Electroshock convulsions usually last
a period of days, arguing that the awakened 15 to 20 seconds; the major serious side effects
patients proved more amenable to other thera- are memory loss and possible cognitive deficits.
pies, but this practice was soon replaced by the Other risks such as fracture have been reduced
shock therapies. Sedative drugs continued in use by the use of muscle relaxants and anesthet-
in psychiatric hospitals until superseded by the ics. ECT remained a recommended therapy for
psychoactive medications in the 1950s. severe depression into the 21st century, although
Fever therapies became popular after Julius the mechanism of action (possibly stimulation
Wagner von Jauregg of Vienna published his stud- of neurotransmission) has never been explained
ies of malaria fever treatment for general paral- and its effectiveness has been disputed. Up to 60
ysis of the insane (GPI, or tertiary syphilis) in percent of patients who show improvement with
1917. Inoculation of GPI patients with the blood ECT experience remission within six months, and
of those previously infected produced high fevers current guidelines recommend continued psycho-
that reliably abated after a few days and resulted therapy or medication as well.
in full remission of symptoms in about 27 percent The best-known and most maligned somatic
of patients and partial remission in another 27 therapy of the early 20th century is prefrontal
percent. Advocates argued that the weakening of lobotomy, the severing of connections to the pre-
the body made it more receptive to available med- frontal cortex. The Portuguese neurologist Anto-
ications or simply destroyed the infectious agent. nio Egas Moniz (1874–1955) conducted his first
Another Viennese physician, Manfred Sakel, lobotomies in 1935, after hearing of significant
stimulated interest in shock therapy in 1933, when behavioral changes in chimpanzees subjected to
he announced his results with inducing hypogly- this procedure by researchers at Yale University.
cemic shock in schizophrenia with extremely high His intent was to destroy the more or less fixed
doses of insulin. Patients lapsed into coma, from arrangements of cellular connections in the brain,
which they were revived with glucose injections eradicating existing cognitive delusions or abnor-
after an hour. Many patients received 50 or 60 malities and allowing new, healthy connections to
such treatments over a period of one to two years; form during functional recovery.
about half reported remission of symptoms. Like Two years later, psychiatrist Walter Freeman
fever therapy, insulin shock treatments became and neurosurgeon James Watts introduced the pre-
standard practice in psychiatry into the 1950s, cision method of lobotomy at George Washington
although the scientific explanations advanced Hospital. Freeman developed a simpler technique
for their effectiveness, that insulin blockaded the in 1945, the transorbital lobotomy, which could be
nerve cell, were never clear. accomplished with a minimum of surgical equip-
Both malaria and insulin treatments were ment and staff and which he performed and advo-
potentially life threatening and required intensive cated throughout the United States over the next
staff time to monitor the patient. The Hungar- several years. Patients subjected to lobotomy gen-
ian neurologist Ladislas Meduna offered what erally became calm and placid and were able to
appeared to be a safer alternative in 1934 when resume work and home life, although with varying
he proposed stimulating convulsions, similar to reported degrees of cognitive loss. Some 40,000
epileptic seizures, with injections of the stimu- individuals were lobotomized in the United States
lant metrazol. Meduna’s initial theory postulated in the 1940s and 1950s, with 17,000 others in the
that epilepsy was a natural antagonist to schizo- United Kingdom. The procedure fell out of favor
phrenia, an idea that was eventually disproven. after the introduction of effective antipsychotic
This therapy appeared to be very successful in drugs and was generally discredited after 1960.
depressed individuals; however, patients often
experienced feelings of intense dread as the treat- Psychotherapies and the
ment began and sometimes fractured limbs in Psychopharmacology Revolution
their convulsive throes. Electroshock convulsant The concept of moral treatment persisted in the
therapy (ECT) effectively replaced metrazol after psychiatric hospitals, despite the extensive use
its introduction by Ugo Cerletti and Lucio Bini of somatic therapies. As Frank Tallman, the
878 Therapeutics, History of

Patients take part in rocking chair therapy on a female ward at the State Mental Hospital in Fulton, Missouri, in 1913 (left). Patients
were placed in steam cabinets for hydrotherapy treatments in 1910 (right). These treatments were intended to soothe and calm the
patient. In the late 19th and early 20th centuries, the somatic view of mental illness held sway. Assuming that a defect in the nervous
system was the culprit, doctors applied various physical therapies such as rest, hydrotherapy, and electrical stimulation.

California Director of Mental Hygiene, wrote in in 1949, although since the compound could not
1950, “Most techniques employed by psychia- be patented, pharmaceutical manufacturers were
trists are experiences in healthful living . . . the uninterested in his discovery, and lithium only
serving of attractive meals, the right kind of recre- appeared on the U.S. market in 1970. Patients in
ation, music, reading material, hobbies, or work the first clinical trials of chlorpromazine in Paris
are all part of the recovery pattern.” and Montreal in 1952 and 1953 showed actual
The psychiatrists also used various forms of improvements in cognition and emotional stabil-
talking therapies; although the talking cure in the ity. Despite many adverse side effects and the anal-
20th century is strongly associated with the tech- ogy made by some observers to a chemical lobot-
niques of Sigmund Freud (1856–1939), physicians omy, chlorpromazine and related drugs quickly
attempted to help patients work through their became the first-line treatment for schizophrenia.
problems verbally, at least since the time of Pinel. An estimated 50 million people had taken chlor-
Freud’s psychodynamic theories of the develop- promazine by 1964. Iproniazid, a monoamine
ment in early childhood of personality conflicts oxidase inhibitor (MAOI) introduced for tuber-
among the id, ego, and superego and of defensive culosis in 1958, so deeply impressed a New York
mechanisms were widely used in the 20th century, psychiatrist with its mood-enhancing effects that
particularly in the treatment of neuroses, phobias, he pushed the manufacturer to develop it as an
and anxiety disorders. Most psychiatrists did not antidepressant; more than 400,000 depressed
see psychoanalysis as useful for the treatment of patients received the new drug within a year.
schizophrenia and other mental disorders involv- The ease of use and amazing effectiveness of the
ing cognitive impairment but were able to adopt new antipsychotic drugs sidelined most somatic
some of its methods, such as free association, to therapies and completely altered the practice of
hospital practice. Indeed, one argument for the psychiatry. New psychotherapeutic methods were
use of ECT and the other shock therapies was developed in the second half of the 20th century
that they made the patient’s mind more accessible to assist patients on medication. Cognitive behav-
to a dialogic approach. ioral therapy (CBT) in particular—which uses a
The 1950s saw the stunning introduction of structured, step-by-step process of helping the
several new drugs that alleviated the symptoms of patient to assess and define individual goals, recon-
severe mental illness. The Australian psychiatrist ceptualize the obstacles and problems involved,
John Cade first published his observation on lithi- and then build and develop the skills to achieve
um’s reduction of psychotic excitement, or mania, the goals—has proven very adaptable to people in
 Therapy, Group 879

recovery from mental illness. CBT in conjunction occupational training—the modern equivalent of
with medication can help the depressed person moral treatment.
to revise his or her bias toward negative thinking
and the recovering schizophrenic to learn how to Marcia Meldrum
manage and avoid relapses. Psychologist Donald University of California, Los Angeles
Meichenbaum at the University of Waterloo in
Canada developed CBT in the 1970s through the See Also: Lithium; Monoamine Oxidase Inhibitor
integration of behavior modification techniques, (MAOI) Antidepressants; Side Effects.
which had been successful in treating addiction
and chronic pain with cognitive methods devel- Further Readings
oped by psychiatrists Aaron Beck and Albert Braslow, J. Mental Ills and Bodily Cures: Psychiatric
Ellis. Other psychotherapeutic approaches that Treatment in the First Half of the Twentieth
have been successful with the mentally ill include Century. Berkeley: University of California Press,
desensitization or exposure methods with post- 1997.
traumatic stress survivors. Eldman, R. P. and J. T. Goodrich. “Psychosurgery: A
The availability of the antipsychotics also Historical Overview.” Neurosurgery, v.48/3 (2001).
offered support for the new interest in community Grob, G. The Mad Among Us: A History of the Care
mental health treatment, backed by policy mak- of America’s Mentally Ill. New York: Free Press,
ers who viewed the overcrowded state psychiatric 2011.
hospitals as expensive and outmoded. The result Hunter, D. “Hysteria, Psychoanalysis, and Feminism:
in the 1960s and 1970s was deinstitutionalization, The Case of Anna O.” Feminist Studies, v.9/3
the rapid closing of many hospitals and release of (1983).
patients to community outpatient facilities for Meichenbaum, D. Cognitive Behavior Modification:
medication, rehabilitation, and care. The national An Integrative Approach. New York: Plenum
census of patients in U.S. public psychiatric facili- Press, 1977.
ties decreased from 558,239 in 1955 to 71,619 in Weiner, D. B. “Philippe Pinel’s ‘Memoir on Madness’
1994, a decrease of nearly 500,000; the shift was of December 11, 1794: A Fundamental Text
mirrored in most industrialized countries. Unfor- of Modern Psychiatry.” American Journal of
tunately, the community clinics lacked the finan- Psychiatry, v.149/6 (1992).
cial resources and trained staff to handle this huge
influx of new patients. Many failed to try to build
lives outside the hospital or even to follow through
with their medication schedules; these patients
remained isolated in family homes or, worse, led Therapy, Group
desperate lives on the streets and in local jails.
The growth of the recovery movement from Group therapy, or group psychotherapy, is a form
the 1990s, spurred in the United States by judicial of mental health treatment in which individuals
action in some states and pioneering legislation afflicted with a problem coalesce to help each
in others, such as the California Mental Health other. These groups can have a wide range of ori-
Services Act of 2004, and supported by advocacy entations, including psychodynamic, activity ori-
groups such as Mental Health America and the ented, support focused, problem solving based,
National Alliance on Mental Illness, had rede- educational, or nonverbal expressive forms such
signed community therapeutic programs across as dance or music therapy. The goal of this treat-
the country by 2010, a phenomenon occurring ment depends on the modality, but focus is placed
in Canada and Europe as well. Twenty-first- on aiding an individual with their current psycho-
century therapeutics combines medication with logical distress.
individual and group psychotherapy and with an The effect of a group on an individual can be
array of programs to assist the patient in adapt- traced back to Gustav LeBon (1841–1931), a
ing to community life—housing support, ben- French social psychologist who described a phe-
efits assistance, social activities, educational and nomenon of the “group mind.” LeBon believed
880 Therapy, Group

that hypnotic forces took control of people when Irvin Yalom (1931– ) made a very influential
in a crowd, and thereby individuals had a higher contribution to group therapy with his theory of
level of suggestibility. interpersonal learning and therapeutic principles.
Later, Sigmund Freud’s (1856–1939) studies He utilized self-report research to elucidate thera-
of group dynamics led to his conceptualization peutic factors that are fundamental in the healing
of the superego, or conscience, in his structural process of group therapy.
model. Freud believed that for a group to have an Yalom postulates these curative principles as
effect on an individual, it required strong leader- the following:
ship and a clear purpose. Individuals involved in
group dynamics gave up their goals to take on • Universality: Members recognize shared
the leader’s aim. The first documented group ther- experiences and feelings among other
apy occurred in July 1905 when Joseph H. Pratt members
(1911–81), an internist at Massachusetts General • Instillation of hope: Members can experi-
Hospital, established a group of 15 tuberculosis ence other members’ successes, thereby
patients to meet to discuss their diagnoses. Dur- developing optimism for their struggles
ing the meetings, Dr. Pratt lectured on tubercu- • Altruism: A group provides a place for
losis and facilitated patients’ discussion of their members to help each other
ailments. • Imparting information. A group allows
Another significant contributor to the field of members to share and learn factual
group psychotherapy was Wilfred Bion (1897– information
1979), a British psychoanalyst whose work • Corrective recapitulation of the primary
stemmed from treating World War II soldiers family experience: Members who had
diagnosed with combat fatigue. Bion noted that trouble with their parents and siblings in
group behavior is based on three basic assump- their formative years may unconsciously
tions: dependency, fight-flight, and pairing. Bion relate to the group as a substitute
believed these group emotional states interfered • Improved social skills: A group provides
with accomplishing group tasks, and as a result, a place to learn effective communication
the group leader needed to identify these states. and a safe environment to gather feedback
Bion had a unique way of identifying these bar- • Imitative behavior: A group leader can
riers to group psychotherapy; he would appear provide a model for members as they
inattentive and distant during meetings, with demonstrate qualities such as active
mystic pronouncements to the group’s uncon- listening, nonjudgmental feedback, and
scious. While Bion’s method was unusual, it had support
a lasting impact on the range of ways that leaders • Cohesiveness: A group allows members
can interact with a group. to feel a sense of belonging, togetherness,
Kurt Lewin (1890–1947), a German American and acceptance
psychologist, had a different approach to the use • Existential factors: A group initiates the
of small groups. He applied the concept of field process of accepting responsibility for
forces in his experiments to understand how to one’s own life decisions
increase group effectiveness and group morale. • Catharsis: A group allows members to
Lewin held “T-groups,” alternatively called train- share emotional distress and experience
ing groups, with no explicit agenda but rather the subsequent relief from exposing their
a focus on sharing emotions and understanding strong feelings
how these disclosures triggered other members. • Interpersonal learning: A group provides
The goal of this method was to find better ways a place for members to gain insight about
to successfully communicate among members. their actions and receive feedback from
His research led him to establish the first agency other members on their effects
designed to study groups, the Research Center for • Self-understanding: Members can gain
Group Dynamics at Massachusetts Institute of insight into the psychological motivations
Technology. underlying their behavior and reactions
 Therapy, Group 881

Group Therapy Structure practitioners believed that groups could help indi-
Group members are commonly selected by the viduals to discover their unconscious feelings and
group leader, a trained therapist who interviews explore their relationships through dialogue and
potential members before adding them to the the connections that individuals made with other
group. Selection is based on a person’s diagnosis members. Group therapies such as psychodrama,
and problems. Individuals who are suicidal, hom- in which individuals play the part of significant
icidal, or psychotic need to be stabilized before people in their lives to solve interpersonal con-
joining a group. People who have had organic flicts, and Gestalt therapy, in which members take
brain injuries, cognitive impairments, or severe turns talking to an empty seat where they imag-
character pathology are poor candidates because ine a person whom they are in a dispute with is
of their limited ability to empathize with others seated, have evolved from this original approach.
and their destructive relationship patterns. Indi- Cognitive behavioral therapy (CBT) was estab-
viduals whose primary problem involves relation- lished with a focus on the interrelated connec-
ship issues can benefit significantly from this form tions of emotions, behaviors, and beliefs. When
of therapy. used in group therapy, CBT allows members to
Groups are defined as “closed” when no new learn more about their behavior patterns and how
individuals are accepted, while “open” refers to actions are reinforced. Research has supported its
groups that allow participants to join or leave use in both group and individual treatment plans
at any time during the course of treatment. The for depression, anxiety disorders, and eating
term heterogeneous is given to groups that have disorders.
member populations that include different diag- Self-help groups have developed to assist indi-
noses, ages, and socioeconomic status. A homog- viduals who are struggling with specific prob-
enous group is limited to participants who have lems, such as Alcoholics Anonymous (AA) and
similar problems and/or demographics. The term Gamblers Anonymous (GA). Group therapy has
majority member is used to describe an individual been so important for substance abuse recovery
with the same background (e.g., socioeconomic that the National Institute of Drug Abuse (NIDA)
status or race) as most of the individuals in the and National Institute of Alcoholism and Alcohol
group, while the term minority member is used Abuse (NIAAA) have mandated its inclusion in
to describe an individual with a different back- all addiction treatments. Other groups may exist
ground than most of the group. solely to provide support by emphasizing cohe-
The size of the group depends on a multitude of sion and shared experience for individuals suf-
variables but will commonly fall between five and fering from the same diagnosis. These groups are
15 people. Many therapists feel that eight to 10 very effective. For example, breast cancer research
members is ideal. Groups can meet for one to two has shown longer survival rates and a reduction
hours on a daily, weekly, or monthly basis. Group in pain for women who have participated in sup-
therapy is utilized in a variety of settings, from port groups.
inpatient care to outpatient treatment. Each group
has designated rules that usually include confiden- Sociocultural Factors
tiality guidelines and restrictions on social contact Psychotherapy began in the Judeo-Christian set-
among members outside the group setting. Group ting of central Europe and has evolved into a
leaders have different roles, depending on the Caucasian, middle-class phenomenon, located
type of therapy, with some treatments calling for primarily in North America. Minority patients are
them to be active instructors, moderators, or pas- under-represented in both individual and group
sive witnesses to the process. therapy and have higher dropout rates in treat-
ment when compared to Caucasians. The etiol-
Types of Group Therapy ogy of this difference is related to cultural biases,
A range of group therapy approaches have language barriers, cost of care, and often a lack of
been developed, depending on an individual’s mental health services in minority communities.
treatment goal. Originally, group therapy was Many recent immigrants are hesitant to reveal
based in psychodynamic theory. Psychodynamic their struggles to nonprofessionals, making group
882 Therapy, Individual

therapy a more difficult treatment to engage in on research of various phenomena and tended to
than individual therapy. Furthermore, group be practiced by medical professionals. Philoso-
members can experience intense pressure to con- phers, physicians, and neurologists were among
form to the majority view of the group, which can the founding fathers of psychology, and the field
be difficult for individuals with divergent cultural did not exist as a separate entity for many years.
value systems. People who received treatment for mental issues
This pressure can make members feel split as in the 19th and early 20th centuries were gener-
they are pulled to accept both the majority group ally treated for symptoms of anxiety and depres-
view and their discrepant personal views. Other sion and were most often treated with hypnosis.
issues may arise during group sessions, such as Hypnosis has come in and out of public favor
minority members feeling inhibited about self-dis- since its inception by Franz Mesmer but continues
closure from a fear of being stereotyped or major- to be used in modern practice. Renowned French
ity members’ concerns about providing feedback neurologist Jean-Martin Charcot studied hypno-
that could be interpreted as racist or biased. sis and trained others such as Sigmund Freud in
Group leaders need to be aware of these pitfalls the practice.
to help create a common bond for participants,
despite their diversity. Group therapy is an impor- Freud Introduces Talk Therapy
tant and relevant treatment model that has come Freud was one of the first neurologists to experi-
to hold a pivotal role in the treatment of a variety ment with “talk therapy” to help a patient’s recov-
of psychological ailments. ery, a therapy he termed psychoanalysis. Accep-
tance of this new method at the time was slow.
David Buxton This reluctance may have been complicated by the
Harvard Massachusetts General Hospital fact that Freud was Jewish (though not practicing)
Andrew Ninnemann and thus was not held in high esteem due to the
Brown University sociopolitical climate in Europe at the time.
When Freud began correspondence with Carl
See Also: Cognitive Behavioral Therapy; Diagnosis; Jung, a budding Swiss psychiatrist in the early
Diagnosis in Cross-National Context; Psychoanalysis, 1900s, the idea of individual psychotherapy
History and Sociology of; Psychoanalytic Treatment. began to spread outside his circle of colleagues.
Gradually, Freud’s ideas on individual therapy
Further Readings began to extend to other professionals throughout
American Group Psychotherapy Association (AGPA). Europe, eventually leading to the establishment
Group Therapy. New York: AGPA, 2012. of the International Psychoanalytic Congress in
Corey, Marianne S., Gerald Corey, and Cindy Corey. 1908. A significant outcome of this meeting was
Groups: Process and Practice. Belmont, CA: the decision to disseminate Freud’s work further.
Brooks/Cole, 2006. Subsequently, in 1909, Freud and Jung traveled
Yalom, Irvin. The Theory and Practice of Group to Clark University in the United States to speak
Psychotherapy. 5th ed. New York: Basic Books, internationally on the topic of psychoanalysis.
2005. This unofficially marked the dawn of psycho-
analysis in America. Shortly thereafter, Jung’s
own ideas of psychoanalysis evolved from those
of Freud, whereby he revised Freud’s theories of
the libido and reduced the emphasis on sex as a
Therapy, Individual motivating factor.
Over the next few decades, the practice of
Though the practice of psychotherapy has a long individual psychotherapy continued to grow but
history dating back to the Middle Ages, individ- remained second to psychological research. How-
ual therapy as it is presently understood has only ever, following World War II, individual psycho-
risen in popularity during the past century. In the therapy rapidly grew due to increased demand
late 19th century, psychology focused primarily for mental health care for returning soldiers. As
 Therapy, Individual 883

a result, the demand for trained and competent Skinner’s behavior therapy, Albert Ellis’s RET, and
therapists also increased. This increased need for Aaron Beck’s cognitive therapy to form cognitive
qualified practitioners led to a shift in the focus behavior therapy (CBT). CBT focuses on maladap-
of training programs, whereby emerging psy- tive thoughts, behaviors, and cognitive processes.
chologists began to receive more intense clinical Key tools include cognitive restructuring, psycho-
training with less emphasis on research. Follow- education regarding the disorder and maladaptive
ing the baby boom from 1946 through 1964, a patterns, and generalization of these concepts to
new trend emerged, namely, the influx of mas- everyday life outside the therapy room. This tra-
ter’s-level social workers and a reduced demand dition of splintering continues presently as new
for Ph.D.-level psychologists to provide mental theories develop and understandings of people
health services. Along with this growth, as well evolve, which creates a call for a parallel evolution
as the increasing differentiation of training, the in the practice of therapy.
types of patients requiring treatment shifted from
those primarily suffering from anxiety and neuro- Technique
ses (such as phobias, obsessions and compulsions, Presently, there are over 100 different types of
hysteria, and hypochondriasis) to treating indi- therapies available, though not all are held in the
viduals struggling with issues related to percep- same esteem nor do they all receive the same pub-
tions, thoughts, behaviors, or any combination of lic acceptance. Acceptability of receiving therapy,
these three broad categories. in addition to preferred therapeutic approach, can
Since its inception, psychoanalysis has taken vary by region, religion, race, social class, gender,
several forms, developed primarily by Freud’s sexual orientation, ethnicity, and age.
pupils such as Alfred Adler and Jung, who incor- Despite the differences, all therapies have the
porated their own understanding of psychoanal- same goal: improvement in mental and behav-
ysis, psychotherapy, and its practice. Further, in ioral health. The tools used to achieve the desired
the 1940s and 1950s, several psychologists began outcome differ depending upon the theoretical
to blend their own theories and Freud’s notion approach but often share similar characteristics in
of individual therapy to create new schools of the frame of individual therapy. The framework
thought. The 1940s brought Carl Rogers’s per- for therapy was originally set by Freud, who
son-centered therapy, an approach characterized believed that therapy should follow strict bound-
by openness on the part of the therapist that is aries to protect both the client and the therapist.
nondirective and free of judgment. A decade He wrote specifically about how to structure the
later, B. F. Skinner, Abraham Maslow, and Albert hour with strict adherence to both the appoint-
Ellis began publishing and educating others on ment time and hour limit, with further detail
their respective theories of behavioral therapy, regarding the fee structure. These original param-
humanistic therapy, and rational emotive ther- eters continue to garner recognition within the
apy (RET). community, as most individual therapy occurs in
Behavior therapy specifically addresses learned a private room, lasts approximately one hour, and
behaviors with modification through reinforce- has a predetermined payment agreement between
ment, conditioning, and exposure. This directive the client and therapist.
approach differed greatly from Maslow’s human-
istic approach to individual therapy, which oper- Efficacy
ated on the belief that all people have a need to A criticism that persists regarding therapy is the
reach self-actualization. RET addresses both dys- misguided belief that therapy is not a scientific
functional behaviors and emotional processes and undertaking and lacks empirical research. How-
is similar to behavior therapy in that it is directive ever, while it can be challenging to adequately
and requires much therapist involvement. Along identify and measure treatment outcome vari-
with psychoanalytic psychotherapy, behavior ther- ables, advances in research methodologies have
apy dominated the field from the 1950s through made this endeavor more feasible, reliable, and
the late 1970s, when Donald Meichenbaum com- accurate, and a large number of outcome studies
bined the theories and therapeutic techniques of have been published since about 1980.
884 Thorazine and First-Generation Antipsychotics

Despite the increasing volume of research mea- Hogue, Aaron, Craig E. Henderson, Sarah Dauber,
suring the efficacy of specific therapeutic approaches Priscilla C. Barajas, Adam Fried, and Howard
as well as individual therapy as a whole, the results A. Liddle. “Treatment Adherence, Competence,
are mixed. One factor continually surfaces as a sig- and Outcome in Individual and Family Therapy
nificant contributor to client success: therapeutic for Adolescent Behavior Problems.” Journal of
alliance. The relationship between the client and Consulting and Clinical Psychology, v.76/4 (2008).
therapist has been found to generally be predic- McWilliams, N. Psychoanalytic Psychotherapy:
tive of client outcomes, with stronger relationships A Practitioner’s Guide. New York: Guilford
leading to more positive outcomes. Therapy rela- Press, 2004.
tionships with a strong alliance imply that both
clinician and client are working together toward
improved mental health as it relates to perception,
emotion, or behavior. This is not to say that the
relationship is always pleasant, with only positive Thorazine and
feelings; in fact, the relationship may include anger,
resistance, and resentment in one or both parties at First-Generation
various points throughout the therapeutic process.
The key to a successful therapeutic alliance lies in
Antipsychotics
the client’s feelings of being ultimately understood Discovered during the 1940s, chlorpromazine
and supported by the clinician. (trade name: Thorazine) is a first-generation,
In recent years, there has been a movement typical antipsychotic drug prescribed to individu-
to provide clients with therapies that are sup- als diagnosed with schizophrenia for the purpose
ported by research, often described as evidence- of reducing positive symptoms (added attributes
based practices in psychology (EBPP). As there is not found in most individuals) such as disorga-
a plethora of individual therapeutic approaches, nized speech, hallucinations (sensory perceptions
utilizing EBPPs ensures that clients will have the occurring without external stimuli), and delusions
most appropriate care for their issues. The Amer- (beliefs without factual basis).
ican Psychological Association (APA) adopted a Although a complex issue, the discovery and
policy in 2005 stating that they strongly encour- use of first-generation pharmaceutical treatments
age both practitioners and policy makers to may have contributed to the deinstitutionalization
incorporate the best research evidence, clinical of U.S. mental patients beginning in about 1955.
expertise, and individual patient values in treat- Once released, individuals frequently stopped tak-
ment and laws concerning mental health and ing their medications, including first-generation
public welfare. antipsychotic drugs. Though the first of these had
been discovered much earlier, the second genera-
Shannon Bierma tion—atypical drugs—were discovered in 1993.
Samantha J. Lookatch Atypical drugs may be more effective in treat-
Alex Khaddouma ing both positive and negative symptoms (absent
Gregory L. Stuart behaviors) such as apathy and social withdrawal
University of Tennessee, Knoxville but with fewer motor side effects. However, other
side effects are a concern (such as type II diabe-
See Also: Cognitive Behavioral Therapy; Freud, tes). Alternative treatments may be lower doses of
Sigmund; Jung, Carl Gustav; Psychoanalysis, History first-generation, typical antipsychotics at a level
and Sociology of; Therapy, Group. that is still effective but does not cause unpleasant
motor side effects.
Further Readings
Barlow, D. Clinical Handbook of Psychological First-Generation, Typical
Disorders, Fourth Edition: A Step-by-Step Antipsychotic Drugs
Treatment Manual. New York: Guilford Press, During the 1940s, research of phenothiazines to
2008. treat allergies led to the discovery of a drug group
 Thorazine and First-Generation Antipsychotics 885

known as typical, or conventional, antipsychotic individuals who are exposed to prolonged treat-
drugs. Typical antipsychotic drugs, including ment with typical antipsychotic drugs (500,000
Thorazine, are major tranquilizers that inhibit to one million in the United States) and is more
activity at the dopamine (D2) receptors. While likely to affect older adults and females. Severity
Thorazine is the most common, there are more dictates treatment for extrapyramidal disorders;
than two dozen drugs in this class, including halo- however, damage may be irreversible even after
peridol (Haldol), prochlorperazine (Compazine), drug withdrawal.
thiothixene (Navane), fluphenazine (Prolixin), thi- In its class, Thorazine is more sedating and
oridazine (Mellaril), and perphenazine (Trilafon). less likely to cause motor side effect disorders
Although ineffective for treating allergies, when compared to other typical antipsychotic
Thorazine was selected from the phenothiazine drugs (such as Haldol and Prolixin). Additionally,
group in the 1950s to calm patients before sur- typical antipsychotic drug treatments have been
gery and was further investigated as a possible linked to higher levels of prolactin (a hormone
antipsychotic medication. In 1954, Thorazine related to breast milk production and libido),
was approved in the United States as a drug treat- with long-term use associated with added risk for
ment for individuals with schizophrenia, paving osteoporosis, altered immune function, and some
the way for it to become an alternative to a frontal cancers.
lobotomy, thus earning it the nickname “chemical
lobotomy.” Societal Shift
While not a cure, first-generation antipsychotic Deinstitutionalization, which is the movement
drugs reduce positive symptoms for approximately of patients out of traditional mental hospitals, is
65 percent of individuals diagnosed with schizo- generally seen as beginning in the United States
phrenia and are more effective than other treat- in 1955, when the mental hospital census first
ments such as psychotherapy or electroconvulsive declined on a national level; However, in some
therapy (ECT). These drugs also provide a mood- states, a shift in policy began somewhat earlier,
stabilizing effect for individuals with bipolar disor- prior to the introduction of first-generation drugs.
der, acute mania, and severe psychotic depression While the declining rates of institutionalization
and are effective for certain gastric conditions, are a complex issue with many factors playing a
vomiting, and persistent hiccups. Typical antipsy- role in the number of mental patients confined to
chotic drugs are also used to treat severe behav- mental hospitals, the pace of decline in inpatient
ioral problems in childhood, especially when the censuses accelerated markedly in the late 1960s
child displays volatile, angry outbursts. Unfortu- and again in the following decade, with many
nately, typical antipsychotics, including Thorazine, state hospitals ultimately closing their doors.
are thought to be less effective for schizophrenics’ Once released from institutions, individuals dis-
negative symptoms (such as scarcity of speech, played a tendency to stop taking their medication,
lack of emotion, loss of energy, apathy, and social because either they believed they were no longer
withdrawal) and their cognitive symptoms (such ill or they wanted to avoid the unpleasant extra-
as poor memory and difficulty with concentration pyramidal side effects caused by extended first-
and task completion). generation drug treatments. Today, many individ-
Over time, first-generation antipsychotic drugs uals are chronically homeless with repeated short
became known as neuroleptic (nerve-seizing) hospital stays to stabilize their medication, only
drugs because of their damaging effects on the to repeat the cycle.
extrapyramidal system of the brain, which results Except for clozapine (Clozaril), which was
in motor symptoms similar to those of neurologi- introduced much earlier, atypical antipsychotic
cal disorders. Examples of extrapyramidal side drugs (also known as second-generation drugs)
effects are foot shuffling or constant leg move- were introduced in 1993. Examples of these
ment; slower, prolonged movements; and tar- drugs include risperidone (Risperdal), ziprasi-
dive dyskinesia (quicker lip smacking, chewing, done (Geodon), and aripiprazole (Abilify). Sec-
tongue protrusion, and facial grimacing). Tar- ond-generation drugs are called atypical because
dive dyskinesia affects about 20 to 25 percent of they do not cause extrapyramidal side effects.
886 Tourette Syndrome

Atypical antipsychotic drugs bind with D2 recep- Tourette Syndrome

tors as well as other receptors in the brain such
as dopamine (D1) and serotonin receptors. They The Diagnostic and Statistical Manual of Mental
are claimed to be especially effective at treating Disorders, fourth edition, defines a tic as a sud-
patients’ negative symptoms; therefore, individu- den, rapid, recurrent, motor movement or vocal-
als may be more likely to continue taking their ization. There are two main categories of tics:
medication. In the wake of the introduction of motor tics and vocal tics. Motor tics involve the
atypical drugs, life expectancy for patients with contraction of muscles, which results in visible
chronic mental illness has improved. However, movement, while vocal tics involve the vocal mus-
other side effects are a concern, such as sudden cles and result in a sound made by the individ-
cardiac death, substantial weight gain, insulin ual. Motor and vocal tics can be simple or com-
resistance, and type II diabetes, which is a prob- plex. Simple tics involve only one or two muscles
lem for schizophrenics who are prone to diabe- meaninglessly contracting, such as an eye blink
tes. The alternative may be to use lower doses or a simple sound. Complex tics involve multiple
of typical antipsychotic drugs such as Thorazine muscles and chains of movements, such as hand
at a level that is still effective but is less likely to gestures or strings of words. Tourette syndrome
cause extrapyramidal side effects. (TS) is classified as a tic disorder in which indi-
viduals experience multiple motor tics and at least
Debra L. Frame one vocal tic almost daily for at least one year.
University of Cincinnati While tics can be suppressed for short lengths
of time, they are generally experienced as irre-
See Also: Asylums; Atypical Antipsychotics; sistible. Some individuals are not aware of their
Clozapine; Community Mental Health Centers; tics, but most individuals with TS experience a
Dopamine; Drug Treatments, Early; Drugs and rising sensation or tension in the body that occurs
Deinstitutionalization; Electroconvulsive Therapy; prior to a vocal or motor tic. After an individual
Iatrogenic Illness; Lobotomy; Pharmaceutical engages in a tic, they often experience a sense of
Industry; Prozac; Schizophrenia; Tardive Dyskinesia; relief and tension reduction. Tics often occur in
United States. bouts of one or more tics followed by a period of
no tics. The severity of an individual’s tics often
Further Readings changes over the course of the day and the activi-
Barnes, Thomas R. E., ed. Antipsychotic Drugs ties the individual is engaging in. For example,
and Their Side Effects. Upper Saddle River, NJ: some children may suppress their tics to varying
Elsevier, 1994. degrees while at school but fully engage in their
Kapur, Shitij and Gary Remington. “Atypical tic behavior at home. The frequency of tics may
Antipsychotics: New Directions and New also increase in times of stress.
Challenges in the Treatment of Schizophrenia.” Some individuals show little to no impairment
Annual Review of Medicine (2001). or distress resulting from their tics and never seek
Leucht, Stefan, Caroline Corves, Dieter Arbter, Rolf out medical intervention. Others experience sig-
R. Engel, Chunbo Li, and John M. Davis. “Second- nificant amounts of distress and impairment, as
Generation Versus First-Generation Antipsychotic their tics may be intrusive and result in social stig-
Drugs for Schizophrenia: A Meta-Analysis.” The matization. Tics can interfere with an individual’s
Lancet, v.373/9657 (2009). daily living experiences and, in extreme cases,
Stroup, T. Scott, Wayne M. Alves, Robert M. can cause injury. Therefore, social, academic, and
Hamer, and Jeffrey A. Lieberman. “Clinical Trials occupational functioning can be highly impaired
for Antipsychotic Drugs: Design Conventions, in individuals with TS.
Dilemmas, and Innovations.” Nature Reviews,
Drug Discovery, v.5 (2006). Incidence and Prevalence Rates
Van Putten, Theodore. “Why Do Schizophrenic U.S. prevalence rates of TS range from 0.1 to 1 per-
Patients Refuse to Take Their Drugs?” Archives of cent, with an estimated 1,000 new cases identified
General Psychiatry, v.31 (1975). each year. Research suggests that the worldwide
 Tourette Syndrome 887

prevalence rate of TS ranges from 0.1 percent to history of tic disorders are diagnosed with TS. The
3 percent. However, these may be underestimates, majority of individuals diagnosed with TS (79 per-
as a large number of those with TS do not seek cent) have another co-occurring mental illness.
out treatment for their symptoms. In the United
States, the disorder is diagnosed more frequently Treatment Interventions
in European Americans than African Americans TS is considered a neurobiological disorder, and
or Latino Americans. The prevalence rate of TS is as such, pharmacotherapy is the intervention
higher in males (1.06 percent) than females (0.25 most often recommended by medical profession-
percent). The median age of onset for motor tics als. One survey found that for the majority of
is about 6 or 7 years. individuals with TS (59 percent), their physician
While TS is thought to be a lifelong disorder, was their primary treatment provider. While drug
some individuals experience a reduction in symp- treatments are popular in the treatment of TS,
toms as they age and may experience complete they are not often used for mild chronic vocal or
symptom reduction by early adulthood. There- motor tics. Instead, pharmacotherapy is typically
fore, the prevalence rate among adults is found to reserved for individuals with moderate to severe
be somewhat lower at around 0.5 percent. There tic symptoms.
appears to be a genetic component to TS as it fre- Several classes of psychotropic medications
quently occurs within families. However, some have been used to treat TS. Typical neuroleptics
children who inherit the genetic vulnerability will are the best-evaluated agents for tic suppression.
not develop TS, and some children with no family However, in actual clinical practice, typical neu-
roleptics are being prescribed less frequently than
before because of concerns over potential serious
and life-threatening side effects. There is growing
evidence that atypical neuroleptics are effective
at suppressing tics, with fewer side effects than
typical neuroleptics. However, the data remains
mixed on their overall effectiveness, and some
have called into question the reliability of out-
come studies conducted by the manufacturers of
the drugs. Atypical neuroleptiocs are gradually
replacing typical neuroleptics as the most com-
monly prescribed medications in the treatment of
tic disorders. Unfortunately, atypical neuroleptics
also have serious potential side effects, including
tardive dyskinesia, neuroleptic malignant syn-
drome, and increased risk of stroke, blood clots,
and cardiac death.
Clonidine, an antihypertensive agent, has often
been used for both the suppression of tics and
attention deficit hyperactivity disorder (ADHD)
symptoms and is a commonly used medication
to treat TS. While controlled trials have shown
some benefit from the use of clonidine to sup-
press tics and ADHD symptoms, its effects are
more modest than those typically achieved with
typical neuroleptics. However, its mild side-effect
Editorial cartoonist and musician Jeff Koterba plays with the profile often makes it the first-line treatment for
Prairie Cats at the Cowtown Jamborama in Omaha, Nebraska, children with TS and ADHD. The Tourette Syn-
September 21, 2008. Koterba has Tourette syndrome, which acts drome Practice Parameter Work Group suggests a
as both a creative and destructive force in his work. graduated treatment for TS based on tic severity:
888 Trade in Lunacy

for mild tics, medication is not recommended; for Morel, Stefan, director. “Voluntary Gestures.” Film.
moderate tics, clonidine may be considered for New York: Houghton Mifflin Harcourt, 2012.
treatment because of its modest effect and safety Robertson, M. and A. Cavann. Tourette Syndrome:
profile; for severe tics, the use of typical and atyp- The Facts. Oxford: Oxford University Press,
ical neuroleptics is recommended. 2008.
While pharmacological treatments have been Scahill, L., G. Erenberg, and the Tourette Syndrome
shown to reduce tics by 50 to 60 percent, they Practice Parameter Work Group. “Contemporary
often result in undesirable side effects. There- Assessment and Pharmacotherapy of Tourette
fore, behavioral interventions, especially habit Syndrome.” NeuroRx, v.3/2 (2006).
reversal training (HRT), have been researched as Woods, D. W., J. C. Piacentini, and J. T. Walkup.
an alternative to pharmacological treatment of Treating Tourette Syndrome and Tic Disorders.
TS. It has also been used in combination with New York: Guilford Press, 2007.
pharmacotherapy. Behavioral models assert that
while tic disorders have a neurobiological ori-
gin, tic severity can be worsened, improved, or
maintained through operant principles and the
environment. HRT typically consists of five com- Trade in Lunacy
ponents: awareness training, self-monitoring of
tics, relaxation training, competing response William Parry-Jones’s characterization of private
training, and motivational techniques. The indi- provision for mentally disordered people in Eng-
vidual with TS is taught to recognize their pre- land in the 18th and 19th centuries as the “trade
monitory urge and engage in relaxation tech- in lunacy” aptly described a key element in the
niques or competing responses when they begin history of Western psychiatry. The development
to feel the premonitory urge until the urge dis- of public institutions for the insane poor in indus-
sipates. Eventually, by not engaging in the rein- trializing Britain was not adequate to meet grow-
forcing behavior of the tic when the individual ing demand from all classes in society. Individual
feels the premonitory urge, both the urges and practitioners and businessmen saw lucrative com-
tic frequency decrease. mercial opportunities and stepped in to fill the
Studies have supported the use of behavior gaps, bringing both benefits and problems. One
therapy to decrease TS symptoms, as behavioral hundred years of almost unchecked expansion
approaches have been shown to result in a 90 followed, but by the mid-19th century, the lunacy
percent reduction in tic symptoms and a 50 per- trade faced significant challenges.
cent reduction in tic severity. When compared
with supportive psychotherapy for individu- The Eighteenth Century
als with TS, HRT was the only treatment that The new Bethlem Hospital in London was
reduced tic severity. opened in 1676, providing charitable care for
the insane poor. By 1700, several private “mad-
April Bradley houses” had been established in London and
Erin Olufs elsewhere to meet the needs for incarceration of
University of North Dakota mad relatives of the wealthier classes. The num-
bers of these madhouses grew steadily through
See Also: American Psychological Association; the century, particularly in the last quarter. They
Attention Deficit Hyperactivity Disorder (ADHD); and their proprietors attracted a certain degree
Cognitive Behavioral Therapy; Pharmaceutical of notoriety as a consequence of allegations of
Industry; Tardive Dyskinesia. ill treatment and the “wrongful confinement” of
people at the behest of unscrupulous relatives or
Further Readings spouses. Some legal safeguards were introduced
American Psychiatric Association (APA). Diagnostic in 1774, including a requirement that madhouses
and Statistical Manual of Mental Disorders. should be licensed and periodically inspected by
4th ed. Washington, DC: APA, 2000. local magistrates.
 Trade in Lunacy 889

Most of the early madhouses were relatively with the several existing charitably funded insti-
small, receiving up to 20 or 30 private patients. tutions, public provision remained insufficient to
However, several in the London area became meet the apparently insatiable demand for place-
large institutions housing in excess of 100 peo- ment of pauper lunatics. The trade in lunacy flour-
ple, many of whom were “pauper” lunatics ished as never before over the next four decades,
whose parishes contracted with the proprietors to as existing private lunatic asylums were expanded
receive them at relatively low cost. By the 1790s, and many new ones established. The reported 45
similar large madhouses, some adopting the title licensed houses of 1807 had more than trebled to
of “lunatic asylum,” had opened in other parts of 140 by 1845. By that time, they accommodated
the country, admitting both private patients and about 5,000 patients compared to just over 6,000
parish paupers. in public lunatic asylums.
Criticisms of the madhouses were justified in Many of the new private asylums established
some cases, where physical conditions were poor during the 1830s and 1840s were based on con-
and patients maltreated and subjected to exces- tracts made between proprietors and the local
sive mechanical restraint. However, there were Poor Law authorities to accept their most dis-
others where standards were high, with comfort- turbed patients at discount rates. Asylums com-
able accommodation in pleasant rural surround- peted with one another for clients, with con-
ings and progressive, enlightened treatment prac- sequent deleterious effects on standards and
tices. In these madhouses, “moral treatment” conditions. In many instances, their private-pay-
approaches were in operation even before the ing patients were comfortably accommodated in
York Retreat opened in 1794. Their patients were the main house with access to pleasant gardens,
treated with kindness and respect, with minimal while the paupers were herded together in cold,
resort to coercion. The proprietor would take a damp outbuildings and allowed to exercise only
close personal interest, encouraging social inter- in confined, walled airing courts.
actions between patients and members of his fam- The inexorable growth of private madhouse
ily. As well as being good practice, this approach or asylum provision aroused increasing concern
made sound business sense by encouraging cus- among an emerging group of influential lunacy
tomers from the growing numbers of affluent reformers. Parliamentary inquiries were held in
people seeking the best care and conditions for 1815 and 1827 and exposed much evidence of
their insane relatives. dilapidated buildings, squalid and overcrowded
Although the proprietors of 18th-century accommodations, inadequate furniture and
madhouses tended to promote them as medi- bedding, and the extensive use of mechanical
cal institutions, only a minority were actually restraint both day and night. Little real change
qualified as physicians or surgeons. Men such as was achieved before a national inspection of all
Francis Willis in Lincolnshire, William Perfect types of institutions in which the insane were held
in Kent, and William Battie and John Monro in was conducted from 1842 to 1843 by the Metro-
London formed a part of the emerging special- politan Commissioners in Lunacy. Its important
ism of “mad doctor.” There were other promi- report published in 1844 presented a comprehen-
nent madhouse keepers such as William Arnold sive survey of all the private lunatic asylums in
in Leicester, Joseph Mason in Bristol, and England and Wales, confirming and condemning
Samuel Proud in Staffordshire. They were lay- their many deficiencies.
men, though they each ensured that their sons The 1844 report was followed by legislation
obtained a medical qualification before the busi- that required county and borough authorities to
nesses were passed to them. provide public lunatic asylums and also estab-
lished a powerful national inspectorate, the Com-
The Nineteenth Century missioners in Lunacy. Within a decade, the situa-
Legislation in 1808 gave English counties the tion of the private lunatic asylums was drastically
authority to use public funds to build a lunatic altered. Most of their pauper patients were gradu-
asylum, and a number of them chose to do so over ally removed to the new county lunatic asylums.
the following years. However, even in conjunction The Lunacy Commissioners were determined to
890 Trauma: Patient’s View

root out the worst practices and scrutinized the describe it. Therapists often try to impose their
private asylums closely, publishing some highly view onto patients in clinical situations, and by
critical reports. Many were forced to close down, looking for PTSD in the brain, therapists might
while most of the remainder continued on a discover new treatments—but at the potential cost
reduced scale, concentrating on up-market provi- of avoiding the patient’s view altogether.
sion for private patients.
The PTSD Diagnosis
Leonard Smith The PTSD diagnosis was first entered in the third
University of Birmingham edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-III) in 1980. The impe-
See Also: Asylums; Deinstitutionalization; Ethical tus behind the diagnosis was not just scientific but
Issues; Eugenics; Inequality; Marketing; Mechanical also moral and political. Proponents wanted to
Restraint; Mental Institutions, History of; Patient end a long-standing prejudice against people who
Rights; Policy: Medical; Sterilization. claimed to suffer trauma. For example, during the
World Wars I and II, most doctors did not believe
Further Readings that war itself could cause psychological dam-
Andrews, Jonathan and Andrew Scull. Undertaker age in good, strong men, or if it did, the veteran’s
of the Mind: John Monro and Mad-Doctoring in problems would quickly pass. If a man showed
Eighteenth-Century England. Berkeley: University signs of long-term problems, it was because of his
of California Press, 2001. personal characteristics, not the horrors of com-
Mackenzie, Charlotte. Psychiatry for the Rich: A bat; he was probably a faker or a wimp. Also,
History of Ticehurst Private Asylum, 1792–1917. doctors thought that children and women would
London: Routledge, 1992. quickly recover from their experiences of sexual
Parry-Jones, William Llywelyn. The Trade in Lunacy: assault. Those who did not had some other psy-
A Study of Private Madhouses in England in the chological or personality problem.
Eighteenth and Nineteenth Centuries. Toronto: However, the PTSD diagnosis established that
University of Toronto Press, 1972. rape, incest, war, and other violence and catastro-
Porter, Roy. Mind Forg’d Manacles: A History of phe can cause severe, long-lasting psychological
Madness in England From the Restoration to the suffering, regardless of individual characteristics.
Regency. London: Athlone, 1987. Certain extreme experiences could severely dam-
age anyone’s psyche. Any man, even a strong and
noble man, can be ruined by combat, and even
psychological healthy women can be destroyed by
rape. The diagnosis offered new respect for trauma
Trauma: Patient’s View patients and shifted blame from the individual to
the event, placing the cause of the trauma solely
The patient’s view has often been neglected in psy- on the dreadful nature of the event.
chiatric approaches to emotional trauma. Origi-
nally, most doctors did not accept that violence or Clinical Ideology and the Patient’s View
catastrophes could cause long-term psychological The PTSD diagnosis suggests a simple model
damage. This is no longer the case, but there is still of trauma: a shocking event happens and auto-
conflict, whether explicit or not, between clinicians matically causes psychological damage for some
and patients on how to understand trauma. The people. This model is widely accepted, almost
current diagnosis for psychological trauma is post- axiomatic, but it is not without critics who argue
traumatic stress disorder (PTSD), which presents that the model inappropriately silences patients
trauma as a single universal condition. However, and disregards the complexity of human suffering
individual, social, and cultural factors shape how and coping. The model frames patients as passive
people experience trauma and what events people victims who lack individuality and self-determi-
view as traumatic, and the clinical account does nation in response to violence and catastrophes.
not necessarily capture trauma as many patients They agree that patients should not be blamed for
 Trauma: Patient’s View 891

their suffering, but they argue that to understand privileged access to the meaning of a patient’s
trauma requires respecting a patient’s view and memories, thoughts, and emotions—the things
the social and cultural processes that shape it. that define a person’s identity, or his or her
The PTSD diagnosis was an attempt to bet- humanity. Consequently, some argue that clinical
ter honor trauma patients’ suffering. However, ideology threatens to dehumanize patients by not
the diagnosis and research on the condition dis- honoring their right to self-determination.
regards the patient’s view in fundamental ways.
First, according to conventional psychiatric wis- Subjectivity and Traumatic Experience
dom, the objective nature of the event, not the sur- Research has consistently shown that the nature
vivor’s characteristics, is what explains PTSD. The of an event alone cannot explain PTSD. From
assumption is that the person’s values and beliefs the perspective of cultural sociology, one reason
matter little for understanding trauma. For exam- for this is that people from different social and
ple, it does not matter whether an individual sol- cultural situations do not view the same kinds
dier sees killing in war as evil or sees it as heroic. of events as horrific. Also, people from different
Second, most psychiatrists and psycholo- cultures respond to horrific events differently. In
gists agree that PTSD exists largely outside the other words, trauma is not just a product of the
patient’s awareness. PTSD occurs, the argument objective nature of the event but also of the indi-
goes, because some events are so frightening or vidual’s subjectivity.
horrific that the person has no way to know what PTSD is a Western idea, and many scholars
happened. The patient cannot fit the event into have argued that the diagnosis might not be sensi-
his or her consciousness of the world and of his tive to how people in other cultures view suffer-
or her self. Consequently, the victim records the ing and experience distress. While psychological
event outside normal consciousness. Doctors and distress might be a common response to trau-
researchers disagree on exactly where the trau- matic events for Westerners, for people of other
matic event gets recorded: in a second conscious- cultures, physical problems might be a more com-
ness foreign to the patient, in the unconscious, mon response to a traumatic event, or people may
or in the body as primitive animal-like associa- show symptoms of PTSD but not find them dis-
tions among sights, smells, sounds, and emotions. tressing or worthy of mention.
Wherever the traumatic event is recorded, many Since most Westerners do not typically experi-
experts agree that it is recorded somewhere hid- ence events such as extreme violence or mass death,
den from the patient. The patient may know he they may be especially shocking for individuals in
or she has psychological problems but will not that culture. However, in many cultures, extreme
understand them, might not see how their suffer- violence and/or mass death are expectable parts of
ing is related to the traumatic event, and might life. For example, people who live in countries with
not even consciously recall the traumatic event. a history of warfare often say that the violence
This theory of trauma is a kind of ideology that itself is not the most distressful part of war. Rather,
gives therapists a sense of authority because the the- they are more concerned with other problems
ory implies that only the therapist can understand caused by war, such as hunger, poverty, geographic
what the survivor is really suffering. However, it dislocation, the dissolution of their community, or
also causes a problem for therapists because what the lack of opportunity to follow traditional burial
the patient says might not fit well into what the rites or to carry out other cultural practices.
therapist assumes to be true. Consequently, when Even among Westerners, individuals differ in
a patient’s statement does not match the thera- what they view as traumatic and how they describe
pist’s ideology, clinicians may attempt to silence or and experience trauma. In Fields of Combat, Erin
ignore the patient’s words. If the patient’s silence Finley illustrates that for U.S. male combat vet-
threatens the therapist’s perspective, he or she will erans, PTSD is not a single condition. How each
provoke the patient to talk. man views his suffering is a product of his per-
Clinical ideology is involved in a struggle over sonality, social relationships, and cultural values
the patient’s identity. The accepted model of PTSD and knowledge. For example, a veteran’s ideas
suggests that researchers and therapists have about manhood, a cultural artifact, influence how
892 Trauma: Patient’s View

he suffers. Some veterans whom Finley encoun- therapists would not accept this interpretation.
tered strongly believed that a good man should They would redefine the veteran’s memory and
be focused on success, and she found that these interpret a lack of distress as “psychic numbing.”
veterans had less severe symptoms of PTSD, pos- The therapists would sometimes impose rules. One
sibly because their values made them more willing such rule prevented patients from using the rest-
to confront their distressful memories. However, room during group therapy. This rule angered the
ideas about masculinity can make PTSD worse. patients, who said it was abusive, but the therapists
Finley found that veterans who reported being would not listen to the veterans. The therapists
highly concerned with the stereotypically mascu- argued that the patients’ anger was not a normal
line qualities of self-reliance and control showed reaction to an unfair rule but a symptom of PTSD.
more severe distress than other veterans suffering Though likely with more subtlety, similar ther-
from PTSD. apeutic persuasion likely occurs in other clinical
Morality is deeply cultural and subjective, and settings. In Accounts of Innocence, Joseph Davis
research comparing cultures, as well as research argues that therapy for sexual assault survivors
focused solely on U.S. veterans, has illustrated that involves the therapist creating a new identity for
a person’s moral values and beliefs greatly influ- the patient. The therapist does this by persuad-
ence the individual’s experience of trauma. For ing the patient to adopt a new narrative that
U.S. combat veterans, memories of moral injury, defines the person’s biography in terms of the
or violations of what the veteran sees as morally assault. First, if the therapist suspects an assault
right related to emotions such as guilt and shame, occurred, the therapist encourages the patient
are often more traumatic than fears of being killed. to remember an assault if she does not. When
the patient remembers an assault, the therapist
The Doctor’s View and the Patient’s View encourages the patient to recognize how harmful
In The Harmony of Illusions, Allan Young pres- it was. The therapist explains to the patient that
ents his study of a U.S. Department of Veter- she has a distorted view of herself, which estab-
ans Affairs hospital. For his study, he observed lishes that the therapist has privileged insight into
patients and therapists in an inpatient ward for the trauma. The therapist tries to convince the
veterans suffering PTSD. Doctors on the ward patient of the therapist’s “undistorted” knowl-
viewed the veteran’s guilt as pathological, a symp- edge: that the patient’s misfortunes and dysfunc-
tom to be eradicated. Patients often resisted this tions—problems in forming healthy relation-
view. They felt a person should take responsibil- ships, anger management, depression, anxiety,
ity for his or her actions, which includes feeling etc.—are a result of the attack rather than a
guilty for having done something wrong. problem with her personality.
This was one battle in an ongoing war between Second, the therapist uses the assault to define the
doctors and patients that Young observed in the patient’s strengths, suggesting that the patient rec-
ward. For Young, what happened on the ward was ognize that she is a survivor. The assault may have
a conflict over the veteran’s identity, his personal damaged her, but it did not completely destroy her.
memories, thoughts, and emotions. For example, Third, the therapist uses the assault to define the
many patients who were admitted to the ward patient’s potential. By seeing her life through the
could not describe a particularly traumatic expe- assault, the patient redefines her identity through
rience. Young argues that this may have occurred the damage and her own survival. In other words,
because the veteran’s distress was due to current the patient now has what the therapist views as a
life circumstances, not because of an old combat realistic consciousness of the trauma. This knowl-
experience. However, therapists pressured patients edge is supposed to be a source of liberation. The
to “recover” a traumatic experience. One way patient can draw upon her strength to escape the
therapists pressured patients was by threatening hold the assault has on her identity.
disciplinary action against veterans who were not
able to describe a traumatic combat experience. The Patient’s Brain
Some veterans described situations of killing that If therapists silence their patients and put words
they said were not particularly distressing, but in their patients’ mouths, it would be inaccurate
 Trauma, Psychology of 893

to blame therapists as intentionally uncaring. Young, Allan. The Harmony of Illusions: Inventing
They do want to help. For this reason, therapists Post-Traumatic Stress Disorder. Princeton, NJ:
and researchers are searching for new and more Princeton University Press, 1995.
efficient ways to treat PTSD. For many, the search
leads them to the brain. Researchers are studying
stress in rats and using brain images on humans
to find out where PTSD is in the brain. Psycho-
therapy techniques thought to directly rewire Trauma, Psychology of
the brain, such as cognitive-processing therapy,
eye movement desensitization and reprocessing, The word trauma is derived from the Greek and
and prolonged exposure therapy, are becoming was originally used in organic medicine in the
increasingly popular, and researchers are testing sense of “lesion” or “wound.” In medical terms,
medications that might treat PTSD. trauma is defined as an injury or accident that
By going straight to the brain, the authority of affects the whole being. There are also many
the patient’s view further erodes, and psychiatry psychoanalytic definitions of emotional trauma,
no longer has to grapple with the patient’s words. beginning with Sigmund Freud and traditional
Going straight to the brain has its benefits, and psychoanalysis. In traditional psychoanalysis,
therapy and research need not always take into the concept of psychological trauma is defined
account the patient’s view. However, too much as traumatic neurosis, an intrapsychic phenom-
emphasis on the brain is risky for the profession’s enon. This concept of psychological trauma was
knowledge of trauma and the ability to help the approach most commonly adopted by the
trauma patients. medical-psychiatric profession from the early
20th century to the end of the Vietnam War era
Justin Snyder in the United States (1962–75).
Saint Francis University Freud, in his 1920 essay “Beyond the Pleasure
Principle,” described his conceptualization of
See Also: Anthropology; Ethical Issues; “traumatic neurosis” as excitations from the out-
Ethnopsychiatry; Identity; Post-Traumatic Stress side that are powerful enough to break through
Disorder; Psychiatry and Neuroscience; Trauma, the protective shield of the ego. Traumatic neuro-
Psychology of; Veterans; Violence; War. sis was believed to be the psychical consequences
of excessive shock and severe somatic concus-
Further Readings sions such as railway collisions, burial under falls
Davis, Joseph E. Accounts of Innocence: Sexual of earth, and the like.
Abuse, Trauma, and the Self. Chicago: University
of Chicago Press, 2005. Brief History of Trauma
Fassin, Didier and Richard Rechtman. The Empire There is a voluminous body of literature focusing
of Trauma: An Inquiry Into the Condition of on theories of traumatic stress, including semi-
Victimhood. Princeton, NJ: Princeton University nal contributions to trauma theories in the 20th
Press, 2009. century. Scientific interest in trauma has a long
Finley, Erin P. Fields of Combat: Understanding and varied history tracing back to the 6th century
PTSD Among Veterans of Iraq and Afghanistan. b.c.e. However, it was the study of “hysteria” in
Ithaca, NY: ILR Press, 2011. the late 19th century that captured public atten-
Shay, Jonathan. Achilles in Vietnam: Combat Trauma tion and spawned research that would later be the
and the Undoing of Character. New York: foundation of psychological trauma theory. Phy-
Scribner, 1994. sicians originally thought hysteria to be a disorder
Summerfield, Derek. “The Social Experience of War found only in women, originating in the uterus.
and Some Issues for the Humanitarian Field.” In It was considered a strange disease with mysteri-
Rethinking the Trauma of War, Patrick Bracken ous symptoms, often attributed to anything men
and Celia Petty, eds. London: Free Association found emotionally unmanageable or inexplicable
Books, 1998. in women.
894 Trauma, Psychology of

The French neurologist Jean-Martin Charcot By the end of 19th century, the study of psycho-
is recognized as the grand patriarch of the study logical trauma came to an abrupt halt. However, a
of hysteria. His work gave credence to the study closer look at Freud’s “Beyond the Pleasure Prin-
of this phenomenon, which was called “the great ciple“ essay reveals that Freud further elaborated
neurosis.” Charcot utilized a systematic scien- on the issue of traumatic neuroses. Freud actually
tific approach that emphasized careful observa- outline the concept of trauma as involving (1) an
tion, description, and classification, demonstrat- external stressor event that overwhelms normal
ing that neurological symptoms could be created ego functioning; (2) a change in the steady state
and relieved by hypnosis. Thus, Charcot came to of the organism, otherwise known as disequilib-
the conclusion that hysteria was psychological in rium; (3) a reduction of ego-defensive and cop-
nature. However, his voyeuristic observations and ing capacity; and (4) the problem of “mastery,” in
exhibitionistic demonstrations of women remain that other stressors can take on traumatic propor-
controversial. Evidence suggests that he instigated tions. Freud recognized the power of trauma to
hysterical symptoms in his patients through tech- change ego states and adaptive behavior, which
niques such as hypnosis, electroshock therapy, later contributed to an understanding of post-
and genital manipulation. Negative judgment of traumatic stress disorder (PTSD)–like states.
Charcot’s work on hysteria led to a significant
shift in diagnostic criteria and conception of hys- Social Causes
teria in the decades following his death. World War I once again brought public attention
to the reality and impact of trauma and evoked
Hysteria and Trauma interest in its treatment. The horrors of trench
Through their work, Pierre Janet and Sigmund warfare caused vast numbers of soldiers to break
Freud came to similar formulations, namely that down, weeping uncontrollably, or display the
hysteria was a condition caused by psychological mutism, blindness, unresponsiveness, paralysis,
trauma. They asserted that unbearable emotional and amnesia earlier attributed to “hysterical”
reactions to traumatic events produced hysteri- women. They also exhibited feelings of helpless-
cal symptoms. Janet claimed that certain hysteri- ness, concern for personal integrity, and fear for
cal symptoms could be related to the existence of their safety. These symptoms came to be recog-
split parts of the personality (subconscious fixed nized as a physical disorder termed shell shock,
ideas) endowed with an autonomous life and which became a way of explaining combat fatigue
development. He called this alerted state “disso- and war neurosis; its cause was initially thought
ciation,” whereas Josef Breuer and Freud called to be directly related to exploding shells and the
it “double consciousness.” Through their work impact of shock waves on the central nervous
came the realization that somatic symptoms of system. It was discovered, however, that the syn-
hysteria were actually disguised representations drome could also be found in soldiers who were
of traumatic events of the past that were exiled not exposed to explosions. Psychiatrists accord-
from conscious awareness. They postulated that ingly had to rethink their theory and came to the
hysterical symptoms could be alleviated when conclusion that the symptoms of shell shock were
memories and intense feelings were recovered due to the psychological trauma of war, violence,
and put into words. This led to the technique and death and not, in fact, to the exposure to
of what Janet called “psychological analysis” exploding shells.
and what Breuer and Freud called “abreaction” Military psychiatrists treated “shell shock” or
or “catharsis.” Through the discovery and sub- “traumatic neurosis” in medical units close to the
sequent dissolution of these subconscious psy- battle lines. Medical staff treated these conditions
chological systems, it was claimed that a cure as “understandable” responses that could be
for hysteria was possible. From this propitious overcome rapidly, and there was an expectation
beginning came the origins of psychoanalysis. that the soldiers would quickly return to active
Freud would later abandon use of hypnosis for duty. This was a shift in thinking, as in the past
the “talking cure” or what he later would call these mental states were considered evidence of a
“psycho-analysis.” major mental illness that would require a lengthy
 Trauma, Psychology of 895

treatment, but in reality, few soldiers were perma- experience in which the construction of the self
nently cured. and the world is halted. Figley views trauma as
World War II once again brought attention an emotional state of discomfort and stress that
to the subject of psychological trauma. Abram results from traumatic experiences that shatter
Kardiner attempted to develop a theory of war one’s sense of invulnerability to harm. Figley fur-
neurosis. He published a comprehensive clinical ther identifies three areas in which assumptions
and theoretical study titled The Traumatic Neu- have been shattered through trauma: personal
roses of War, in which he described that those invulnerability, the world as a meaningful place,
exposed to the trauma of war were hypervigilant and positive self-perceptions. Herman states that
to environmental cues and displayed extreme trauma undermines the belief systems that give
physiological arousal. They were fixated on the meaning to human experience. They violate the
trauma, acted as if the traumatic experiences victim’s faith in natural or divine order and cast
were still in existence, and engaged in protective the victim into a state of existential crisis.
devices that failed. Aside from the physiological Herman’s expanded construction of PTSD,
effects, Kardiner noted that trauma sufferers also known as complex PTSD syndrome, is seen in
had an altered conception of self and the outer survivors of prolonged and repeated victimization
world. Kardiner can be credited with developing such as systematic torture (both psychological
the clinical outlines of the traumatic syndrome as and physical) and/or sexual abuse. The syndrome
it is recognized today. is characterized by a varied and complex symp-
tom picture, enduring personality changes, and
The Development of a Diagnosis high risk for repeated harm, either self-inflicted
It was Kardiner’s work and studies of Vietnam vet- or at the hands of others. It emphasizes the adult
erans that led to the development of the diagnosis consequences of trauma experienced during child-
of PTSD and its relationship to combat exposure. hood, including high risk for rape, sexual harass-
PTSD is now regarded as an anxiety disorder ment, battering, and becoming an aggressor. It is
that can develop after exposure to a severe trau- a syndrome that is not without controversy, and a
matic event that results in psychological trauma. debate continues as to whether it is in fact PTSD
The diagnosis entered the American Psychiatric or a separate symptom picture that is a result of
Association’s Diagnostic and Statistical Manual the trauma. However, failure to recognize this
of Mental Disorders third edition (DSM III) as a syndrome as a predictable consequence of pro-
diagnostic entity in 1980, following extensive lob- longed, repeated trauma contributes to the mis-
bying by veterans and their supporters. Thus, the understanding of survivors, and this misunder-
syndrome of psychological trauma gained formal standing is shared by society at-large. Research
recognition and had substantial implications for has shown there is an association between trau-
the treatment of trauma survivors. The diagnosis mas experienced earlier in life and the increased
of PTSD resolved a quandary over how to classify risk factors for medical diseases later in life, even
a chronic condition in normal people who devel- the higher risk of premature death.
oped long-term symptoms following an extremely
traumatic event. The diagnostic entity of PTSD Emerging Neurobiology
also provides an observational framework for There are clear signs of mind/body interactions
studying the effects of stress and trauma. after stressful events. Hans Seyle pioneered studies
of stress and physiological changes. Alterations in
Modern Psychological Models these and other neurotransmitters and hormones
of Trauma and Trauma Theory after stressful events are under current study. It
There are several psychological theories of trauma appears that the neurotransmitter catecholamine
in the 20th century that have brought attention changes in times of stress and involves neural net-
to the impact of trauma on the individual. Bes- works that link the limbic, frontal cortical, basal
sel Van der Kolk, Charles Figley, and Judith Her- gangliar, and hypothalamic structures. Imbalances
man are among the leaders of modern theory. in these networks and regions can disturb levels of
Van der Kolk views trauma as an overwhelming arousal and alter the regulation of the emotional
896 Trauma, Psychology of

An American infantryman whose friend has been killed in action clings to his fellow soldier for comfort in the Haktong-ni area, Korea,
August 28, 1950. Meanwhile, a nearby corpsman carries out his grim duties of filling out casualty tags. Abram Kardiner’s studies on
the neurosis that developed in soldiers who were exposed to the trauma of World War I, as well as later studies of Vietnam veterans,
led to the development of the diagnosis of post-traumatic stress disorder (PTSD) and its relationship to combat exposure.

responses (as in rage attacks). Changes may take have demonstrated that the key elements of PTSD
place in the brain: the amygdala may alter its dan- may in fact be a progressive sensitization of bio-
ger-recognition set points, the hippocampus may logical systems that leave the individual hyper-
alter its memory-encoding properties, and the responsive to a variety of stimuli.
medial prefrontal cortex may alter its abilities to
establish or reduce the ability to associate danger. Conclusion
Multiple research findings have found that The study of psychological trauma is far more
there are biological changes following exposure complex than just the study of PTSD. Psychologi-
to trauma that are associated with the symptoms cal traumas come in many forms and are not lim-
of PTSD. When scientists look at the biological ited to just extreme situations. How one responds
basis of stress versus PTSD, they find that PTSD psychologically to trauma is complex and based
has distinct features. It is now clear that PTSD on a combination of factors, including early
does provide a model for a process of adjustment childhood and lifetime exposure to trauma, psy-
and destabilization to trauma that has biologi- chological development, premorbid personality,
cal, psychological, and phenomenological dimen- coping skills, and resiliency. Rapidly accumulat-
sions. The most current biological investigations ing evidence indicates that psychological trauma
 Treatment 897

is related to physiological responses that continue worlds in which these occur. There are many forms
long past the original event. of healing across cultures, however, these all have
in common the creation of shared meaning in the
Robin Green context of human suffering. When discussing cul-
Kris Bevilacqua ture as it relates to mental health treatment, a basic
Albert Einstein College of Medicine framework for understanding the term must be
established. Culture is a general and malleable term
See Also: Cognitive Behavioral Therapy; Disasters; to describe any population that adheres to a simi-
Dissociative Disorders; DSM-IV Classifications; lar way of life or has complementary worldviews
Freud, Sigmund; Military Psychiatry; Mind–Body and schemas. An individual’s cultural identity may
Relationship; Post-Traumatic Stress Disorder; be predicated on his or her religious affiliation, sex-
Psychopharmacology; Shell Shock; Stress; Trauma: ual orientation, nationality, race, gender, age, dis-
Patient’s View; Veterans; Violence; War. ability, or any other facet deemed pertinent to the
self. While cultural identity is commonly bestowed
Further Readings from family of origin to offspring, it can also be
Ellenberger, H. F. The Discovery of the Unconscious: redefined in adulthood based on subsequent life
The History and Evolution of Dynamic Psychiatry. experiences.
New York: Basic Books, 1970.
Everly, G. S. and J. M. Lating, eds. Culture and Mental Illness
Psychotraumatology: Key Papers and Core Culture and mental illness intersect on three
Concepts in Post-Traumatic Stress. New York: planes: symptomatology (i.e., the types of symp-
Plenum Press, 1995. toms or complaints), the illness, and treatment
Goldschmidt, O. “A Contribution to the Subject modalities. How a particular culture makes sense
of ‘Psychic Trauma’ Based on the Course of a of these three elements largely determines which
Psychoanalytic Short Therapy.” International approach is undertaken to ameliorate the suffer-
Review of Psychoanalysis, v.13 (1986). ing. Culture-bound explanatory models for symp-
Herman, J. Trauma and Recovery. New York: Basic tomatology give reason for why and how mental
Books, 1977. illness is identified, which further determines the
Horowitz, Mardi J., ed. Essential Papers on Post- type of treatment. A variety of culture-bound syn-
Traumatic Stress Disorder. New York: New York dromes are listed in the Diagnostic and Statistical
University Press, 1999. Manual of Mental Disorders, fourth edition, text
Kleespies, P. M., ed. Emergencies in Mental Health revision (DSM-IV-TR), published by the Ameri-
Practice: Evaluation and Management. New York: can Psychiatric Association.
Guilford Press, 1998. This manual is used by mental health profes-
Wolf, E. S. “Psychic Trauma: A View From Self sionals, largely because of its ability to supply
Psychology.” Canadian Journal of Psychoanalysis, organized groupings of disorders through a com-
v.3/2 (1995). mon language. The DSM is a tool used for diag-
nosing a variety of mental illnesses, and it stresses
that manifestations of culture-bound syndromes
mainly occur within centralized, limited, and con-
textually appropriate groups of people. Culture-
Treatment bound syndromes are created and maintained by
societal forces as expressive means of coping and
American psychiatrist Jerome D. Frank, in 1961, serve as explanations of the physical surroundings
classified psychotherapies into Euro-American (i.e., and daily encounters within a group’s existence.
empirico-scientific) and religio-magical approaches As such, mental health professionals should not
(i.e., traditional-folk-indigenous healing practices) automatically consider the presenting “symp-
in his book Persuasion and Healing: A Compara- toms” to be pathological illnesses but, instead, as
tive Study of Psychotherapy. Both kinds of thera- physical and cultural representations of socially
pies depend on cultural context and the assumptive normed responses.
898 Treatment

Examples of culture-bound syndromes include mental illness and HIV/AIDS are not just thought
spirit sickness, which is also known as ghost sick- to be co-occurring conditions but that one is the
ness, a condition typically found among Native cause of the other. A perception in Zambia’s gen-
American cultures, which commonly manifests in eral population is that if someone is mentally ill,
symptoms of anxiety, crying, and preoccupations they must also be HIV-positive. The consequence
with relatives who have died. In Latin America, of this is that someone suffering exclusively from
susto is an illness described as the loss of soul mental illness may not seek treatment for fear of
from fright. This culture-specific illness is a form being accused of having HIV/AIDS. Lack of men-
of psychological distress that is expressed somati- tal health treatment utilization can therefore be
cally and includes loss of appetite, body aches, attributed to fear of medical discrimination and
intestinal distress, disrupted sleep, and muscle social persecution.
tics. Some examples of culture-bound syndromes Culture provides an explanation of stressful
that bear religious focus are the Caribbean-orig- and catastrophic events and the anguish associ-
inated rootwork, and zar, a condition centered ated with these events. For instance, some stud-
within Middle Eastern and North African cul- ies following the 2004 tsunami in Sri Lanka
tures, where individuals believe that spirit pos- found that health behaviors and rates of post-
session causes a lack of appetite, dissociation, traumatic stress disorder (PTSD) were correlated
head banging, and social isolation. Koro, found with whether individuals believed in the law of
in south and east Asia, manifests as an extreme karma. Karma is a Hindu construct and deter-
fear that an individual’s sexual organ will retract ministic belief that is understood as a process
and that this will result in death. Some experts whereby one’s prior actions or intentions, in this
have argued that while it appears that the physi- life and lives past, determine present or future
cal manifestations of these “syndromes” are often destinies. Thus, morally correct actions lead to
debilitating and even frightening to the afflicted positive consequences, and immoral actions lead
individual, their presence could also be seen as an to negative outcomes. This belief system tends
outward expression of cultural restrictions and to provoke a passive acceptance of misfortunes,
frustrations. including sudden and tragic death, illness, and
Other culture-bound explanatory models for poverty. The belief in karma in the tsunami dev-
mental illness make the claim that mental ill- astation provided a meaning for the event, which
ness is a matter of personal responsibility and a in this case acted as a protective factor against
reflection of personal weakness. Illnesses of psy- the development of mental illness. In fact, spiri-
chological origins are not widely accepted in all tual and religious views are often utilized by
cultures, and in some cases, stigma against those many groups as a means of coping with daily life
with mental illness can be quite severe. In eastern and stress, and these beliefs have contributed to
Chinese communities, it is of great importance to individuals’ mental and physical well-being.
protect ancestral legacy as well as the social pres-
tige of the family. Therefore, when mental illness Cultural Competence
is perceived as a deficit, that deficit is attributed Culture is implicated in the client’s beliefs about
not only to the individual with the mental illness the efficacy of the modality or type of interven-
but also brings shame and dishonor to the entire tion selected, as well as the professionalism of
family unit. the provider. Professional cultural competence is
In Zambia, the stigma against mental illness is often described as the ability to deliver a method
pervasive and thought to arise from widely held of treatment that is compatible with the client’s
beliefs of mental illness as a contagious condi- culture, along with a practitioner’s recognition of
tion, or that those with mental illness are acutely personal and institutionally based biases. Help-
dangerous. Complicating the situation in Zambia ing professionals in the United States (e.g., social
is the perceived association in the general popu- workers, psychologists, and counselors) have the
lation between HIV/AIDS and mental illness. ethical responsibility of being sensitive to issues of
Since there is a high prevalence rate of HIV-pos- client diversity and providing culturally appropri-
itive patients in mental health treatment settings, ate services to the clients they serve. Additionally,
 Treatment 899

if the type of intervention attempts to ameliorate D. W. Sue provides a comprehensive model of

a particular mental illness using an ideological cultural competence that integrates race and cul-
framework that does not coincide with how the ture-specific constituencies in the United States,
client perceives their illness, it may be met with along with practitioner competencies divided
resistance and may not be viewed by the client as into three domains (e.g., beliefs/attitudes, knowl-
credible or effective. edge, and skills) within four levels of analysis
For some cultural groups, health and sickness (e.g., individual, professional, organizational,
include coexisting medical and nonmedical com- and societal). A helping professional needs to
ponents, including convictions about the super- evaluate the client’s degree of acculturation in
natural, black magic, and religious ideologies. order to determine the presenting problems and
Clinicians should acknowledge and integrate prescribe a corresponding treatment. Accultura-
their clients’ models of explanation into sensi- tion is often defined in the literature as the degree
tive and culturally competent discussions and to which an immigrant (or someone from a dif-
treatment plans. S. Sue recommends that mental ferent culture that is not considered part of main-
health practitioners use a cultural competence stream society or the majority) has adapted to the
model comprised of three elements. The first ele- host culture while retaining elements from their
ment is called “hypothesis testing,” whereby a culture of origin.
clinician utilizes cultural knowledge about partic- While cultural competence models have added
ular group in an exploratory manner with the cli- value to psychotherapeutic work with cultur-
ent, rather than voicing solid opinions or reaching ally diverse groups in terms of increasing thera-
premature conclusions about particular clients pist awareness, the critics of having specific cul-
based on their cultural backgrounds. tural competencies for distinct groups refer to
Dynamic sizing is the second element of this this as “psychological essentialism.” This term
model, where clinicians have knowledge about refers to the between-group categorizations that
a particular cultural group, yet the individual is can occur and the possible perpetuation of ste-
also considered as outside the group context (i.e., reotypes. Additionally, psychotherapy is based
each individual is also unique). The third element on Euro-American assumptions and structures
is the development of culturally specific expertise, that do not necessarily correspond to the world-
which according to Sue, includes a practitioner’s views of diverse clients. Experts caution against
understanding of worldviews held by members of superficial adaptations of conventional Western
different cultural groups (as well as the practitio- models in the name of cultural competence. Sci-
ner’s own worldviews), and possessing skills that entifically derived evidence-based psychotherapy
enable them to use culturally based interventions practices may not pertain to all groups. Although
and adapt interventions into culturally relevant scientific methods are utilized to evaluate the effi-
strategies. cacy of conventional treatment protocols, eth-
Pinderhughes provides an additional model nic or diverse groups are seldom included in the
for practitioners working with culturally diverse research studies. Methods of promulgating true
clients. According to Pinderhughes, there are cultural responsiveness can occur through the
four psychological dynamics that are at play in incorporation of traditional healing practices and
the practitioner–client relationship: the psychol- community-based indigenous treatments.
ogy of difference, ethnicity, race, and power. The
practitioner’s task, according to this model, is to Traditional Healing
understand how these factors influence the cli- Traditional folk healing, including indigenous
ent’s behaviors and experiences, as well as how and religious practices worldwide, utilizes ritual-
these impact the practitioner’s view of the client istic and symbolic ceremonies as a way of puri-
(and ultimately his or her approach toward the fying and curing physical, social, emotional,
client). Additionally, Pinderhughes recommends and spiritual ills, as well as for preparation for
that the client assume the role of cultural expert, religious rites, hunting, or war. A medicine man
and that the client instruct the practitioner on the or woman (e.g., also called by different cultures
client’s culture. healer, shaman, witch doctor, elder, or curandero)
900 Treatment

is typically consulted and leads healing ceremo- of indigenous cultures, many such peoples have
nies. Indigenous and native cultures worldwide maintained their core belief systems, and West-
differ in some practices, but most hold communal ern medical or psychotherapeutic (talk-therapy)
and cosmological ideologies that include a deep approaches are viewed even today with some
respect and harmony with nature, as well as unity skepticism because Westernized cultures sub-
with the Earth, universe, and spirit world. These scribe to disease-based biological and rational-
cultures hold an animist worldview, where a soul positivistic frameworks for explanatory models
or spirit exists in every object, and the human soul of health, mental illness, and their correspond-
is forever in the universe (beyond physical death) ing treatments. Many Western cultures hold the
and may inhabit other humans, animals, plants, premise that problematic human conditions,
and inanimate objects. In this model, humans are along with any possible solutions, arise through
the cosmic link that join lower orders (miner- a linear, cause-and-effect process. Experts deem
als, plants, and animals) to higher orders (spir- that any notion that mental health could be
its, ancestors, and gods), and all of them must viewed in relation to a need for circular balance
be accessed to heal human suffering in whatever between the body, spirit, mind, and cultural con-
form the suffering manifests (physical, emotional, text is often discounted, pathologized, or ignored
or interpersonal). in Western models.
Indigenous healers are thought to be interdi- Indigenous tribes in the Americas, for instance,
mensional middlemen or -women who intercede often rely on traditional remedies such as “heal-
on behalf of an afflicted individual through a con- ing stories,” which are recited much like a dream
nection with ancestors and the spirit world in the sequence, when addressing mental health con-
context of community (social and kinship networks ditions from a therapeutic point of view. They
that participate in healing ceremonies). Traditional believe holistically that recovery occurs when the
songs, dance, drumming, storytelling, dreams, the quadrants of mind, spirit, context, and body are
use of sacred herbs and medicinal plants, and the properly balanced and maintained. Likewise, in
speaking of native tongues, along with supernat- traditional Chinese medicine, health is based on a
ural types of healing (trance-like altered states of harmonious relationship between heaven, Earth,
consciousness where healers are transformed into and people, where the force of vital energy (qi)
sacred animals or connect with the dead) are the and order (li) and a balance between the ying and
many methods utilized by healers. yang are the essence of overall health. Confucian
Healers are “called” to serve by ancestors, and and Taoist influences contribute to the notion of
in some cultures, they play different roles and harmony and balance, where emotional distur-
have specializations. For example, in some Afri- bances are caused by imbalances in organs that are
can nations, depending on the size of the com- often treated with acupuncture (needles inserted
munity, one healer will attend to all health, social, at specific meridian points that are aligned to a
and spiritual needs, and in larger communities specific organ in the body) and use of particular
there may be several (e.g., herbalists versus indig- herbs (e.g., gingko, kava, and valerian).
enous doctors). Typically, herbalists use plants, Traditional Buddhist beliefs purport that by
bark, and roots and know the form, dosages, practicing mindfulness through meditation and
and combinations that can be used as healing habitually offering kindness and compassion to
agents. Indigenous doctors will commonly throw others, spiritual growth can be attained while
animal bones, sticks, and stones to read their cli- increasing well-being (mental and physical). Bud-
ent’s problems, and based on how these elements dhism is based on the teachings of Buddha and
configure in their landing (i.e., diagnosis), they the Four Noble Truths. One of the central con-
will prescribe an intervention that will alleviate cepts is that “sitting” (i.e., learning to be present)
or counteract the evil forces that are acting upon with suffering (uncomfortable feelings and physi-
the client. cal pain), rather than distancing from suffering
Although historically speaking, European (through problem solving or intellectualizing), is
colonization has eroded many original sociocul- part of the human condition, and that this accep-
tural-religious belief structures and worldviews tance is part of healing.
 Treatment 901

Hinduism is based on the holy books known as Christian or pastoral counseling draws from
the Vedas, which prescribe rituals, mantras, and the teachings of Jesus Christ. Worldwide, the
worship to a pantheon of Vedic gods. In Hindu- largest Christian groups are the Roman Catholic
ism, deity-directed animal sacrifices and physical Church, Eastern Orthodox Church, and denomi-
charms (amulets) are used in attempts to relieve nations of Protestantism. In the African Ameri-
unwanted psychiatric symptoms, as well as the can community, the Black Church, through the
use of confinement (to a hermitage or ashram), counsel of pastors and ministers, has often been
meditation, exorcism, yoga, and pilgrimage to sought out as a place to find psychological heal-
religious temples or holy places. Hindu approach ing. The “Spirit-filled” Christianity movement is
to health and illness is based on caste contamina- a modern derivative of the contemplative tradi-
tion (Indian caste system), pollution and purifica- tion, where dramatic deliverance types of inter-
tion (in a spiritual context), rituals, law of karma, ventions are used to battle demonic presence in
astrological and planetary events, and demonic an individual or “lies” developed from painful
spirits. childhood experiences and where Jesus reveals
From the Islamic point of view, mental distress his truth. A person perceives Christ’s healing
is conceived as resulting from moral transgres- presence through visual imagery, sense of peace,
sions or divine will. Intervention methods include or hearing the voice of Jesus.
fasting, repentance, ritual prayer, and regular rec- Judaism is a monotheist religion based on the
itation of the Koran (the book of healing). The Hebrew bible (Five Books of Moses) and law and
teachings of the Prophet Muhammad and faith in is practiced in several forms and traditions (i.e.,
Allah comprise the central tenets of Islam. Islamic Orthodox, Conservative, and Reform). Healing
healers utilize holy water, and cleansing rituals rituals include instrumental music, song, prayer,
hold curative powers. and reflection on Jewish texts or teachings. Jews
adhere to Western medicine approaches, and in
some Jewish circles, old traditions and supersti-
tious beliefs. A sense of community is important
to this group as a shared ethnicity. God is viewed
as the ultimate healer, and recovery from any ill-
ness only occurs through God’s will assisted by
healing prayers and charitable acts. Jews are dis-
persed throughout the world because of persecu-
tion and anti-Semitism. The experience of oppres-
sion and trauma in any group must be considered
in any therapeutic approach, as well their ability
to be resilient.
Culture has been described by Terry Cross as a
resourceful and structured means for responding
to the elemental needs of human beings. Many
experts in the cross-cultural psychotherapy lit-
erature ascertain that Westernized mental health
practitioners can demonstrate increased cultural
competency as they allow their philosophies and
treatment approaches to be shaped by the indig-
enous and diverse clients and communities who
seek culturally relevant and desired outcomes.

A Guarani shaman in Paraguay, January 2006. Guarani healing Eugenia L. Weiss

is an ancient, energy-based healing system that has been used Taj Artis
for the past 6,000 years in South America. Traditional folk Erin Voss
healers utilize symbolic ceremonies in their treatments. University of Southern California
902 Tricyclic Antidepressants

See Also: DSM-IV; Religion; Religiously Based the resulting compound had no commercial use
Therapies; Spiritual Healing. as a dye, it was shelved but remained in Geigy’s
chemical files to be reexamined 50 years later in
Further Readings the search for new antihistamines. The research-
Abdullah, T. and T. L. Brown. “Mental Illness ers generated 42 derivatives, all of which were
Stigma and Ethnocultural Beliefs, Values, found to have some level of antihistamine effects.
and Norms: An Integrative Review.” Clinical One of these 42, designated G22150, was sent to
Psychology Review, v.31/6 (2011). Roland Kuhn at the Thurgauishe Heil und Flege-
Balhara, Y. P. S. “Culture-Bound Syndrome: Has anstalt in Münsterlingen for testing in 1950. After
It Found Its Right Niche?” Indian Journal of Kuhn decided that it was not effective in promot-
Psychological Medicine, v.33/2 (2011). ing sleep, interest in the iminodibenzyls dwindled
Cross, T., J. Bartgis, and K. Fox. “Rethinking for a couple of years.
the Systems of Care Definition: An Indigenous Following the startling results seen with chlor-
Perspective.” Evaluation and Program Planning, promazine at the Saint Anne hospital in Paris,
v.33 (2010). pharmaceutical companies were determined to
Hodge, D. R., G. E. Limb, and T. L. Cross. “Moving miss no opportunity to get a foot in the door of the
From Colonization Toward Balance and Harmony: nascent psychiatric market. Roland Kuhn worked
A Native American Perspective on Wellness.” with Geigy on testing a different iminodibenzyl,
Social Work, v.54/3 (2009). G22355, which had a similar structure to chlor-
Smith, T. B., M. D. Rodriguez, and G. Bernal. promazine. He tried out the new drug on patients
“Culture.” Journal of Clinical Psychology, v.67/2 with a wide variety of diagnoses, including some
(2011). patients who had been improving on chlorproma-
zine. These patients rapidly began to deteriorate,
at which point the study was discontinued. Dur-
ing the brief trial, however, Kuhn noted that some
of his subjects seemed to display some positive or
Tricyclic Antidepressants even manic effects. In 1955, he proposed to Geigy
that another study be set up to test G22355 in 40
Tricyclic antidepressants (TCAs) were the princi- depressed patients.
pal medications for depressive disorders from the After dramatically positive results were seen
1960s to the early 1980s. Their antidepressant in the first few patients, Geigy, Kuhn, and ward
effects were a chance discovery at a time when the nurses were in no doubt of the success of G22355.
concept of a general antidepressant medication did Kuhn wrote to Geigy, endorsing it as an antide-
not exist. In the late 1940s, under the guidance of pressant shortly after the trial had begun, and the
pharmaceutical company Geigy’s director of phar- compound was given the generic name of imipra-
macology, Robert Domenjoz, Swiss researchers mine. Kuhn noted that he felt the compound was
began searching for new antihistamines, which they a euphoriant as opposed to an antidepressant and
hoped would be commercially successful as seda- would be most useful in cases of what he called
tives and hypnotics, and focused on compounds vital depression. Patients given the new drug
similar to phenothiazines. They concentrated their exhibited restored interest, increased appetite, and
studies on the iminodibenzyls, which shared with improved sleep. The medical community was skep-
the phenothiazines the three-ring structure that tical as current theory attributed clinical depres-
would eventually give the TCAs their name. sion primarily to unresolved interpersonal con-
The first phenothiazines had been developed in flicts. At the time, few believed that a drug could
the 1880s by Professor Heinrich August Bernth­ ever be found that could do more than alleviate
sen at the chemical company Badische Anilin some depressive symptoms. However, the support
und Soda Fabrik (BASF) in his experiments with of a few key specialists, including Paul Kielholz
the chemical dye methylene blue. One of these and Raymond Battegay, encouraged Geigy to put
became the basis for the synthesis of the first imi- imipramine on the European market in 1957 and
nodibenzyl at the turn of the 20th century. As 1958 under the trade name of Tofranil.
 Tricyclic Antidepressants 903

The next tricyclic, amitriptyline (trade name: These understandings of depression also
Elavil), came into use three years later in 1961. relieved family members and individuals suffer-
Three companies, Merck, Roche, and Lundbeck, ing from depression from the moral implications
had simultaneously developed amitriptyline, facil- often present in psychodynamic theories. No lon-
itating rapid worldwide distribution. Merck and ger were the individuals or their family members
Roche had better-developed marketing strategies the responsible parties in the illness, but instead,
than Geigy and thus were able to sell the new they could point to a biological cause, a chemi-
compound to more prescribing physicians. Merck cal imbalance that could be relieved by chemical
developed the key strategy of describing Elavil treatments, the TCAs (and monoamine oxidase
as a possible solution to all forms of depressed inhibitors [MAOIs]), which rapidly proliferated
mood rather than just as another TCA. The high during the rest of the decade.
financial returns promised by antidepressants led In 1958, Geigy tried to create a stronger medi-
to a fight for the rights to amitriptyline, in which cation by chlorinating imipramine. They called
Merck emerged as the victor. this compound chlorimipramine. It made its way
to market slowly, hampered somewhat by the
Cultural Shift FDA’s concerns about overleniency in licensing
This strategy reflected a larger cultural shift compounds too closely related to ones already
within psychiatry to emphasize specific diagno- available. In fact, chlorimipramine took more
ses and targeted treatments. Previous treatments than 30 years to appear on the U.S. market. It
of depressed mood had been sold as tonics or entered the European market under the name
psychic energizers. The TCAs were the first med- Anafranil in the mid-1970s, where physicians
ications to be marketed as working specifically accepted it in part because of its availability in
on the clinical disease of depression. The accep- an intravenous solution. George Beaumont, the
tance of not only amitriptyline but also of the medical director of Geigy UK, and Isaac Marks,
larger concept of a true antidepressant drug also of the Maudsley Hospital in London, became
helped imipramine to become a widely accepted interested in the possible use of Anafranil in
treatment. the treatment of obsessive-compulsive disorder
While this conceptual jump was a major (OCD) but found no significant difference com-
milestone in the history of antidepressants, it is pared to behavioral therapy. The torch was then
interesting to note that even the pharmaceutical taken up by Stuart Montgomery of St. Mary’s
companies still did not anticipate how large the Hospital, whose study comparing chlorimipra-
market would become. The 1960s were a time mine to placebo found it to have significantly
when depression was generally perceived as a rare superior effects in OCD. Subsequent studies had
illness that necessitated inpatient treatment. Anxi- mixed results. Marks found again that behavior
ety was the most commonly recognized outpatient therapy appeared to be superior, but perhaps due
complaint, and the superstars of the psychiatric to the absence of any other specific marketable
medication market were Librium and Valium. therapy, chlorimipramine was licensed for the
In 1965, the catecholaminergic theory of treatment of OCD in the United States and UK
depression was proposed by Jacob Schildkraut’s around 1990.
seminal article, which remains the most-cited arti- Although the primary indications for TCAs
cle in the history of the American Journal of Psy- have remained major depressive disorder and
chiatry. He suggested that most depressions were anxiety disorders like OCD, they have been stud-
caused by a deficit of catecholamines (hormones ied and shown to have some effectiveness for vari-
and neurotransmitters derived from the amino ous off-label indications including panic disorder,
acid tyrosine), especially noradrenaline, in the social phobia, insomnia, post-traumatic stress
intersynaptic cleft. The TCAs, as amine reuptake disorder (PTSD), generalized anxiety disorder
inhibitors, fitted nicely into this emerging hypoth- (GAD), attention deficit hyperactivity disorder
esis and satisfied the Food Drug Administration (ADHD), migraine headache, chronic pain syn-
(FDA) requirements for specificity in treatments dromes, premature ejaculation, substance abuse
and the disease they sought to ameliorate. disorders, and eating disorders.
904 Turkey

Side Effects in Europe. Formerly part of the Ottoman Empire,

As with all psychotropic medications, the TCAs today Turkey is a secular republic, and Islam is
also produced significant side effects. As early as the dominant religion. Care for the mentally ill in
the first trials, Kuhn had described a variety of Turkey has historically been carried out primar-
side effects. These included dry mouth, excessive ily by the families of affected individuals, thus
sweating, constipation, and confusion in patients the country has been relatively slow to establish
with brain disorders. The relief in mood overshad- national laws and regulations regarding the rights
owed these effects, however, and for close to 30 of those suffering from mental illness.
years, the TCAs ruled the antidepressant market. The first hospital wards for the treatment of the
The introduction of fluoxetine (trade name: Pro- mentally ill in Turkey were established in the 15th
zac) and its stunning commercial success led to century, and care was based on the precepts of
the rapid eclipse of the TCAs. Designated a selec- Islamic medicine; mentally ill persons were gen-
tive serotonin reuptake inhibitor (SSRI), this new erally treated kindly and with respect, and psy-
class of drugs blocked the reuptake of serotonin, chotic individuals were considered to have par-
in contrast to the TCAs, which inhibited the reup- ticular closeness to God. Care for mental patients
take of both norepinephrine and serotonin. Mar- deteriorated with the decline of the Ottoman
keted as possessing greater specificity and fewer Empire, and modern methods of treatment were
side effects, the SSRIs (and their progeny) have only consistently established after the founding of
successfully dominated and expanded the antide- the republic in 1923. However, the first attempt
pressant market, creating one of the most lucrative to regulate mental health services in Turkey may
sectors in the pharmaceutical industry. Though be dated back to 1876, during the Ottoman
studies have failed to demonstrate substantially Empire, with the issuance of the Bimarhanelere
greater efficacy of any of the new antidepressants Dair Nizamname (Regulatory Rules for Mental
over TCAs, the far cheaper TCAs have become Health Institutions and Asylums).
relegated to second- and third-line treatments for Academic study of psychology in Turkey
depressive disorders. began in 1915, when German psychologist Georg
Anschutz taught a course in experimental psy-
Rebecca Wilkinson chology at Istanbul University. The same year, the
University of California, Los Angeles Binet-Simon intelligence test was translated into
Turkish, and teacher training institutes began
See Also: Anxiety, Chronic; Monoamine Oxidase offering instruction in psychology. Muzafer Sherif,
Inhibitors (MAOI) Antidepressants; Obsessive- who studied in the United States and taught in
Compulsive Disorder; Serotonin Reuptake Inhibitors. Ankara from 1936 to 1945, was an influential fig-
ure in Turkish psychology. He worked on every-
Further Readings thing from intelligence testing to social psychol-
Healy, D. The Antidepressant Era. Cambridge, MA: ogy, while two of his students, M. Kiray and F.
Harvard University Press, 1997. Basaran, did important work on the psychologi-
Lopez-Munoz, F. and C. Alamo. “Monoaminergic cal effects of social change. American psycholo-
Neurotransmission: The History of the Discovery gists exerted strong influence in Turkey beginning
of Antidepressants From 1950s Until Today.” in the 1960s, and the field greatly expanded in the
Current Pharmaceutical Design, v.15 (2009). 1970s with the establishment of new university
departments.
In 1961, the Socialization Law of the Turk-
ish Ministry of Health established governmental
mental health services, including hospitals, occu-
Turkey pational therapy, and rehabilitation units, but
there were no national mental health policy and
Turkey is an upper-middle-income country, with laws governing matters such as the rights and
most of its landmass in Asia, although much of responsibilities of families and physicians toward
Istanbul, Turkey’s capital and chief city, is located the mentally ill. The fact that traditionally
 Turkey 905

mentally ill persons were cared for primar- referring individuals from primary to secondary
ily by their families, with only the most severe or tertiary care also provide guidance.
cases staying in institutions, has been suggested In 2011, Turkey had eight mental hospitals
as one reason why Turkey was slow in develop- with 3,440 beds (4.5 beds per 100,000 popula-
ing national mental health laws and policies. In tion), six day treatment facilities, and 4,208 psy-
1986, a national health policy was developed chiatric beds (5.6 beds per 100,000 population)
under the leadership of Dr. Bulent Coskun, and within general hospitals. The rate of admission to
in 2002, the Psychiatric Association of Turkey general hospitals was 70.6 per 100,000 popula-
published a document titled “The Rules of Pro- tion, and the rate of admission to psychiatric beds
fessional Ethics in Psychiatry.” However, a 2005 in general hospitals was 69.8 per 100,000. Com-
report by Mental Disability Rights International munity mental health services are deficient by
stated that many children and adults with mental European standards, and more individuals have
illness in Turkey were victims of human rights long-term stays in mental hospitals than is typical
abuses, spurring renewed interest in creating of many European countries. While 75 percent of
additional legal regulations regarding care of the Turkish patients’ stays in mental hospitals were
mentally ill. for less than one year, 13 percent were for one to
Turkey spends 6.7 percent of its gross domes- five years, and 12 percent were for longer than
tic product on health care, and neuropsychiatric five years.
disorders are estimated to constitute 17 percent
of Turkey’s global burden of disease. A large- Sarah Boslaugh
scale survey conducted in 1998 found that the Kennesaw State University
prevalence of psychiatric disorders in people
over age 18 was 17.2 percent, but the use of See Also: Diagnosis; Diagnosis in Cross-National
mental health services remained relatively low. Context; Family Support; Law and Mental Illness;
Besides the national tradition of families car- Religion.
ing for the mentally ill, underuse of professional
services occurs partly because Turkey has few Further Readings
people trained to deal with mental illnesses; in Akbiyik, Derya Iren. “The Doors Are Open: Mental
2011, Turkey had 2.1 psychiatrists per 100,000 Health Law and Organization of Services in
population, while other professions working in Turkey.” International Journal of Mental Health,
the mental health sector included nurses (2.2 per v.36/3 (2007).
100,000), psychologists (1.6 per 100,000), and Gökalp, R. Peykan and Z. Nergis Aküzüm.
social workers (0.8 per 100,000). Primary care “Community Mental Health Services in Turkey:
doctors may prescribe psychiatric medicines, Past and Future.” International Journal of Mental
with some restrictions, but most primary care Health, v.36/3 (2007).
physicians and nurses have not received recent World Health Organization Regional Office for
official in-service training in mental health. Europe. “Policies and Practices for Mental Health
However, official manuals for the care and man- in Europe: Meeting the Challenges” (2008).
agement of mental disorders are available in http://www.euro.who.int/document/e91732.pdf
most health clinics, and official procedures for (Accessed January 2013).
 U
Uganda drugs, a problem for all Ugandans with chronic
conditions. Even when they are available, pre-
The Republic of Uganda is a landlocked east Afri- scription medications are financially out of reach
can country bordered by Kenya, the new nation for many Ugandans. Counseling, when it is avail-
of South Sudan, the Democratic Republic of the able, is usually performed by clergy, teachers, and
Congo, Rwanda, and Tanzania. It shares Lake health care workers. Some researchers have sug-
Victoria, bordering the southern region of the gested that the easiest way to better the state of
country, with Kenya and Tanzania. Nationwide Ugandan mental health care would be to build
studies of mental illness prevalence in Uganda cooperation between traditional healers and for-
have not been conducted. Two prevalence sur- mal health care, to collaborate on treatments.
veys have been conducted of single communities Christianity was not introduced to Uganda
in Uganda and found that 30.7 and 25.3 percent, until the end of the 19th century. African tradi-
respectively, of adults had suffered from a men- tional religion includes the belief in a creator, a
tal illness within the year before the survey. There holistic view of life, and the belief in contact with
is little history of formal mental health care in a spirit world, which not only can influence the
Uganda, and the earliest centers for the mentally physical world but does so on a daily basis. Afri-
ill in the 1930s chained their patients, waiting can traditional religion has many adherents in
for the illness to pass, a method called “custo- Uganda, and even many Ugandans who formally
dial care.” The first national mental health facil- belong to another faith may integrate that faith
ity in Uganda opened in 2012, a unit at Butabika with many of the elements of traditional Ugandan
Regional Referral Hospital. Nevertheless, there religious beliefs.
was less than one psychiatrist for every 1 million Individuals may seek health care from indig-
people in Uganda in 2012. The country’s entire enous traditional healers, rather than health care
psychiatric professional community would fit into professionals, especially when their ailment is
a public school classroom. not addressed by doctors and hospitals in their
Years of political instability, civil unrest, and conceptual model. “Madness” is most commonly
disease have left Ugandans in need of mental understood by such healers as spiritual or physi-
health services, but little in the way of formal ological in origin, and conceptualized in models
mental health care exists in the country, and tied to the history and sociopolitical culture of
there are frequent shortages of many prescription the various peoples of Uganda. In sub-Saharan

907
908 Uganda

Cultural celebrations resume with the end of the Lord’s Resistance Army conflict in northern Uganda, December 16, 2009, bringing
hope of change for this war-torn country. The first national mental health facility in Uganda opened in 2012. However, years of political
instability, civil unrest, and disease have created a severe lack of formal mental health care and prescription drugs in the country.

African belief, the mind is often thought of as refer patients to hospitals on a regular basis. Tra-
residing in the heart or the abdomen, rather than ditional healers can also be counterproductive,
in the brain. Not all symptoms that modern psy- though, when they blame mental illnesses on
chiatry considers as mental illnesses are viewed spiritual causes that cannot be addressed, or on
as such in these traditional models. While psy- witchcraft.
chosis, usually generically referred to as madness, Traditionally thought of as rare in Uganda, sui-
has long been understood as a disease, neurotic cide is not as rare as it once was as a result of the
conditions, anxiety disorders, and mood disor- turmoil and anomie of recent decades. Ugandan
ders are often not seen. They are often considered religious belief emphasizes the importance of the
physiological problems, to be dealt with accord- individual’s role in the collective, and as Ugandan
ingly. As in many cultures, some symptoms are society has broken down in many parts of the
not understood as problematic at all but rather as country, that loss of cohesion and internal strife
manifestations of spiritual activity. has motivated both individual and mass suicides.
Traditional healers in Uganda include herbal- The mentally ill face stigma in many countries,
ists and spirit diviners; some healers practice both but the stigma is deeper and broader in Uganda
disciplines. Contrary to the depiction common in than in much of the world. Because of the long
popular culture, many healers work directly with recognition of psychosis as a mental illness, Ugan-
government health services and share information dans often view any mental illness as synonymous
about the individuals who come to them. Most with psychosis and “madness,” and thus the
 Ukraine 909

mentally ill are viewed as erratic, unpredictable, Ukraine

untrustworthy, and dangerous. This is also true
of neurological conditions such as epilepsy and Ukraine is a former republic of the Soviet Union
developmental disorders such as mental retarda- that became independent in 1991 after the Soviet
tion. The stigma makes it difficult for the men- Union disintegrated. It has a population of 48
tally ill and their families to overcome shame and million. Ukraine after the fall of the Soviet Union
self-consciousness in order to seek treatment. needed substantial financial support and reached
The mental illness stigma runs deep enough out to the International Monetary Fund and the
that studies have found that health care work- World Bank, whose monies came with demands
ers typically do not want to work in the mental for substantial funding cuts, including for social
health care field, and prospective doctors have services, and increasing competition and invest-
little interest in psychiatry. Even medical students ment.
widely report a disinterest in psychiatry out of Per capita income and indices of corruption and
fear that exposure to mental illness would cause transparency in government are still behind the
them to become mentally ill. Many believe that European standard, but it enjoyed both industrial
mental illness simply cannot be addressed by and agricultural economic growth of 10 percent
medical remedies but only by spiritual ones. annually in the first years of the 21st century. The
Incorporated in 2004, Mental Health Uganda 2004 presidential elections and Orange Revolu-
(MHU) is a nongovernmental organization tion are indicators that democracy is strong and
formed to bring together sufferers of mental ill- Ukrainians are ready for radical change, includ-
ness and to advocate better mental health ser- ing in psychiatric methods and principles.
vices in the country. MHU views mental illness
not simply as a medical problem but also as a Prevalence of and Attitudes Toward
social and developmental issue. It works in 18 of Mental Health Care
Uganda’s 80 districts to improve mental health In 2004, the World Health Organization (WHO)
care, improve the lives of the mentally ill, reduce conducted a survey of 14 countries for preva-
the stigma associated with mental illness, influ- lence of mental illness. The study indicated that
ence policy and legislation, and build the capac- Ukraine had a 20.4 percent prevalence of mental
ity of people with mental illness and their affected disorders, with 4.8 percent severe. Ukraine’s 9.1
families. percent prevalence of mood disorders was highest
of the 14 countries measured, and its 6.4 percent
Bill Kte’pi substance abuse disorder percentage was higher
Independent Scholar than the United States, which led the group with
an overall prevalence rate of 26.4 percent, with
See Also: Congo, Democratic Republic of the; problems including depression, anxiety, substance
Kenya; Spiritual Healing; Sudan; Tanzania. abuse, and eating disorders. Other reports indi-
cate that Ukraine and the former Soviet Union
Further Readings have lower incidences of depression than some
Kabura, Paschal, Linda M. Fleming, and David northern European countries, where one in 14
J Tobin. “Microcounseling Skills Training for men and one in seven women suffer depression.
Informal Helpers in Uganda.” International In comparison, Belgium had a 12 percent overall
Journal of Social Psychiatry, v.51/1 (2005). prevalence rate.
Kasoro, S., S. Sebudde, G. Kabagambe-Rugamba, Ukraine has yet to come to grips with its chang-
E. Ovuga, and A. Boardman. “Mental Illness in ing social structure and changing mental and other
One District of Uganda.” International Journal of health care needs. Rural residents are more prone
Social Psychiatry, v.48/1 (2002). to the depression that comes with depopulation
Teuton, Joanna, Richard Bentall, and Chris Dowrick. and unemployment. Kievian media and profes-
“Conceptualizing Psychosis in Uganda: The sionals acknowledge that mental health issues
Perspective of Indigenous and Religious Healers.” are real, but most Ukrainians still regard depres-
Transcultural Psychiatry, v.44/1 (2007). sion as shameful personal failure and therefore
910 Ukraine

stigmatize it. Regardless, treatment is lacking for treatment, from socialized to privatized or insur-
mental disorders, regardless of type or severity. ance-financed care, and from the hospital-based
The 2004 report indicated that only 4.9 percent of Soviet system to the decentralized American health
Ukrainians suffering from mental illness had any care system. Although the reception is positive, it
treatment at all during the preceding 12 months, means a reduction in the number of available psy-
and only 19.7 percent of those with severe disor- chiatric beds in order to move money to local vil-
ders received treatment during the year. lages and cities where the money may or may not
Westerners tend to stereotype the Slavic go to psychiatric care, depending on infrastruc-
approach to mental health as a matter of misdi- ture. The insurance-based system is under testing,
agnosis or underdiagnosis, poor treatment, and with implementation scheduled for 2015 or 2016
political abuse. The Soviet tradition deempha- at the earliest.
sized mental health in favor of repression, and Obsolete practices and inadequate funding
Ukraine retained the tradition. Ukraine inherited have been problems. Nonspecialist general prac-
87 psychiatric hospitals with 47,000 beds (9.8 titioners have difficulty identifying mental illness,
per 100,000) where most of the 4,000 psychia- and there is a tendency to allow only psychiatrists
trists (8.4 per 100,000) practiced Soviet-taught to prescribe psychotropic drugs. This rule adds
psychiatry. The preference was for pharmaco- to the stigma of mental illness. There are efforts
logical intervention with older and cheaper drugs to encourage family practitioners with financial
except when the patient or family paid for the incentives for those who improve their commu-
more expensive choices. Outpatient care was lim- nication skills and knowledge of psychological
ited, with few nondrug treatment options and vir- illness.
tually no community care. The command-system Between 2000 and 2005, Ukranian psychia-
mentality of the Soviet era remained in operation, trists began to create organizations and build
with authoritarian and arbitrary decision making training and practice standards up to the Euro-
common in the psychiatric hospitals. Ukraine did pean level. The use of the International Classifica-
discontinue the political abuses, however, with tion of Diseases (ICD-10) classification was offi-
only a handful of cases occurring in a given year. cial if not universal in Ukraine. The switch was
under way from central management to social
Mental Health Care Systems health insurance with managed care, with train-
The Ukrainian mental health system is in a tran- ing also under way for psychiatric nurses, social
sition. Currently, it resembles that of the United workers, and community mental health teams.
States at the beginning of the 20th century, New delivery methods for psychiatric services
with most care taking place in large, state-run were being attempted.
mental hospitals. Hospitals provide services to However, the shift has been bumpy. Shelly
those residing within a specific geographic zone. Yankovskyy, who conducted her anthropological
Although services are theoretically free or at dissertation fieldwork in Ukraine in 2008, inter-
nominal cost, in practice, budgetary constraints viewed several Ukrainian practitioners who felt
force hospitals to charge for services. The system that the country was not ready to transition to
retains the shadows of the old Soviet approach community-based services, as they related that
that used psychiatric diagnosis and confinement they had observed mental patients at the hands of
as a political tool. family, neighbors, police, and government. Fur-
In reaction, Ukraine is moving to tear down ther, the infrastructure for care and medications
and privatize the formerly centralized institu- is inadequate. While the structure and policy is
tions, including health care. Reforms are exter- heading toward change, there is a tension between
nally funded by the U.S. Agency for International Ukrainian culture and these reforms, with a seri-
Development (USAID), the WHO, and the U.S. ous debate between advocates of neoliberalism
government, with internal change and reform and state-centered programs.
from nongovernment organizations. Further, some Ukrainian human rights orga-
The major change in Ukraine has been nizations criticize the current mental health pro-
from institutionalization to community-based gram as inhumane and abusive of human rights,
 Unemployment 911

while observing that the overall Ukrainian society Unemployment

is struggling with the changes that are generating
hardship and tension. Their goal is to raise these In the United States and other countries, rates of
issues in advance so the health care reforms will unemployment have increased during the eco-
be pressured to take them into account. nomic downturn in the early part of the 21st
The Ukrainian Psychiatric Association has a century. Thus, unemployment remains a serious
legal unit to investigate those who misdiagnose economic problem. It is also a major public health
and mistreat for financial gain. Ukraine approved issue. An extensive body of literature has revealed
the Law on Psychiatric Assistance in 2000, which that unemployment is associated with mental
is similar in principle to the general European health problems.
standard but still deficient in practice. Ukraine
is getting assistance from the European Commit- Defining Unemployment
tee for the Prevention of Torture and Inhumane Studies on mental health usually measure unem-
and Degrading Treatment or Punishment (CPT), ployment status by including those who are seek-
which offers monitoring of facilities for patients ing jobs and those who are “out of the labor
and prisoners. force” and not looking for work. There is a dif-
ference, however, between involuntary and vol-
John H. Barnhill untary unemployment. Those who chose to be
Independent Scholar out of the paid labor force for different reasons,
such as attending school, focusing on being a par-
See Also: Anxiety, Chronic; Depression; Mental ent, and keeping house are considered voluntarily
Institutions, History of; Psychiatric Training; Russia; unemployed. Those who are actively looking for
United States. employment and are unable to succeed are invol-
untarily unemployed.
Further Readings Does unemployment when looking for a job
European Committee for the Prevention of Torture and being ‘‘out of the labor force’’ when not seek-
and Inhumane and Degrading Treatment or ing work have distinct mental health ramifica-
Punishment. “Ukraine.” http://www.cpt.coe.int/en tions? Longitudinal research in the United States
/states/ukr.htm (Accessed May 2013). has shown that the duration of being out of the
Ougrin, Dennis, Semyon Gluzman, and Luiz labor force when not looking for a job does not
Dratcu. “Psychiatry in Post-Communist Ukraine: predict symptoms of depression or heavy alcohol
Dismantling the Past, Paving the Way for the consumption among young adults, but the dura-
Future.” http://pb.rcpsych.org/content/30/12/456 tion of unemployment when seeking work is a
(Accessed January 2013). significant risk factor for depression and heavy
Styles, Richard. “Staying Sane in Ukraine.” drinking. More mental health research should
BusinessUkraine, v4/6 (June 2010). http://www distinguish between these different forms of
.bunews.com.ua/index.php?option=com_content& unemployment.
view=article&id=358:staying-sane-in-ukraine-&cat According to the life course perspective, unem-
id=25:industry-&Itemid=34 (Accessed January ployment can have different meanings for individ-
2013). uals during specific life stages, depending on their
Yankovskyy, Shelly. “Mental Health Care in Ukraine: personal expectations about their lives and the
Twenty Years After the Soviet Union” (November social norms during different historical periods
14, 2011). http://somatosphere.net/2011/11/mental or economic climates. Thus, if employment is not
-health-care-in-ukraine-twenty-years-After-the-soviet achieved at an age when it is typically expected
-union.html (Accessed January 2013). by young adults, persistent unemployment can
Zwillich, Todd. “Rate of Mental Illness Is become chronically stressful and increase the risk
‘Staggering’” (June 1, 2004). WebMD Health of becoming mentally ill. The onset of mental
News. http://www.webmd.com/mental-health/ illness can often occur during the transition to
news/20040601/rate-of-mental-illness-is adulthood, of which employment is considered to
-staggering?page=2 (Accessed January 2013). be a key marker. Midlife is a time when employed
912 Unemployment

people expect to have achieved more job security a significantly increased risk of developing symp-
as their careers and experience have advanced. toms of mental illness. Moreover, it is crucial to
Yet this may no longer be the case for younger differentiate between a causal relationship and an
generations who are growing up during an eco- association. For example, the association between
nomic downturn and changing social norms. It unemployment and mental illness is measured at
is becoming more common for young people to a single point in time. To come closer to proving
change jobs, perhaps experiencing episodes of social causation, temporal ordering needs to be
involuntary or voluntary unemployment during established to demonstrate that unemployment
this process and sometimes completely switching precedes mental illness. Longitudinal data sets
careers. In contrast, it is more likely for members that follow respondents over time can determine
of older generations to have had longer careers temporal ordering.
with the same employer. In sum, the effect of Why does unemployment cause subsequent
unemployment on mental health can vary by life mental illness? Social stress theory contends that
stage or birth cohort and be explained in part by the experience of unemployment is linked with
life-course expectations about the timing of entry economic hardship, which exposes the individual
into adult social roles. to financial stressors and damages social and psy-
chological coping resources, which in turn impair
Measuring Mental Health mental health and lead to mental illness. From
Many social scientific studies have primarily a social and psychological perspective, employ-
focused on symptoms of depression to assess psy- ment and specifically an occupation provide a
chological distress as a form of human suffering. social identity that is often a salient part of the
It has been argued, however, that to more com- self-concept. The self-concept is a vital resource
prehensively measure mental health problems, for coping with stress. According to social stress
research should examine symptoms of internal- theory, the self-concept is the mechanism through
ized mental disorders such as depression as well which stress leads to mental illness. To elaborate,
as symptoms of externalized mental disorders employment can bolster psychological, social, and
such as alcohol abuse/dependence. Studies sug- financial resources, whereas being unemployed
gest that in general, females are more likely to can be stressful and negatively affect an individu-
internalize their distress via depression, while al’s thoughts and feelings about him/herself, lead-
males are more likely to externalize their dis- ing ultimately to mental illness. The deleterious
tress through substance abuse/dependence such effect of an individual’s unemployment status on
as heavy alcohol consumption. The literature has his/her mental health is called intragenerational
not yet reached a consensus about the relation- social causation.
ship between unemployment and heavy drinking In addition, the mental health of children,
of alcohol in general. Stress has been identified as adolescents, and young adults can be negatively
a conduit through which unemployment and job affected by the unemployment status of their par-
loss increase the probability of heavy drinking. ents as well as their disadvantaged socioeconomic
status. This is considered intergenerational social
The Relationship Between Unemployment causation.
and Mental Illness In contrast to the social causation hypothesis,
An important question has motivated numer- the selection/drift hypothesis posits that mental
ous studies: Which comes first, unemployment illness can inhibit socioeconomic attainment via
or mental illness? Two approaches have been job loss or prolonged unemployment and lead
posited: the social causation hypothesis, which people to eventually drift into a lower social class.
contends that mental illness is caused by unem- From this perspective, mental illness comes first
ployment, and selection/drift hypothesis, in which and is followed by job loss or ongoing unemploy-
mental illness can limit job opportunities and lead ment. Severe symptoms of mental illness can limit
to unemployment. social functioning to the extent that a person
According to the social causation hypothesis, may have difficulty keeping a job or finding a job
individuals who experience unemployment have and sink downward in socioeconomic status and
 Unemployment 913

even enter poverty. The selection hypothesis can mental health should include multiple indicators
be tested by taking into account earlier mental of socioeconomic status to capture economic
health with longitudinal data. well-being, such as employment status, occupa-
In essence, there is some evidence that ear- tional prestige, income, education, and wealth
lier mental health problems help to explain why (net worth).
there is a relationship between unemployment Unemployment status should not simply be
and mental illness, but there is more evidence for conceptualized as being attached to the individ-
social causation. ual or family but also the neighborhood or state.
Unemployment rates at the neighborhood or state
Longitudinal Studies and Future Research level encompass a more macrostructural analysis
A number of longitudinal studies have provided of socioeconomic status and the economy. Neigh-
compelling evidence of social causation by dem- borhood-level indicators of economic deprivation
onstrating that past unemployment and its dura- are gaining more attention in the mental health lit-
tion have harmful effects on mental health. U.S. erature. In economically deprived neighborhoods,
longitudinal research has indicated that prior residents report a higher frequency of unemploy-
unemployment and job disruption (being fired, ment, criminal activities, vandalism, graffiti, loi-
laid off, downgraded, or leaving work because tering, abandoned buildings, broken windows,
of illness) during two- to 15-year intervals were garbage, and noise. In conclusion, unemployment
linked with subsequent symptoms of depression. status is an integral piece of the puzzle of social
Many of these studies controlled for prior symp- inequality in an individual’s daily life, neighbor-
toms of depression to test for selection, and they hood, community, and country.
found that earlier mental health did not entirely
explain the relationship between unemployment Krysia N. Mossakowski
and depression. Finally, an international meta- University of Hawai‘i, Manoa
analysis of longitudinal studies indicated that
changing one’s status from employment to unem- See Also: Alcoholism; Economics; Employment;
ployment, measured between six months and Environmental Causes; Gender; Life Course;
three years, led to worse mental health in general. Measuring Mental Health; Neighborhood Quality;
Additional longitudinal research will help Social Causation; Social Class; Stress; Women;
disentangle the reciprocal relationship between Work–Family Balance.
unemployment and different types of mental ill-
ness. Regarding gender differences, a topic for Further Readings
future research is whether mental health problems Dooley, David, Ralph Catalano, and Richard Hough.
among wives who are in or out of the labor force “Unemployment and Alcohol Disorder in 1910
are affected by their husbands’ unemployment or and 1990: Drift Versus Social Causation.” Journal
out-of-the-labor-force status. Moreover, longitu- of Occupational and Organizational Psychology,
dinal studies on mental health will help to further v.65 (1992).
explore the timing of unemployment entries and Eriksson, Tor, Esben Agerbo, Preben Bo Mortensen,
exits for different cohorts or generations, as well and Niels Westergaard-Nielsen. “Unemployment
as underemployment, which refers to poverty- and Mental Disorders.” International Journal of
level wages and involuntary part-time work. Mental Health, v.39/2 (2010).
Future mental health studies need to spec- Mossakowski, Krysia. “The Influence of Past
ify involuntary and voluntary unemployment. Unemployment Duration on Symptoms of
For example, voluntary unemployment can be Depression Among Young Women and Men in the
because of wealth and having enough assets to United States.” American Journal of Public Health,
live on without needing an income from a job, v.99/10 (2009).
which is a very different financial situation than Murphy, Gregory C. and James A. Athanasou. “The
involuntary unemployment, having a low level of Effect of Unemployment on Mental Health.”
education, and negative net worth (more finan- Journal of Occupational and Organizational
cial debts than assets). Therefore, studies on Psychology, v.72/1 (1999).
914 United Kingdom

United Kingdom also became a center for psychiatric research

after World War I, with Edward Mapother serv-
The United Kingdom (UK) is a northern Euro- ing as the first director. Britain established itself
pean island nation comprised of four constituent as a leader in the study of child guidance and psy-
countries: England, Northern Ireland, Scotland, chology with the establishment of the Institute of
and Wales. The UK has a 2012 population esti- Child Psychology in 1928 at the University of
mated at 63 million, of whom 80 percent live in London, and the creation of a nationwide net-
urban areas. The UK is classified by the United work of guidance clinics and special schools in
Nations Development Programme as having very the period between world wars.
high human development (the highest category); World War II also served as an important stimu-
life expectancy at birth in 2012 was estimated at lus to psychiatric research. Maxwell Jones devel-
80.2 years, among the highest in the world, and oped the concept of the therapeutic community
per capita gross domestic product (GDP) in 2011 during this period, working with demoralized
was estimated at $35,900. As is characteristic of soldiers, while Eliot Slater and William Sargant
industrialized countries, the UK has a relatively developed a number of physical treatments for war
low percentage (17.3 percent) of its population neuroses. At about the same time, Wilfrid Bion and
aged 14 and under and a relatively high percent- Siegfried Heinrich Foulkes developed a method of
age (17.3 percent) aged 65 and older; the fertility group therapy based on Freudian principles while
rate of 1.9 children per woman (below replace- working with soldiers at Northfield Hospital near
ment level) is also typical of many industrialized Birmingham. Passage of the National Health Act
countries. In 2010, the UK spent 9.6 percent of in 1948 created the National Health Service and
its GDP on health, of which 83.2 percent came directed large sums of money toward psychiatric
from public sources; total per capita expenditure facilities, thus providing much greater access to
on health was $2,433. mental health services for the general population.
As in many other countries, in the 1960s, the
History: Psychiatry and Psychology UK began to deinstitutionalize mental patients,
In the 19th century, British psychiatry was noted shifting emphasis from care provided in large
more for its social and practical concerns than for mental hospitals to community-based care. Also
groundbreaking research. While this led to impor- similar to some other countries during that time,
tant reforms in the treatment of the mentally ill, the UK experienced an antipsychiatry movement
it also tended to isolate the study and practice of led by individuals such as psychiatrists R. D. Laing
psychiatry from the mainstream of British medi- of Scotland and David Cooper, who was born in
cal practice. At the same time, several British sci- South Africa but practiced in London; both chal-
entists, including Francis Galton and Karl Pear- lenged existing definitions of mental health and
son, were distinguishing themselves in the fields sanity. Today, the UK is a world leader in the
of psychometrics (some credit Galton with found- training of both psychiatrists and psychologists,
ing this field) and cognitive testing. with particular distinction in child psychology.
World War I provided an important stimulus
to the development of psychiatry in Britain, as History: Psychoanalysis
large numbers of veterans suffering from shell Psychoanalytic ideas were introduced to the
shock needed treatment. In 1919, the first chair UK in 1893 through an article by Frederick W.
in psychiatry in the UK was created at Craig H. Myers on hysteria. Havelock Ellis was also
House, a branch of the Royal Edinburgh Hospi- highly influential in popularizing psychoanalyti-
tal in Scotland; George Robertson was the first to cal ideas, which ran contrary to the neurological
hold this position. Robertson was succeeded by basis of most psychiatric work in Great Britain
David Henderson, who had studied in the United at the time. In the early 20th century, psycho-
States and Germany and was a pioneer in clini- analytic ideas spread throughout the country,
cal and forensic psychiatry and in the employ- aided in particular by the Bloomsbury Group of
ment of occupational therapists and psychiatric intellectuals at Cambridge University, including
social workers. Maudsley Hospital in London James and Alix Strachey (both of whom became
 United Kingdom 915

psychoanalysts), and Adrian and Karen Stephen but each manages health care delivery somewhat
(brother and sister-in-law of Virginia Woolf). differently and may have different priorities. Sta-
David Eder presented a psychoanalytic paper in tistics are reported either for the UK as a whole or
1911 to members of the British Medical Associa- for just one of its constituent countries; if no coun-
tion, Ernest Jones founded the London Psycho- try is specified in this article, the statistic refers to
Analytic Society in 1913 (it disbanded and then the UK as a whole, while statistics referring to a
reorganized in 1919), and Henry Butter Stoddart single country are identified as such. The NHS was
presented a well-received series of lectures on psy- created in 1948 and provides universal access to
choanalysis in Edinburgh in 1915. health care, funded through national taxation. Pri-
Psychoanalysis gained ground following World vate insurance is also available, and a 2004 World
War I, as physicians were searching for new ways Health Organization study found that 11.5 per-
to treat the many military veterans who returned cent of the population had supplemental or com-
home suffering from shell shock and other psycho- plementary voluntary health insurance, providing
logical disorders. However, psychoanalysis also benefits such as quicker access to services.
faced opposition from a group of influential psychi- Mental health care is included in the NHS and
atrists in Britain, some of whom viewed it as a Ger- is organized mainly by primary care trusts, which
man import not suited to British culture. The Brit- are local administrative bodies that contract with
ish Medical Association recognized psychoanalysis providers (including physicians) to provide ser-
as a legitimate type of treatment in the 1920s, but vices to the local population. Most mental health
the number of psychoanalysts remained relatively care is provided on an outpatient basis, but care
small; the only training center in the country was in hospitals, regional secure units, and secure
located in London. In 1926, Melanie Klein arrived hospitals is also available. An individual may vol-
in Britain, and her views on early psychic develop- untarily commit themselves to mental hospital
ment became influential. Psychoanalysis received treatment with the agreement of their psychiatrist
a further boost in Britain in 1938, when Sigmund or can be compulsorily detained under the provi-
Freud, his daughter Anna, and a number of their sions of the Mental Health Act.
supporters arrived in London. Conflict between In 1989, the national service framework for
followers of Freud and Klein caused the British mental health outlined a 10-year plan to trans-
Psycho-Analytical Society to split into three parts: form mental health services, including early inter-
followers of Klein, followers of Freud, and inde- vention, care provided close to the patient’s home,
pendents who adhered to neither camp. tailored care, use of modern medicines, services
Today, psychoanalysis is a respected type of delivered by multidisciplinary teams, around-the-
mental health therapy in the UK, with several clock provision of home treatment, and increased
rival groups representing different aspects of the use of talking therapies. The 2000 NHS Plan
field; these include the United Kingdom Council named mental health as a clinical priority, with
for Psychotherapy and the British Confedera- initial focus on providing specialist mental health
tion of Psychotherapists. College London has a services, although community mental health has
Chair of Psychoanalysis and offers a Ph.D. in more recently been given greater emphasis. Eng-
psychoanalytic research, and the Tavistock Clinic land ranks high among European countries in
in London, founded in 1920 by Hugh Crichton- terms of mental health services provision, but
Miller, offers a four-year course in psychoanalytic the government has set priorities to improve care
therapy. In Scotland, psychoanalytic training is further by removing inequalities in access to care,
available through the Scottish Institute of Human improving access to psychological therapies, and
Relations and the London Institute of Psycho- improving the lives of those with mental illness,
Analysis, and psychoanalytic training is also including fostering their social inclusion.
available in Northern Ireland.
Epidemiology: Adults
Mental Health Services In 2007, the National Health Service Information
England, Northern Ireland, Scotland, and Wales Centre for health and social care commissioned a
are all part of the National Health System (NHS), national interview survey of adults (aged 16 and
916 United Kingdom

older) living in private households in England. One-third (33.3 percent) of adults reported
This survey found that 16.2 percent of adults met having experienced a traumatic event since age
the diagnostic criteria for at least one common 16, with men (35.2 percent) reporting higher
mental disorder in the previous week, with the indication of trauma than women (31.5 percent);
most common disorder being mixed anxiety and 42.2 percent of adults reported experiencing a
depressive disorder (9 percent), followed by gen- trauma at some point in their life, with higher
eralized anxiety disorder (4.4 percent), depres- percentages of men (44.1 percent) than women
sive episodes (2.3 percent), phobias (1.4 percent), (40.4 percent) reporting this. Overall, 3 percent of
panic disorder (1.1 percent), and obsessive-com- women screened positive for post-traumatic stress
pulsive disorder (1.1 percent). disorder (PTSD), with the rate slightly lower for
Women (19.7 percent) were more likely than men (2.6 percent) than for women (3.3 percent).
men (12.5 percent) to have a common mental In general, PTSD was highest in the 16 to 24 age
disorder, and rates for specific disorders were group for both sexes and then declined with age,
also higher for women than for men, except for with the exception of women aged 45 to 54, who
panic disorder and obsessive-compulsive disorder. had the highest rate of any age-sex group.
There was little variation in the rate of mental After age standardization, trauma was highest
disorders among white, black, and south Asian among black men (45.7 percent versus 36 percent
men, but for women, all disorders except phobias for white men and 29.3 percent for south Asian
were more common among south Asians. Mental
disorders were also more common among those
living in the lowest-income households compared
to those in the highest-income households. Men-
tal disorders for both sexes generally increased up
to middle age and then declined, with the lowest
prevalence in the 65 and older age group.
Just under one-fourth (24 percent) of individu-
als with a mental disorder were being treated, most
often by medication, but almost half (48 percent)
of those with two or more disorders were receiv-
ing treatment. Those with phobias were the most
likely to be receiving treatment, with 23 percent
being treated with medication only, 13 percent
with counseling only, and 21 percent with both
medication and counseling. Half of those suf-
fering a depressive episode were receiving treat-
ment, with 25 percent receiving medication only,
8 percent counseling only, and 17 percent both
medication and counseling. Of those with gen-
eralized anxiety disorder, 66 percent received no
treatment, 18 percent medication only, 7 percent
counseling only, and 9 percent both medication
and counseling. Of those with obsessive-compul-
sive disorder, 69 percent received no treatment,
12 percent medication only, 6 percent counseling
only, and 12 percent both medication and coun-
seling. Mixed anxiety and depressive disorder
was least treated, with 85 percent receiving no
treatment, 11 percent medication only, 3 percent A statue of Sigmund Freud presides over London’s Tavistock
counseling only, and 2 percent both medication Clinic, which was founded in 1920 by Hugh Crichton-Miller. It
and counseling. offers a four-year course in psychoanalytic therapy.
 United Kingdom 917

men), and black men were also most likely to 8.1 percent of boys aged 11 to 16 years having
screen positive for PTSD (7.4 percent versus 2.5 this diagnosis, as compared to 2.8 percent and 5.1
percent for white men and 3.1 percent for south percent of girls in those age groups, respectively.
Asian men). For women, south Asians were the Hyperkinetic disorders such as attention deficit
most likely to have experienced trauma (43.9 hyperactivity disorder (ADHD) were much more
percent compared to 31.4 percent for both black common among boys, with 2.7 percent of boys
and white women), but rates of PTSD did not aged 5 to 10 years and 2.4 percent of boys aged
vary among the racial groups. The experience of 11 to 16 affected, as compared with 0.4 percent
trauma did not vary significantly across income of girls in each of those two age groups. In con-
groups, but PTSD was more common in lower- trast, emotional disorders were more common
income households: for instance, 6.2 percent of among girls, with 2.5 percent of girls aged 5 to
men and 4.1 percent of women in the lowest 10 years and 6.1 percent of girls aged 11 to 16
income quintile screened positive for PTSD, while years having an emotional disorder, compared to
in the highest income quintile, only to 2 percent 2.2 percent of boys aged 5 to 10 and 4 percent of
of men and 1.7 of women screened positive. boys aged 11 to 16. Children in the care of local
Overall, 16.7 percent of adults said they had authorities had an extremely high prevalence of
considered suicide at some point in their lives, mental health problems (45 percent), with con-
with 5.6 percent attempting suicide and 4.9 per- duct disorders being most common (36 percent
cent engaging in self-harm; however, less than for those aged 5 to 10 years and 40 percent for
1 percent (0.7 percent) said they had attempted those aged 11 to 15 years).
suicide in the past year and less than 0.1 percent Overall, the ONS survey found the prevalence
in the past week. Women were more likely than of mental health problems in children and ado-
men to have thought about suicide (19.2 percent lescents to be higher in families in which neither
versus 14 percent) and were also more likely to parent was working (20 percent) than in those
have attempted suicide (6.9 percent versus 4.3 where one (9 percent) or both (8 percent) parents
percent); however, men and women were about worked. Children from low-income families also
equally likely to report self-harm. had a higher prevalence of mental health prob-
lems: 16 percent of children with a weekly family
Epidemiology: Children and Adolescents income under £100 had a mental health problem,
According to the British Medical Association, the versus 5 percent for those with a family income
prevalence of clinically diagnosed mental health over £600. Children living in public housing were
disorders in the UK is about 10 percent among more likely (17 percent) to have mental health
children under age 16, with a higher prevalence problems than those in private rented housing (14
among older children: among those in the 11 to percent) and much more likely than those living
16 age group, the prevalence is 13 percent for in owned housing (7 percent). Children in single-
boys and 10 percent for girls. Depression is rela- parent families were also more likely (16 per-
tively rare, affecting about 1 percent of children cent) to have mental health problems compared
and 3 percent of adolescents. Self-harm is more to those living with married parents (7 percent).
common, with an estimated 6.9 percent of young Of those children living in single-parent families,
people having committed an act of self-harm, boys (18 percent) were more likely than girls (7
and a higher prevalence among boys (11.2 per- percent) to have mental health problems.
cent) than girls (3.2 percent), with an average
age of onset of 12 years. Eating disorders such as Sarah Boslaugh
anorexia and bulimia begin somewhat later, with Kennesaw State University
an average age of onset of 15 for anorexia and 18
for bulimia. See Also: Adolescence; Children; Community
According to a survey by the Office of National Psychiatry; Deinstitutionalization; Epidemiology;
Statistics (ONS) in 2004, conduct disorders were Psychoanalysis, History and Sociology of;
more common in the UK among boys than girls, Psychoanalytic Treatment; Racial Categorization;
with 6.9 percent of boys aged 5 to 10 years and Shell Shock; Voluntary Commitment; War.
918 United States

Further Readings Nov/1645_Squires_intl_profiles_hlt_care_systems

British Medical Association. “Child and Adolescent _2012.pdf (Accessed May 2013).
Mental Health: A Guide For Healthcare Welsh Government. “Together for Mental Health:
Professionals” (2006). http://www.familieslink A Strategy for Mental Health and Wellbeing in
.co.uk/download/jan07/ChildAdolescentMental Wales” (2012). http://wales.gov.uk/docs/dhss/pub
Health%202006.pdf (Accessed May 2013). lications/121031tmhfinalen.pdf (Accessed May
Commonwealth Fund. “International Profiles of 2013).
Health Care Systems, 2011” (2011). http://www World Health Organization (WHO) Regional Office
.commonwealthfund.org/Publications/Fund-Re for Europe. “Policies and Practices for Mental
ports/2011/Nov/International-Profiles-of-Health Health in Europe: Meeting the Challenges.”
-Care-Systems-2011.aspx (Accessed May 2013). Copenhagen, Denmark: WHO Regional Office for
Halliwell, Ed, Liz Main, and Celia Richardson. Europe, 2008.
“The Fundamental Facts: The Latest Facts and
Figures on Mental Health” (2007). Mental Health
Foundation. http://www.mentalhealth.org.uk/con
tent/assets/PDF/publications/fundamental_facts
_2007.pdf (Accessed May 2013). United States
National Health Service. “Adult Psychiatric
Morbidity in England—2007, Results of a The United States is a North American country
National Household Survey” (2009). http:// with an area of 3.8 million square miles (9.8 mil-
www.hscic.gov.uk/pubs/psychiatricmorbidity07 lion square kilometers) and a 2012 population esti-
(Accessed May 2013). mated at 313.8 million, of which 82 percent live
National Health Service. “Making Mental Health in urban areas. The United States ranks highly on
Services More Effective and Accessible.” https:// human development (tied for third on the United
www.gov.uk/government/policies/making-mental Nations Human Development Programme’s
-health-services-more-effective-and-accessible--2 Human Development Index in 2011) and had a
(Accessed May 2013). per capita gross domestic product (GDP) in 2011
Northern Ireland Department of Health, Social of $48,110, among the highest in the world. Life
Services, and Public Safety. “Service Framework expectancy at birth is 78.5 years, with 25 percent
for Mental Health and Wellbeing.” http://www of the population under 18 years of age and 13
.dhsspsni.gov.uk/mhsf_final_pdf.pdf (Accessed percent above 60. The United States expends 16.2
May 2013). percent of its GDP on health, with a per capita
Organisation for Economic Co-operation and government expenditure of $3,076. In the United
Development. “Society at a Glance 2011: OECD States, neuropsychiatric disorders contribute an
Social Indicators” (2011). http://www.oecd-ilib estimated 28.4 percent of the burden of disability,
rary.org/social-issues-migration-health/society-at-a as measure by disability-adjusted life years.
-glance_19991290 (Accessed May 2013). In 2003, 6.2 percent of all health spending
Ryan, Tony, Barbara Hatfield, Indhu Sharma, Vicky went to mental health treatment, with $11.6 bil-
Simpson, and Alastair McIntyre. “A Census Survey lion going to specialty mental hospitals. Over half
of Independent Mental Health Sector Usage Across (58 percent) of mental health spending was pro-
Seven Strategic Health Authorities.” Journal of vided from government sources, with the Medic-
Mental Health, v.16/2 (April 2007). aid program accounting for 26 percent, followed
Scottish Government. “Mental Health Strategy for by private insurance (24 percent).
Scotland 2012–2015.” http://www.scotland.gov.uk/
Publications/2012/08/9714 (Accessed May 2013). History
Thomson, Sarah, Robin Osborn, David Squires, and Institutional care of the insane was established
Sarah Jane Reed. “International Profiles of Health early in U.S. history. Mental health care was pro-
Care Systems, 2011.” Commonwealth Fund vided at the Pennsylvania Hospital from 1752,
(2011). http://www.commonwealthfund.org/~/ and Williamsburg, Virginia, founded a public
media/Files/Publications/Fund%20Report/2012/ infirmary in 1773. Multiple sanatoriums, based
 United States 919

on the model of the Bethlem Royal Hospital in a fictional community governed by what might be
London, were also found around the country. By called social engineering. Other major psychologi-
1861, the United States had almost 50 asylums, cal theories developed in the United States include
many of which mixed a variety of patients with client-centered therapy, developed by Carl Rogers
conditions such as mental retardation and senility in the 1940s; humanistic psychology, developed
with paupers and those with psychiatric condi- by Abraham Maslow in the 1950s; and cognitive
tions, offering a variety of treatments of varying behavioral therapy, developed by Albert Ellis in
effectiveness, from surgery to faith healing to spe- the 1950s. The United States is a center for psy-
cialized diets and hydrotherapy. chological research today, exerting influence on
Religious organizations, including the Society the world psychological and psychiatric com-
of Friends (Quakers), and reformers such as Doro- munity through the American Psychiatric Asso-
thea Dix pioneered the more humane treatment of ciation’s Diagnostic and Statistical Manual of
the mentally ill in the 19th century. A visit by Sig- Mental Disorders (DSM). The first DSM edition
mund Freud to the United States in 1909 focused appeared in 1952, and the most recent DSM-5 in
more interest on psychiatry as well on psychoanal- 2013.
ysis, and in the same year, the concept that mental The United States also has a fairly long history
disorders could be prevented was introduced by with psychoanalysis. In 1909, Sigmund Freud
child psychiatrist and criminologist William Healy. delivered a series of lectures at Clark University
The Swiss émigré Adolf Meyer was instrumental in Worcester, Massachusetts, bringing attention
in developing a psychobiologic approach to men- and credibility to the field of psychoanalysis in
tal illness, and as head of the Phipps Psychiatric the United States. These lectures, which were
Clinic at Johns Hopkins University, which opened covered in the popular press and attended by
in 1913, trained and influenced many leading U.S. many notable individuals such as Franz Boas,
psychiatrists. The United States benefited from the William James, Edward Bradford Titchener, and
emigration of many eminent European psychia- Emma Goldman, encouraged widespread adop-
trists in the 1930s and 1940s and is now a world tion of ideas from psychoanalysis, although to
leader in psychiatric training and research. orthodox Freudians these applications were
The first experimental psychologists working often oversimplified and superficial. The Ameri-
in the United States were heavily influenced by the can Psychoanalytic Association and the New
German model of research in the 19th century, York Psychoanalytic Society were both founded
with Edward Bradford Titchener, who taught at in 1911, and the Boston Psychoanalytic Society
Cornell University, credited with introducing the in 1914. Concerns about unqualified practitio-
ideas of Wilhelm Wundt to the United States. Wil- ners, as well as self-interest, led the American
liam James, who taught at Harvard University in Psychoanalytic Association to ban lay analysts
the 19th and early 20th centuries, pioneered a (those who were not qualified as physicians) in
different approach, one based on accepting the 1924, thus violating the rules of the Interna-
complexity of mental experience rather than try- tional Psychoanalytic Association, a decision
ing to break it down to constituent parts. He was condemned by Sigmund Freud.
interested in how mental processes adapted to Psychoanalysis in America got a second boost
real situations, and that emphasized introspection in the 1930s and 1940s, when large numbers of
(in the common sense of the word) rather than European-trained analysts arrived in the United
experiment. States as refugees. These new arrivals faced a
John B. Watson developed the theory of behav- number of barriers before they were allowed to
iorism in the early 20th century. However, the practice (for instance, most states required that
term behaviorism is more often associated with they become U.S. citizens before being allowed
a younger psychologist influenced by Watson— to practice medicine, and the American psycho-
B. F. Skinner—who developed a theory of radi- analytic tradition required therapists to be phy-
cal behaviorism that has been adapted in many sicians), but they proved influential in making
social and behavioral settings. Skinner is also well the United States, rather than Europe, the center
known for his novel Walden Two, which describes of psychoanalytic work. Karen Horney, Erich
920 United States

Fromm, Erik Erikson, Anna Freud, and Theodore In 2011, the United States had 6,179 mental
Reich were among the influential émigrés who health care outpatient facilities (1.95 per 100,000
came to the United States during this period. They population), 2,074 community residential facili-
helped make psychoanalytical ideas common in ties (0.65 per 100,000), and 803 mental hospitals
American culture, where they appeared in diverse (0.25 per 100,000), with 45,622 psychiatric beds
works such as the 1940 musical Lady in the Dark in general hospitals (14.36 per 100,000), 70,808
and Alfred Hitchcock’s 1945 film Spellbound. beds in community residential facilities (22.29
Today, 30 institutes across the United States offer per 100,000), and 61,753 beds in mental hospi-
training programs accredited by the American tals (19.44 per 100,000). The United States had
Psychoanalytic Association. 7.79 psychiatrists per 100,000 working in the
mental health sector, along with 29.03 psycholo-
Mental Health Care System gists per 100,000, 17.93 sociologists per 100,000,
The U.S. health care system is extremely complex and 3.07 nurses per 100,000. The rate of people
because there is no national system of insurance or treated in mental health outpatient facilities was
service delivery—instead, care is financed through 931.86 per 100,000 (of which 51 percent were
a combination of private, federal, state, and local female and 29 percent under age 18), admissions
government funds, with much private insurance to mental hospitals were 256.89 per 100,000, and
based on employment, and with state and local admissions to psychiatric beds in general hospi-
funding and services in particular subject to fre- tals was 479.78 per 100,000.
quent change. Care is also delivered through a
variety of public and private systems, and wide Mental Health Surveillance Systems
variations have been observed in the charges for The United States has a highly developed system
comparable procedures across different hospitals, of mental health surveillance, with the Centers
as well as for different patients within the same for Disease Control and Prevention (CDC) con-
hospital, the latter depending in part on the type ducting numerous national surveys that include
of insurance an individual has. Since 2008, group mental health components. Among the popula-
health plans have been required to provide cov- tion-based surveys conducted by the CDC are
erage for mental health conditions equally with the Behavior Risk Factor Surveillance System
physical conditions, but many critics believe this (BRFSS), which collects data annually through
goal has not yet been achieved in practice. telephone surveys, conducted in conjunction
As of 2010, 56 percent of U.S. residents were with state health departments; the National
covered by private insurance; 27 percent were cov- Health Interview Survey (NHIS), a continuous
ered under public programs, including Medicare survey conducted through in-person interviews;
(a federal program for the disabled and those 65 and the National Health and Nutrition Exami-
and older) and Medicaid (a joint federal-state pro- nation Survey (NHANES), which is conducted
gram, primarily for people with low incomes), and continuously and includes physical exams and
nearly 17 percent had no insurance. The U.S. sys- lab tests as well as in-person interviews. The
tem is undergoing a series of incremental reforms National Survey on Children’s Health (NSCH) is
since the passage of the Patient Protection and conducted irregularly, with the 2007 survey the
Affordable Care Act of 2010, which is aimed in most recent with data fully available. The Youth
part at reducing the number of uninsured. Major Risk Behavior Survey (YRBS) is conducted
changes have been set up to take place in 2014, every two years with a representative sample of
including penalties for those who do not have students in the 9th through 12th grades, most
insurance, expansion of the Medicaid program in recently in 2011.
many states to insure more poor individuals, the The CDC also conducts national surveys of
establishment of health care exchanges to make it health care. The National Ambulatory Medical
easier for individuals to purchase insurance, and Care Survey (NAMCS) collects information on
increased restrictions on health insurers, including medical care provided in physician’s offices and
removal of lifetime spending caps and an end to community health centers. The National Hospi-
discrimination based on pre-existing conditions. tal Ambulatory Medical Care Survey (NHAMCS)
 United States 921

collects information about care provided in hos- percent). According to the BRFSS, in 2006, the
pital emergency rooms and through outpatient states with the highest prevalence of depression
services. The National Hospital Discharge Sur- were West Virginia (13.7 percent), Mississippi
vey (NHDS) collects information from nonfed- (13 percent), and Alabama (12.5 percent), while
eral, short-stay (less than 30 days) hospitals. The those with the lowest prevalence were North
National Nursing Home Survey (NNHS) collects Dakota (5.3 percent), Nebraska (5.6 percent),
information from a national sample of nursing and Iowa (5.8 percent).
homes, residents, and staff members. According to the 2008 BRFSS, 12.3 percent
of adult Americans have received a diagnosis of
Prevalence: Adults anxiety at some point in their life, with women
According to the 2009 BRFSS, 3.9 percent of U.S. (15.2 percent) having this diagnosis more often
adults aged 18 or older reported serious psycho- than men (9.1 percent). Among racial and ethnic
logical distress, with a higher percentage of women groups, non-Hispanic whites are mostly likely to
(4.4 percent) than men (3.5 percent) reporting this have this diagnosis (12.9 percent), followed by
condition. Non-Hispanic blacks reported higher other non-Hispanics (11.8 percent), Hispanics
prevalence (5.4 percent) compared to Hispanics (9.7 percent), and non-Hispanic Blacks (9.3 per-
(5.3 percent), non-Hispanic whites (3.5 percent), cent). An anxiety diagnosis was most common in
and other non-Hispanics (3.1 percent). Prevalence those aged 45 to 54 (14.1 percent), followed by
was also distributed differently across age groups, those aged 35 to 44 (13.6 percent), 18 to 24 (13
with those aged 45 to 54 reporting the highest percent), 25 to 34 (11.9 percent), and 55 or older
prevalence (4.9 percent), followed by those aged (10.3 percent).
25 to 34 (4 percent), 35 to 44 (3.8 percent), 55 or According to the 2007 NHIS, the lifetime prev-
over (3.7 percent), and 18 to 24 (3.1 percent). In alence of a bipolar disorder diagnosis among U.S.
2007, according to the BRFSS, Mississippi (6.6 adults was 1.7 percent, with diagnoses more com-
percent), Kentucky (6.5 percent), and Puerto Rico mon among women (1.9 percent) than men (1.4
(6 percent) had the highest prevalence, and Iowa percent). A bipolar diagnosis was more common
(2.3 percent), Alaska (2.4 percent), and Hawai‘i among younger people, with a rate of 2.2 percent
(2.4 percent) had the lowest. among those aged 18 to 39, 1.9 percent among
In 2009, according to the BRFSS, U.S. adults those aged 40 to 54, and 0.8 percent among those
suffered an average of 3.5 mentally unhealthy 55 or older. Bipolar diagnosis was more common
days in the previous 30 days. Women had more among non-Hispanic whites (1.9 percent), fol-
mentally unhealthy days (4) on average than men lowed by non-Hispanic blacks (1.3 percent), and
(2.9). Non-Hispanic blacks reported the highest Hispanics (0.9 percent). Among all adults, the
number of mentally unhealthy days (4.1), fol- lifetime prevalence of a schizophrenia diagnosis
lowed by Hispanics (3.8), other non-Hispanics was 0.6 percent, with diagnosis more common
(3.6), and non-Hispanic whites (3.3). Kentucky among men (0.8 percent) than women (0.4 per-
(4.6), Oklahoma (4.3), and Alabama (4.2) had cent). It was also slightly more common among
the highest average number of mentally unhealthy non-Hispanic blacks (0.8 percent) than non-
days, and Wyoming (2.1), South Dakota (2.4), Hispanic whites (0.6 percent) or Hispanics (0.5
and North Dakota (2.4) had the lowest. percent), and among people aged 40 to 54 (0.7
According to the 2005–2008 NHANES, the percent) than those aged 18 to 39 (0.6 percent) or
prevalence of depression among U.S. adults 55 or older (0.5 percent).
aged 18 or older was 6.8 percent. Depression The National Hospital Ambulatory Medical
was more common among women (8.4 percent) Care Survey (NHAMCS) for 2007 to 2008 found
than men (4.9 percent) and among non-Hispanic that Americans made 47.83 care visits for mental
blacks (9.7 percent) and Mexican Americans health disorders for a rate of 2,138 per 10,000
(7.2 percent) than whites (6.2 percent). People population. Most (80.7 percent) were physician
aged 40 to 59 years had the highest prevalence office visits, followed by outpatient hospital vis-
of depression (8.4 percent), followed by those its (11.8 percent) and emergency department vis-
aged 18 to 39 (6.2 percent) and 60 and over (5.2 its (7.5 percent). The most common reasons for
922 United States

care visits included psychoses (378 per 10,000), 10.6 percent of U.S. children aged 6 to 17 have
major depressive disorders (337 per 10,000), repeated a grade in school; for children with one
other depressive disorders (326 per 10,000), and emotional, behaviorial, or developmental condi-
anxiety states (299 per 10,000). According to the tion, 22.2 percent have repeated a grade; for those
2007 NHDS, the rate of hospital discharge with with two conditions, 22.2 percent; and for those
a primary diagnosis of mental illness was 64.4 with three conditions, 38.2 percent.
per 10,000, with the most common causes being Children with one or more of these conditions
mood disorders (19.2 per 10,000), alcohol and are also more likely to display problem social
drug use disorders (9.8 per 10,000), and schizo- behaviors such as bullying or being disobedient,
phrenia (6.1 per 10,000). Among nursing home stubborn, sullen, or irritable. Among all children
residents aged 65 and older, according to the aged 6 to 17 years, 8.9 percent are reported by
2004 NNHS, 23.5 percent had a mental health their parents to usually or always display two or
diagnosis, with the most common being dementia more of these behaviors, while for children with
(18.6 percent), followed by mood disorders (1.9 one condition, 19 percent usually or always dis-
percent); in addition, 12 percent had a diagnosis play two or more problem behaviors; for children
of Alzheimer’s disease. with two conditions, 30.5 percent; and for those
with three or more, 46.1 percent.
Prevalence: Children and Adolescents According to data from the 2011 YRBS, 15.8
The 2007 NSCH found that overall, 11.3 percent percent of U.S. students in grades nine through 12
of American children (aged 2 to 17 years) suffer reported that they seriously considered suicide in
from one or more of the following: depression, the 12 months preceding the survey, and 12.8 per-
anxiety, attention deficit disorder/attention deficit cent reported that they made a plan about how
hyperactivity disorder (ADD/ADHD), conduct they would attempt suicide. Both statistics show a
disorders, autism spectrum disorders, develop- substantial decrease from 1991, when 29 percent
mental delay, or Tourette syndrome; 6.7 percent of students said they seriously considered suicide
suffer from one condition, 2.6 percent suffer and 18.6 percent said they made a plan about
from two conditions, and 1.9 percent suffer from attempting suicide. In 2011, 7.8 percent said they
three or more. Of the 7.4 million children with attempted suicide at least once in the preceding 12
one or more of these conditions, just over half are months, and 2.4 percent said they made a suicide
between the ages of 12 and 17; almost two-thirds attempt that required treatment by a doctor or
(65.7 percent) are boys, and almost one-quarter nurse due to injury, poisoning, or overdose in the
(24.8 percent) live below the poverty line. previous 12 months. The percentage of students
The most common of the seven conditions was reporting at least one suicide attempt ranged from
ADD/ADHD, diagnosed in 6.4 percent of Ameri- 6.3 percent (in 2009) to 8.8 percent (in 2001),
can children aged 12 to 17, followed by conduct while the number of suicide attempts requiring
disorder (3.3 percent), developmental delay (3.2 medical treatment ranged from 1.7 percent (in
percent), anxiety (2.9 percent), depression (2 per- 1991) to 2.9 percent (in 2003).
cent), an autism spectrum disorder (1 percent), In 2011, 5.9 percent of respondents to the
and Tourette syndrome (0.1 percent). Almost half YRBS reported they did not go to school at least
(45.6 percent) of the children with one or more one day in the previous 30 because they felt unsafe
of these conditions also had a learning disability, at school or on their way to school; this percentage
and 33.3 percent had a chronic physical condition has ranged from 4 percent in 1997 to 6.6 percent
as well, including asthma, diabetes, or hearing or in 2001, over the years 1993 (the first year data
vision problems. was collected) to 2011. In 2009 (the first year data
Children with one or more of these disorders was collected), 19 percent reported that they had
are more likely to have public rather than private been bullied on school property in the previous
insurance, and their parents were more likely to 12 months, while in 2011, 20.1 percent reported
report that insurance did not cover all their needs. being bullied. In 2011, 16.6 percent reported car-
Children with one or more of these conditions are rying a weapon in the prior 30 days, including 5.1
more likely to have difficulty in school. Overall, percent who reported carrying a gun, while 32.8
 United States 923

percent reported being in at least one physical 34, 20.4 percent agreed strongly and 37.9 percent
fight in the previous 12 months and 3.9 percent agreed slightly; and among those aged 18 to 24,
reported being injured in a physical fight. 22.8 percent agreed strongly and 43.5 percent
agreed slightly.
Attitudes Toward Mental Illness Hispanics (31.7 percent strongly and 35.7 per-
The attitudes of American adults toward mental cent slightly) and those of “other” race (32.2 per-
illness, as measured by the 2007 BRFSS, showed cent strongly and 35 percent slightly) were more
considerable variability depending on age, sex, and likely to endorse this statement than white non-
other factors. Data was collected from 35 states, Hispanics (19.3 percent strongly, 38.4 percent
Puerto Rico, and Washington, D.C. Overall, most slightly), or black non-Hispanics (27.2 percent
adults said they believed that people with mental strongly, 31.7 percent slightly). Lower levels of
illness could be helped by treatment to lead nor- education were also associated with stronger lev-
mal lives: 62.8 percent said they agreed strongly els of agreement: for those without a high school
with this statement, and 25.8 percent said they diploma, 38.8 percent agreed strongly and 32.4
agreed slightly with it. Women were somewhat percent slightly; among high school graduates,
more likely to endorse the belief that treatment 27.7 percent agreed strongly and 36.2 percent
could help people with mental illness lead normal slightly; among those with some college, 20.4
lives, with 70.6 percent agreeing strongly and 23 percent agreed strongly and 36.8 percent agreed
percent agreeing slightly with this statement, as slightly; and among college graduates, 15.6 per-
opposed to 60.7 percent of men agreeing strongly cent agreed strongly and 39.8 percent slightly.
and 30.7 percent agreeing slightly. Interestingly, overall, people with mental health
Older people were more likely to endorse this problems were less likely to agree that treatment
statement: among people over age 55, 69 percent could help them lead normal lives, but those
agreed strongly and 23.6 percent slightly; among currently receiving treatment were more likely
those aged 35 to 54, 69.9 percent agreed strongly to agree. Of those currently receiving treatment
and 23.9 percent slightly; among those aged 25 to from a health professional for an emotional prob-
34, 61.2 percent agreed strongly and 31.0 agreed lem, 70.2 percent agreed strongly and 20.3 per-
slightly; and among those aged 18 to 24, 50.5 cent agreed slightly, compared to those who were
percent agreed strongly and 38.4 percent agreed in frequent mental distress (61.5 percent and 24.8
slightly. Belief that mental illness could be helped percent, respectively) or serious psychological dis-
with treatment was also associated positively with tress (54.6 percent and 24.6 percent, respectively).
being white, non-Hispanic, and having higher lev- On the question of whether people are generally
els of education. People residing in Connecticut, caring and sympathetic to others with mental ill-
Washington, D.C., Louisiana, Oregon, Vermont, ness, only 17.3 percent of those with frequent
Virginia, and Washington State were most likely mental distress agreed strongly with this state-
to agree that treatment could help people with ment and 28.1 percent agreed slightly; among
mental illness lead normal lives; agreement was those with serious psychological distress, 14.4
lowest in Puerto Rico. percent agreed strongly and 22.9 percent agreed
In contrast, overall, only 22.3 percent said they slightly; and among those receiving health care
agreed strongly that most people are caring and for an emotional problem, 17.6 percent agreed
sympathetic to people with mental illness, and 35 strongly and 29.3 percent agreed slightly.
percent said they agreed slightly with this state-
ment. Males (24.1 percent agreed strongly, 40.6 Sarah Boslaugh
percent agreed slightly) were more likely than Kennesaw State University
females (21.5 percent and 33.9 percent, respec-
tively) to endorse this statement. Among persons See Also: American Psychiatric Association;
55 and older, 27.2 percent agreed strongly and American Psychological Association; Cross-
34.5 percent agreed slightly; among those aged National Prevalence Estimates; Department of
35 to 54, 20.5 percent agreed strongly and 37 Health and Human Services, U.S.; Food and Drug
percent agreed slightly; among those aged 25 to Administration, U.S.; Incidence and Prevalence;
924 Unquiet Mind, An

Law and Mental Illness; Legislation; Medicare and .cdc.gov/mmwr/preview/mmwrhtml/su6003a1.htm

Medicaid; National Alliance on Mental Illness; (Accessed May 2013).
National Institute of Mental Health; Policy: Federal Thomson, Sarah, Robin Osborn, David Squires, and
Government; Policy: State Government; Unquiet Sarah Jane Reed. “International Profiles of Health
Mind, An; Veterans’ Hospitals. Care Systems, 2011.” New York: Commonwealth
Fund, 2011. http://www.commonwealthfund.org/
Further Readings ~/media/Files/Publications/Fund%20Report/2012/
Aron, L., R. Honberg, and K. Duckworth, et al. Nov/1645_Squires_intl_profiles_hlt_care
“Grading the States 2009: A Report on America’s _systems_2012.pdf (Accessed May 2013).
Health Care System for Adults With Serious U.S. Department of Health and Human Services
Mental Illness” (2009). National Alliance on (HHS), Health Resources and Services
Mental Illness. http://www.nami.org/Content/Nav Administration, Maternal and Child Health
igationMenu/Grading_the_States_2009/Method Bureau. “The Mental and Emotional Well-Being
ology1/Methodology_Brief.htm (Accessed May of Children: A Portrait of States and the Nation
2013). 2007.” Rockville, MD: HHS, 2010. http://
Bagalman, Erin. “Mental Disorders Among OEF/ mchb.hrsa.gov/nsch/07emohealth/moreinfo/pdf/
OIF Veterans Using VA Health Care: Facts and nsch07titlecitetoc.pdf (Accessed May 2013).
Figures.” (February 4, 2013). Congressional Young, Mary de. “Madness: An American History of
Research Service 7-5700. http://www.fas.org/sgp/ Mental Illness and Its Treatment.” Jefferson, NC:
crs/misc/R41921.pdf (Accessed May 2013). McFarland, 2010.
Centers for Disease Control and Prevention.
“Attitudes Toward Mental Illness: 35 States,
District of Columbia, and Puerto Rico, 2007.”
Morbidity and Mortality Weekly Report, v.59/20
(May 28, 2010). http://www.cdc.gov/mmwr/pdf/ Unquiet Mind, An
wk/mm5920.pdf (Accessed May 2013).
Centers for Disease Control and Prevention. “Trends Kay Redfield Jamison, in her book An Unquiet
in the Prevalence of Behaviors That Contribute Mind, shares her own experience of bipolar
to Violence: National YRBS 1991–2011.” http:// disorder with its extreme experiences of manic
www.cdc.gov/healthyyouth/yrbs/pdf/us_violence highs and despondent depressions. She offers a
_trend_yrbs.pdf (Accessed May 2013). unique voice detailing her life journey of deal-
Centers for Disease Control and Prevention. “Trends ing with mental illness from the perspective of
in the Prevalence of Suicide-Related Behaviors: patient and clinician, as Jamison is also trained
National YRBS 1991–2011.” http://www.cdc.gov/ as a psychologist and serves as a professor of psy-
healthyyouth/yrbs/pdf/us_suicide_trend_yrbs.pdf chiatry at the Johns Hopkins University School
(Accessed May 2013). of Medicine. Additionally, Jamison is the Dalio
National Institute of Mental Health. “Disorders Family Professor in Mood Disorders as well as
Within the Neuropsychiatric Category.” http:// the codirector of the Johns Hopkins Mood Dis-
www.nimh.nih.gov/statistics/2CDNC.shtml orders Center. She was diagnosed in early adult-
(Accessed May 2013). hood, shortly after she joined the University of
Organisation for Economic Co-operation and California, Los Angeles faculty as an assistant
Development. “Society at a Glance 2011: OECD professor of psychiatry.
Social Indicators” (2011). http://www.oecd In her memoir, Jamison sheds light on the per-
-ilibrary.org/social-issues-migration-health/society sonal experience of coming to terms with accept-
-at-a-glance_19991290 (Accessed May 2013). ing she has a mental illness, including a period
Reeves, William C., Tara W. Strine, Laura A. Pratt, of time in her early episodes of manic-depressive
William Thompson, and Indu Ahluwalia, et al. states that comprised a fundamental denial that
“Mental Illness Surveillance Among Adults in the she really had an illness, and entrenched beliefs
United States” Morbidity and Mortality Weekly that she could just deal with it on her own
Report, v.60/3 (September 2, 2011). http://www without treatment. Jamison shares the internal
 Unquiet Mind, An 925

struggle and battle she went through in order

to accept the need for psychotropic medication
and psychotherapy to treat her mental illness. As
Jamison explores her struggle with the need for
medication, she highlights the lure and seduction
of not taking medication because of side effects
such as cognitive blunting that dampened brain
functions such as concentration and her ability to
read. However, Jamison also emphatically advo-
cates the veracity of psychotropic treatment of
bipolar disorder, especially from the dual view of
clinician and healer, as she has seen “up close and
personal” the lethal effects of bipolar disorder if
not properly treated.
Furthermore, Jamison provides insight into
the dichotomous experience of euphoric highs
experienced in her manic moods versus the severe
depressions that constituted lethargic, melan-
cholic states, both of which have endangered
her existence due to onsets of suicidality. While
Jamison highlights in great clarity the intense
turmoil and tragic anguish that can occur as the
result of bipolar disorder, she also offers a peek
into the exquisite joys in the face of her unique
experience. Interestingly, as Jamison puts her Kay Redfield Jamison, a psychologist and professor of psychiatry
experience of her illness in perspective, she shares at the Johns Hopkins University School of Medicine, shares
that although she has had a life with storms, she her own experience of bipolar disorder in her 1996 book An
believes that as a result of this illness she has Unquiet Mind. She was diagnosed in early adulthood.
been able to feel things more deeply, love more,
appreciate life experiences, and test the limits of
her mind. Relatedly, Jamison compares manic-
depression to fire, believing that this illness is an following agendas in the treatment of bipolar
experience that both kills and gives life. In a pow- disorder: congruent use of medications and psy-
erful manner, Jamison also shares her experiences chotherapy, increased education about bipolar
of deep love throughout her life that has had a disorder for patients and families, recognition
compelling ability to heal and create meaning and mitigation of clinical states most likely to
throughout her journey. result in suicide, and increased understanding
regarding why patients resist taking psychotro-
Patient and Clinician pic medications.
As Jamison shares her courageous journey in Jamison also captures and covers her initial
being both a patient and a clinician, she is able dilemma of being open about her illness and the
to talk about the balance between knowing what potential impact on her career as a professor and
it is like to dually experience bipolar disorder clinician. She relates that she initially had a wealth
and serve in the role of clinician treating others of concerns about sharing that she had bipolar
who have had similar experiences. In some ways, disorder, which included any potential repercus-
her ability to be in both worlds has given her a sions from her licensing board or being required
uniquely informed perspective that has contrib- to give up her clinical practice and teaching. As
uted and informed both roles. Her perspective those who held supervisory positions over Jamison
has allowed her to help lead the Johns Hopkins learned about her illness showed acceptance and
Mood Disorders Center with emphasis on the support, and in fact held views that she may be
926 Urban Versus Rural

even more apt to be an expert on the treatment of Sass, Louis A. “Romanticism, Creativity, and the
bipolar disorder, she voiced her own experience Ambiguities of Psychiatric Diagnosis: Rejoinder
of being able to feel more freedom in being open to Kay Redfield Jamison.” Creativity Research
about her illness. Jamison also speaks out about Journal, v.13/1 (2001).
the historical problem with medical students and
psychology trainees being denied admission or
dismissed from training due to psychiatric illness
and the importance of getting treatment, as well
as working with programs and employers so that Urban Versus Rural
individuals who are clinicians and patients can
continue in their academic and career pursuits. In epidemiological and clinical research on men-
tal illness, considerable investigation has focused
Destigmatization of Mental Illness on the differences between urban and rural
Befittingly, Jamison is an advocate for the des- dynamics. Definition of both rural and urban
tigmatization of mental illness and provides communities has been fraught with difficulty,
discourse about the need for even more pub- and it has primarily relied upon population den-
lic emphasis on changing public attitudes about sity. Research investigating differences in onset
mental illness. Jamison underscores the meaning- and intervention for mental illness among rural
ful gains of mental health advocacy groups that and urban counterparts has shown that this clas-
have been effective in providing increased educa- sification is somewhat less central to differences
tion to the public, media, and state and national than other mediating variables; however, such
governments, which in effect has brought about research has generally shown that serious and
some changes in medical care, increased money chronic mental illness is more common in urban
for research, and jobs for the mentally ill. She settings. Although urbanicity is associated with
advocates the relevance of aggressive public edu- higher rates of serious and chronic mental illness,
cation efforts, successful psychiatric treatments, the idyllic notions of rurality seem to be mythical.
biological research related to the causes of men- Depression, substance abuse, and domestic vio-
tal illness, the development of blood tests for lence are prevalent in rural settings, and formal
psychiatric illnesses, and continued legislative intervention is less available.
action. Ultimately, Jamison is hailed as a coura-
geous leader in the mental health field and a light Defining Urban
that can help guide clinicians and patients alike While there are many defining traits of rural and
toward a vision of recovery. urban settings, definitions of the two tend to rely
on population and population density. The popu-
Erika Carr lation requirements vary by nation. In China, an
Memphis VA Medical Center urban area is defined by having at least 1,500
people per square kilometer. Canada defines any
See Also: Bipolar Disorder; Creativity; Patient locale with more than 1,000 inhabitants and a
Accounts of Illness; Patient Activism; Patient Rights; density of 400 per square kilometer as urban.
Stigma; Stigma: Patient’s View; Suicide. Mexico defines any incorporated area with more
than 2,500 residents as urban. Since the 2000
Further Readings census in the United States, the nomenclature has
Jamison, Kay Redfield. An Unquiet Mind: A Memoir focused on core-based statistical areas (CBSAs),
of Moods and Madness. New York: Vintage Books, which can take the form of metropolitan statis-
1996. tical areas (MeSAs) or micropolitan statistical
Salmon, Jacqueline L. “Kay Redfield Jamison: A Profile areas (MiSAs). MeSAs include urbanized areas
in Courage.” BP Magazine (Winter 2009). http:// containing at least 50,000 people, and MiSAs
www.bphope.com/Item.aspx/482/kay-redfield-jam include urbanized clusters containing 10,000 to
ison-a-profile-in-courage (Accessed May 2013). 49,999 people. The core portion of CBSAs in the
United States includes a density of 1,000 people
 Urban Versus Rural 927

per square mile. However, according to U.S. cen- Regarding the sociology of mental illness,
sus definitions, any incorporated locale with at there are a number of variables related to rural-
least 2,500 residents is urbanized. ity. While rural populations are more likely to be
As of the 2010 U.S. census, 80.7 percent resided consistently employed than urban counterparts,
in urbanized areas, whereas only 19.3 percent they are more likely to experience long-term pov-
lived in rural areas. Some countries, in addition erty. In rural areas, there is a lower job density,
to population density, include other character- which makes upward mobility in salary difficult.
istics in their definition of urbanicity. Japan, for While work orientation is not statistically differ-
example, includes in its definition a requirement ent between urban and rural counterparts, the
that 60 percent of the residents be employed in latter population tends to deemphasize educa-
manufacturing, trade, or other urbanized busi- tion because of a perceived lack of benefit, which
ness. Many countries, including Georgia and deflates economic prospects. Moreover, rural
Botswana, exclude agricultural work in their defi- workers tend to experience longer commuting
nition of urbanization. Urbanization in Peru, on distances than urban counterparts.
the other hand, is defined as any area with 100 or Communal exclusivity can promote social isola-
more dwellings. tion, particularly among women, and has resulted
In addition, the conceptualization of urban- in a paucity of institutional supports for behav-
ization includes traits beyond population. With ioral and physical health care. While communal
regard to the sociology of mental illness, locales exclusivity tends to isolate rural populations from
with higher population densities tend to experience suburban and urban counterparts, social capital
higher crime rates. Additionally, the mortality rate is a key aspect of rural sociology. Research dem-
is higher. Air pollution and noise are also associ- onstrates that social capital is found in higher
ated with urbanization. Although poverty is com- intensities among rural populations in compari-
mon in rural areas, it tends to be more centralized son to urban counterparts. Broadly defined, social
in urban centers. Urbanization also tends to pro- capital includes entities of reciprocity, trust, cohe-
mote extensive differentiation across life domains sion, social engagement, and a sense of commu-
that may be occupational, familial, recreational, nity. Rural populations tend to emphasize social
and institutional. This promotes less social engage- capital within the community through religious,
ment and increased risk for social withdrawal. occupational, familial, and recreational groups in
a manner that serves as a protective factor.
Defining Rural
Rural is often defined by exclusion. For example, Mental Illness in Rural and Urban Settings
in the U.S. census, rural was defined broadly as Although mental illness extends to individuals
an incorporated area with less than 2,500 inhab- across sociodemographic classifications, there
itants. Thus, anything not defined as urban was are distinctions in its manifestation among urban
rural. A review of research on rural locales sug- and rural populations. However, these differences
gests that they tend to rely on agricultural busi- seem to be explained by mediating variables. Such
ness, and residents tend to be classified in low- variables include being female, being separated or
income groups. Rural areas tend to be isolated never married, lower socioeconomic status, alco-
from urban centers and communally exclusive. hol abuse, social isolation, history of childhood
Isolation can be promoted geographically by land sexual abuse, adverse life events, and low per-
distance or natural structures (i.e., mountains and ceived social support. Evidence shows that urban
rivers). In rural research, differentiation between settings experience higher prevalence of mental
rural and frontier areas can be made based upon illness, but within-group analyses suggest that
population. While rural areas are defined by 2,500 the populations show similarities. For example,
residents or fewer, frontier areas are comprised depression and alcohol-related disorders tend to
of less than seven people per square mile. In the be the most common disorders in both groups.
United States, frontier areas consist of approxi- Women experience higher levels of depression in
mately 45 percent of the land mass, but less than both rural and urban settings, and men are more
1 percent of the population. likely to experience alcohol abuse.
928 Urban Versus Rural

Serious mental illness, particularly schizophre- of substance-related disorders among urban and
nia, is more common in urban areas, and rural rural populations. However, it appears that alco-
populations seem to rehabilitate more effectively. hol-related disorders are more common among
Urban men are 68 percent more likely than rural rural populations and drug-related disorders
counterparts to be admitted for a first episode of are more prevalent in urban settings. Increased
psychosis, and urbanized women are 77 percent alcohol-related disorder rates among rural pop-
more likely. The disparity appears to be partially ulations have been demonstrated in the United
explained by downward drift. Individuals diag- States, South Korea, and other countries. Preva-
nosed with schizophrenia tend to migrate to low- lence of obsessive-compulsive disorder is not
cost housing in urban centers, where they live in different among rural and urban populations in
social isolation. Rural resilience tends to be pro- NIMH studies. However, higher lifetime preva-
moted by the experience of higher levels of social lence rates for generalized anxiety were found
capital because rural individuals tend to receive in urban settings. In South Korea, rural settings
more familial and community support than urban were found to exhibit higher levels of agorapho-
counterparts. Additionally, rural individuals bia and panic disorder than urban counterparts,
experiencing serious mental illness tend to engage even as no differences were found in mood disor-
in more social activities than urban counterparts, ders. While most research has shown that urban
which increases social capital. settings experience a higher prevalence of mental
Most of the available research suggests that health concerns, such findings are not universal
mood disorders such as major depressive disorder and may emphasize the impact of methodologies
and bipolar disorder are also more common in that accentuate some of the possible mediating
urban settings. In Canada, 1 to 2 percent of rural variables.
inhabitants experienced depression at a given time,
in comparison to 3 to 5 percent of urban counter- Gerald E. Nissley, Jr.
parts. These findings are consistent with those in East Texas Baptist University
other countries, suggesting that major depressive
episodes are more frequent in urban settings. In See Also: Depression; Epidemiology; Mental Illness
the United States, studies by the National Institute Defined: Sociological Perspectives; Social Support.
of Mental Health (NIMH) suggest that rural indi-
viduals were three times less likely to experience Further Readings
clinical depression, and the risk was primarily Hall, Susan, Jay Kaufman, and Thomas Ricketts.
decreased among the young and women. NIMH’s “Defining Urban and Rural Areas in U.S.
research suggested that bipolar disorder is two to Epidemiological Studies.” Journal of Urban
four times more common among urbanized popu- Health, v.83 (2006).
lations; however, other studies have found no dif- Judd, Fiona, Henry Jackson, Angela Komiti, Greg
ference in the prevalence of the disorder. Murray, Gene Hodgins, and Caitlin Fraser.
While urban settings show higher prevalence “High Prevalence Disorders in Urban and Rural
of serious mental illness and mood disorders, Communities.” Australian and New Zealand
substance-related and anxiety disorders show Journal of Psychiatry, v.36 (2002).
less clear discrepancies. Many studies show no Stamm, B. H., ed. Rural Behavioral Health Care:
significant difference in the general prevalence An Interdisciplinary Guide. Washington, DC:
American Psychological Association, 2003.
 V
Veterans population. Specific at-risk populations (includ-
ing survivors of various types of trauma such as
The experience of veterans who have served in the rape, military combat, captivity, internment, and
U.S. military provides deep insight into the psycho- genocide) have prevalence rates that range from
logical impact of war. Numerous studies, including one-third to one-half.
those from World War II and Vietnam, have dem-
onstrated a link between combat and the develop- History and Recognition
ment of post-traumatic stress disorder (PTSD) and The symptoms associated with PTSD have
other associated problems relating to the psycho- been documented in literature since the ancient
social adjustment of veterans’ transitioning home Greeks. The Greek historian Herodotus wrote
from combat. In recent U.S. military conflicts about an Athenian soldier who suffered no physi-
revolving around the global war on terror (post- cal wounds but became permanently blind after
9/11), service member exposure to combat has also witnessing the death of a soldier standing next
been associated with increased risk of PTSD, major to him. Jonathan Shay wrote about the similari-
depression, substance abuse, suicide, and problems ties of Vietnam veteran combat stress reactions to
with social and occupational functioning. those represented in the tales of the Trojan wars,
Post-traumatic stress disorder was officially as written in the Iliad by Homer.
recognized by the American Psychiatric Associa- In the United States, the first evidence of the
tion (APA) in 1980 and introduced as a diagnos- relationship between traumatic stress and psycho-
tic entity in the publication of the third edition of pathology was recognized by Dr. Jacob Mendes
the Diagnostic and Statistical Manual of Mental DaCosta in 1871. He studied Civil War veterans
Disorders (DSM). Since 1980, the diagnostic cri- who complained of various physical symptoms
teria have changed with each subsequent edition such as heart palpitations, chest pain, headaches,
of the DSM (1987, 1995, and 2000). In fact, the and vision problems. DaCosta found no basis for
APA expanded the diagnostic criteria for PTSD cardiac disease; therefore, he deduced it was a dis-
in the publication of the DSM-5 in 2013, adding turbance of the sympathetic nervous system and
a fourth diagnostic cluster capturing behavioral labeled the condition “irritable heart.” In 1889,
symptoms. According to DSM-IV-TR (the text ver- Pierre Janet, a French psychiatrist, published an
sion of the DSM), there is lifetime prevalence for essay arguing that when an individual experiences
PTSD of approximately 8 percent in the U.S. adult emotions that overwhelm his or her capacity to

929
930 Veterans

take appropriate action or challenge the ability DSM in 1952 described the diagnostic category
to cope, the memory of the traumatic experience “gross stress reaction” to apply to combat stress
cannot be “properly digested.” Janet was the first reactions. Later, others identified a second injury
to identify dissociation as the crucial psychologi- that refers to the experiences of trauma survivors
cal mechanism involved in the genesis of a wide not receiving the understanding and support they
variety of post-traumatic symptoms. need from human service agencies and society as
The relationship between traumatic life events a whole. The classic example of the second injury
and subsequent psychological problems was also was Vietnam veterans’ counterproductive encoun-
observed by Josef Breuer and Sigmund Freud in ters with some mental health treatment facilities
1895. In 1918, B. Oppenheimer used the term as well as from civilians upon their return home,
neurocirculatory asthenia and Sir Thomas Lewis associated with the unpopularity of the war.
used the term soldier’s heart and the effort syn- In 1990, R. A. Kulka and colleagues intro-
drome. Since these observations were made, what duced the concept of partial PTSD. Their book
is now recognized as post-traumatic stress disor- reported on the findings from the National Viet-
der has been relabeled with each major war or nam Veterans Readjustment Study (NVVRS),
conflict with such terms as combat stress or battle which included 3,016 interviews. Two types of
stress, shell shock, war neurosis, combat neurosis, PTSD prevalence among Vietnam veterans were
acute combat reaction, and combat stress or battle identified: full PTSD syndrome and partial PTSD.
fatigue. During the 1950s, “traumatic neurosis” The latter was reserved for veterans who suffered
became the popular term. The first iteration of the from many of the core symptoms of PTSD, had

A Vietnam War veteran pays his respects to the Vietnam Women’s Memorial in Washington, D.C., on Veterans Day, November 11,
2008. The Vietnam Veterans Counseling Center in Syracuse, New York, offers a four-phase treatment approach for treating Vietnam
veterans, who experienced the second injury of not receiving understanding and support from society upon their return from the war.
 Veterans 931

disrupted lives, and appeared to be in urgent need of historical trends indicated that 25 to 50 per-
of treatment but did not have all the features cent of suicides occurring in 2008 may have been
necessary to receive the full syndrome diagnosis. related to the major commitment of troops to
Later, other scholars used the term post-traumatic combat beginning in 2003. Additionally, the
stress symptoms (PTSS) to refer to subjects who recent increase in suicides parallels an increase
did not show diagnosable PTSD but have some in the prevalence of mental disorders within the
symptoms of PTSD. This phenomenon was subse- army. Bachynski and Canham-Chervak suggest
quently termed subthreshold or subclinical PTSD. that increasing rates of clinically treated psycho-
Subclinical or subthreshold classifications tend to pathology are associated with increasing rates
significantly increase the number of people meet- of suicides. This implies that soldiers who are
ing the definition of mental illness and in need of seeking treatment for mental disorders and sub-
psychiatric services. The political, economic, and stance abuse should also be screened for suicide
social implications under this umbrella have sig- prevention.
nificant impact for the delivery of services. Recent studies on veteran postdeployment
adjustment have also linked risk-taking behaviors
The Mental Health of Iraq and (such as reckless driving and engaging in unpro-
Afghanistan Veterans tected sex) and other unhealthy related habits
The last three decades have seen an increase in the (such as junk food and alcohol consumption)
identification of combat-related stress reactions. with combat exposure. Child maltreatment and
Although the understanding of combat stress is partner violence rates have also increased during
increasing, assessment issues remain complicated. the recent years of stressful, repeated, and lengthy
PTSD is not the only potential outcome of expo- combat deployments. Military sexual trauma
sure to extreme events in the war zone. Mental (MST) has also been a source of trauma; with
health professionals are constantly challenged to more women in the U.S. armed forces, there have
assess other potential reactions to traumatic stress been increasing incidents of sexual assault and/or
as well as the problems that tend to co-occur (or sexual harassment perpetrated on female service
simultaneously occur) with PTSD, such as sub- personnel by fellow service members, although
stance abuse, personality disorders, mood disor- men have also been victims of MST. Additionally,
ders (such as depression), other anxiety disorders, while service members have been surviving in bat-
and anger and aggression. tle zones because of improved protective gear and
Recent conflicts in Iraq (Operation Iraqi Free- technology, polytraumatic injuries (injuries to dif-
dom and Operation New Dawn) and Afghanistan ferent body systems) have also added to the stress.
(Operation Enduring Freedom) have resulted in Not everyone who is exposed to combat or
service members’ suffering from traumatic brain trauma will develop PTSD or associated prob-
injury (TBI) such as concussion due to blast expo- lems. Studies suggest that there may be benefits
sure from improvised or intermittent explosive (such as growth) as well as costs associated with
devices (IEDs). Traumatic brain injury has been exposure to traumatic events. The literature refers
identified by experts as the “signature injury” in to these benefits as “post-traumatic growth.”
current veteran cohorts, and TBI will often co-
occur with PTSD. PTSD estimates for this popu- Stigma and Mental Health
lation fall somewhere between 15 and 30 percent. The general public has little knowledge about
Additionally, suicide rates have been alarm- traumatic processes. For instance, a common atti-
ingly high for this cohort; for instance, U.S. Army tude is that a traumatic experience and its ensu-
rates have surpassed the civilian suicide rate for ing symptoms are often associated with personal
the first time since the Vietnam War. According weakness, cowardice, hysterical exaggeration, or
to research by Kathleen Bachynski and Michelle malingering for financial gain. Many people tend
Canham-Chervak that was published in 2012, to blame traumatized individuals for their symp-
suicides among active-duty U.S. Army personnel toms and view subsequent post-traumatic symp-
have been increasing since 2004 and surpassed tomology as self-inflicted wounds. Others have
comparable civilian rates in 2008. An analysis noted that there is a popular misconception that
932 Veterans

if someone is truly traumatized, the person will for service member health concerns, includ-
be nonfunctional or an emotional cripple. As a ing mental health (such as symptoms of PTSD,
result of these attitudes, many trauma survivors depression, suicide ideation, and aggression);
hide their true thoughts and feelings because of ascertain service member interest in seeking men-
guilt or shame. This reaction is the primary rea- tal health services; and assess for psychosocial
son why post-traumatic stress reactions become issues and deployment-related exposures. The
even more problematic. The stigma attached to PDHA is a self-administered questionnaire that
reporting mental health issues continues to be sig- relies on the willingness of the service member to
nificant with recent veterans who have served in report problems and symptoms. Service members
Operation Enduring Freedom (OEF), Operation receive referrals for mental health services, are
Iraq Freedom (OIF), and Operation New Dawn further evaluated, or provided immediate assis-
(OND). OEF began on October 7, 2001; OIF tance (in the case of suicide ideation). Once the
began on March 9, 2003, and officially ended on service member separates or retires from military
August 31, 2010; and OND was the final oper- service, their health and mental health care is
ation in Iraq, marking the end to the Iraq war transferred to the Department of Veterans Affairs
beginning September 1, 2010 and officially end- (VA), depending on eligibility.
ing on December 31, 2011. Behavioral health experts agree that the most
Admitting to mental health issues by those serv- important therapeutic effects in working with the
ing in active-duty military settings may be particu- veteran population are obtained by encouraging
larly challenging in that disclosure or help seeking the veteran to talk about his/her experience and
for these problems may affect a service member’s listening with sensitivity to what he/she is say-
ability to promote, jeopardize security clearances, ing. This is also accomplished by the therapist
and impact other military career options. Histori- approaching the veteran as a survivor rather than
cally, mental health issues were often viewed pejo- as a psychiatric case or victim. The notion of a
ratively in the military, mostly as a sign of char- provider being competent in understanding mili-
acter weakness, although efforts are currently tary service and lifestyle (military culture) is essen-
being made in the military to destigmatize mental tial. It is standard practice that a mental health
health issues and mental health services. The war- professional develop an individualized treatment
rior ethos and worldviews (belief systems) held by plan by compiling a comprehensive list of treat-
military personnel based on military culture also ment alternatives for PTSD symptoms and other
contribute to the sense of stigma in service mem- behaviors that have been identified as problem-
bers (aside from the externally driven stigma). atic and requiring treatment.
Military culture has been described as a subcul- Peter Hayman, director of the Vietnam Veter-
ture of American society that holds a set of eth- ans Counseling Center in Syracuse, New York,
ics, values, morals, and code of conduct that are and colleagues offer a four-phase treatment
distinct from those of civilian society. These rules approach for treating Vietnam veterans. This
and values are indoctrinated early and govern ser- model has utility for other veteran groups as well
vice member behavior and attitudes and are often as for any PTSD survivor. The model is a pro-
carried beyond military life. For example, the cess of four overlapping, sequential phases. Each
most common of these behaviors include a pen- phase includes techniques and tasks that need to
chant for order, respect, timeliness, and discipline. be achieved prior to moving to the next phase.
For many individuals who have served in combat The four phases are as follows:
theaters, hypervigilance often becomes an endur-
ing personality trait. Phase one. Phase one involves assessment and
building trust and consists of three components.
Mental Health Treatment of Veterans The first component is asking for premilitary and
In 2003, the U.S. Department of Defense (DoD) postmilitary histories, including the veteran’s fam-
required all service members to complete a brief ily, education, employment, and relationships.
Post-Deployment Health Assessment (PDHA) Taking the client’s religious and spiritual histories
upon their return from any deployment to screen is as important as their psychological and social
 Veterans 933

histories. Alcohol and drug use patterns are col- to read) and audiotherapy (listening to audio
lected during this phase. The second component tapes) can also be implemented as part of therapy.
involves assessing the type and severity of PTSD The use of animal-assisted therapy has also been
symptoms and differentiating the disorder from included as a complementary approach in the
other possible diagnoses. As previously noted, treatment of trauma.
PTSD sometimes occurs with other mental disor- Psychopharmacology is also used to manage
ders. A complete assessment will identify the pos- anxiety and physiological reactivity as well as
sibility of multiple diagnoses. The third compo- reduce symptoms of depression. Comprehensive
nent, and one most often overlooked by mental treatment plans must include strategies for disor-
health professionals, is the gathering of a detailed ders that co-occur with PTSD, notably interven-
military history. It is the sensitivity of questioning tions for alcohol and drug abuse, panic and anxi-
during the history taking that develops the foun- ety attacks, and depressive episodes. The goal of
dation for trust between any combat veteran and treatment is to design the most comprehensive,
therapist. efficacious, individually tailored intervention
possible. Ideally, the clinician and veteran client
Phase two. The second phase involves stabiliza- develop the plan together. It is recommended that
tion. All distressing symptoms need to be imme- the therapist continuously monitor the effective-
diately and directly addressed and brought under ness of the interventions and revise treatment
control. The goal in this phase is to instill a sense strategies depending on the client’s response to
of hope in the veteran. Presenting symptoms treatment.
may include depression, rage, suicidal or homi-
cidal ideation, flashbacks, disturbed sleep pat- Phase four. The fourth phase is assistance with rein-
terns, substance abuse, and anxiety. Additional tegration into employment, education, interper-
problems may include alienation and emotional sonal relationships, and family life. Employment
numbing that often render the veteran insensitive counseling may include career assessment, educa-
to the needs of others and can cause marital and tion, occupational training, and job placement.
family problems. There are a range of behavioral Developing or augmenting skills in interpersonal
techniques that have been found effective for relationships includes appropriate expression of
treating arousal and avoidance symptoms associ- anger, assertiveness training, and communication
ated with intrusive traumatic memories such as skill building. Reintegrating the veteran into fam-
stress inoculation training, systematic desensitiza- ily life may involve treatment for family mem-
tion and flooding, and exposure techniques. As bers, including spousal support groups, couples
the intensity of the symptoms is reduced, the next counseling, multiple couple groups, and family
phase may begin. counseling. As part of the reintegration, it is also
important to assist veterans in connecting with
Phase three. The third phase involves the process- community and VA-related resources so they can
ing of traumatic stressors with the ultimate goal access their benefits and entitlements.
of traumatic stress resolution. The most common
interventions employed are group and individual The mental health professional treating vet-
psychotherapies. The individual psychothera- erans or active-duty military may be confronted
pies typically include cognitive behavioral types with some degree of resistance by these clients
of approaches and their derivatives. Cognitive related to treatment. Experts have delineated
behavior therapy methods are used to treat intru- some of the barriers to mental health treatment,
sive memories of extreme events and restructure including distrust in mental health profession-
cognitive distortions (negative or distorted attri- als and concerns with the efficacy of treatment.
butions, appraisals, and meanings) associated Veterans may express a desire to resolve their
with the event. Other behavioral interventions problems on their own, hold misperceptions that
include the use of biofeedback and relaxation chronic PTSD symptoms will eventually remit
training, including breathing exercises, medita- without intervention, have concerns about reveal-
tion, and yoga. Bibliotherapy (assigning books ing classified military information, fear judgment
934 Veterans

by the therapist because of their combat actions, Post-Traumatic Stress Disorder; Psychoanalytic
and fear losing emotional control if traumatic Treatment; Psychosocial Adaptation; Shell Shock;
memories are reactivated in treatment. Social Support; Stigma; Suicide;
Another consideration in the treatment of vet- Violence; War.
erans is that military and veteran populations also
include members of ethnically and racially diverse Further Readings
groups. Thus, mental health practitioners need American Psychiatric Association (APA). Diagnostic
not only to be versed in military culture but also and Statistical Manual of Mental Disorders. 4th
be sensitive to the needs of diverse and minority ed. Washington, DC: APA, 2000.
populations. Those service members who identify Bachynski, K. E., et al. “Mental Health Risk Factors
as homosexuals (since the repeal of “Don’t Ask, for Suicides in the U.S. Army, 2007–08.” Injury
Don’t Tell” policy) serve openly in the military and Prevention, v.18/6 (2012).
may also have mental health needs that should Department of Veterans Affairs (DVA). VA/DoD
be addressed in a culturally sensitive manner. In Clinical Practice Guidelines. Washington, DC:
fact, mental health professionals have an ethical DVA, 2011.
responsibility to provide culturally appropriate Department of Veteran Affairs (DVA), National
services. Practitioners should also recognize that Center for PTSD. Iraq War Clinician Guide. 2nd
each branch of the military is a culture of its own ed. Washington DC: DVA, 2011.
and it is important to be familiar with each branch, Exum, H. A., J. E. Coll, and E. L. Weiss. A Civilian
including the National Guard and Reserve forces Counselors Primer to Counseling Veterans. Deer
(“citizen soldiers”) who have also served as part Park, NY: Linus, 2011.
of the total force. National Guard and Reserve Foa, E. B., G. Steketee, and B. Olasov-Rothbaum.
members and their families are vulnerable because “Behavioral/Cognitive Conceptualizations of Post-
they are often geographically distant from military Traumatic Stress Disorder.” Behavior Therapy,
installations and VA resources and thus do not v.20 (1989).
have easy access to services or may not be eligible. Hayman, P. M., R. Sommers-Flanagan, and J. P.
Parsons. “Post-Traumatic Stress Disorder in the
Conclusion General Population: Findings of the Epidemiologic
Developing cultural competence in working with Catchment Area Survey.” New England Journal of
military personnel and veterans as well as under- Medicine, v.317 (1987).
standing diverse groups is essential for mental Hoge, C. W., C. A. Castro, S. C. Messer, D. McGurk,
health practitioners to be effective with this pop- D. I. Cotting, and R. L. Koffman. “Combat Duty
ulation. It is estimated that military and veteran in Iraq and Afghanistan: Mental Health Problems
clients will be seeking behavioral health services and Barriers to Care.” New England Journal of
provided by community agencies and civilian Medicine, v.351 (2004).
practitioners as many of the existing resources Keane, T. M., J. A. Fairbank, J. M. Caddell, R.
may not be able to meet their needs. Practitio- T. Zimering, and M. E. Bender. “A Behavioral
ners should have an understating of both risk fac- Approach to Assessing and Treating PTSD in
tors and strengths associated with military ser- Vietnam Veterans.” In Trauma and Its Wake: The
vice with the recognition that most veterans lead Study and Treatment of Post-Traumatic Stress
meaningful and productive civilian lives after Disorder, C. R. Figley, ed. New York: Brunner/
military service. Mazel, 1985.
Kulka, R. A. et al., eds. “Trauma and the Vietnam
Eugenia L. Weiss War Generation: Report of the Findings From the
Michael G. Rank National Vietnam Veterans Readjustment Study.”
University of Southern California New York: Brunner/Mazel, 1990.
Lewis, T. The Soldier’s Heart and the Effort
See Also: Cognitive Behavioral Therapy; Depression; Syndrome. New York: Hoeber, 1919.
Dissociative Disorders; Drug Abuse; DSM-IV; Luxton, D. D., J. E. Osenbach, M. A. Reger, D. J.
Employment; Military Psychiatry; Policy: Military; Smolenski, N. A. Skopp, N. Bush, and G. A.
 Veterans’ Hospitals 935

Gahm. “Department of Defense (DoD) Annual by Abraham Lincoln. Soldiers of the Civil War
Suicide Report.” Washington, DC: DoD, 2012. took up residence in national home branches,
Rubin, A., E. L. Weiss, and J. E. Coll, eds. Handbook which were constructed away from large cities
of Military Social Work. Hoboken, NJ: Wiley & to protect the veterans from vices. Confederate
Sons, 2013. soldiers were not afforded this benefit, so the
Scurfield, R. M. and A. S. Blank. “A Guide to southern states established soldier homes at the
Obtaining a Military History From Vietnam states’ expense. After World War I, the national
Veterans.” In The Trauma of War: Stress and homes saw an increase in younger soldiers who
Recovery in Vietnam Veterans, S. M. Sonnenberg, received assistance with their short-term medical
A. S. Blank, and J. A. Talbott, eds. Washington, care or psychiatric problems. In 1989, the VA was
DC: American Psychiatric Press, 1985. changed to the Department of Veterans Affairs,
Shay, J. Achilles in Vietnam: Combat Trauma and the achieving cabinet status.
Undoing of Character. New York: Scribner, 1994. The mental health of U.S. veterans and sol-
Tanielen, T. and L. H. Jaycox. Invisible Wounds of diers has been a concern since World War I and
War. Psychological and Cognitive Injuries: Their the transition from national home branches into
Consequences, and Services to Assist Recovery. medical centers. The effects of war and combat
Santa Monica, CA: RAND, 2008. trauma on the human psyche have long been
Weiss, E. L., J. E. Coll, and M. Metal. “The Influence known and observed by mental health profes-
of Military Culture and Veteran Worldviews on sionals. The VA, until after the Vietnam War,
Mental Health Treatment: Implications for Veteran ignored this causal relationship between combat
Help-Seeking and Wellness.” International Journal trauma and mental health issues. Many veterans
of Health, Wellness, & Society, v.1/2 (2011). came home with serious cognitive issues, one
Weiss, E. L., J. Daley, and T. DeBraber. Military Social now known as post-traumatic stress disorder
Work. New York: Oxford University Press, 2013. (PTSD). Veterans struggled to help the VA health
system recognize the disorder and provide the
treatment needed to assist those suffering from
it. In the mental health community, this com-
ing together movement is known as consumer
Veterans’ Hospitals empowerment.
In 1987, the VA established the Mental Health
The national veterans’ health care system was Intensive Case Management (MHICM) program.
introduced in 1930, when President Herbert The MHICM provided veterans with a diagnosis
Hoover was authorized by Congress to “consoli- of persistent and severe mental illness (e.g., bipo-
date and coordinate Government activities affect- lar disorder, schizophrenia, or severe PTSD) with
ing war veterans.” This agency became known as intensive case management. The MHICM utilized
the Veterans Administration (VA) and was respon- outpatient clinics and veteran centers instead of
sible for veterans’ health care. Indirectly, the VA the usual inpatient psychiatric hospital model.
can trace its American historical beginnings back Veterans in the program are seen on average two
to 1636, when the colonies provided support for to three times per week, or at least nine hours,
disabled soldiers who fought against the Pequot by a member of their mental health team. After
indigenous people for Plymouth Colony. The a year of intense weekly care, the veteran may
states and local communities provided disabled be deemed ready to transition to a less intense
war veterans with medical care in the early stages weekly schedule or possibly only monthly visits.
as a U.S. republic. The federal government in Data from the Department of Veterans Affairs
1811 established the first national medical facility reveal that as of 2006, over 6,000 veterans are
for war veterans, known as the U.S. Naval Asy- served by the MHICM at over 100 VA health care
lum (in 1873, “asylum” was dropped from the centers. MHICM has been shown by research to
name). The National Home Asylum for Disabled improve the veteran’s quality of life, reduce symp-
Volunteer Soldiers was formed in 1865, by Con- tom severity, reduce hospital stays, and save hos-
gress after the Civil War, and was signed into law pital resources.
936 Veterans’ Hospitals

Substance Abuse a loss of purpose and control in life. Suicide rates

Veterans have a higher propensity for developing are substantially higher for combat veterans than
substance abuse disorders than the general popu- for the general population. For over a decade, the
lation. Data from the VA in 2002 suggested that United States has been at war, and this may have a
approximately 12 percent of veterans who utilize dramatic impact on the rise in suicide rates among
VA facilities are treated for a substance disorder. the veteran population.
Veterans’ high risk for substance disorders may In 2004, the VA began to implement its Mental
stem from combat trauma, high job-related stress, Health Strategic Plan (MHSP), which was devel-
presence of co-occurring disorders (e.g., PTSD or oped with recommendations from the president’s
depression), readjusting to civilian life, and sexual New Freedom Commission on Mental Health.
trauma. Many veterans will self-medicate with The MHSP has six domains with 242 sections.
drugs and alcohol; male veterans have twice the Some of the key components of the MHSP are
risk for drug and alcohol abuse than female veter- integrating primary care and mental health care,
ans. Programs offered by the VA health care sys- increasing capacity and access to mental health
tem emphasize peer support, typically in the form care, suicide prevention, and implementing evi-
of group psychotherapy. Medications are also dence-based practices. The MHSP targeted fund-
used to decrease the desire for alcohol and other ing for mental health services, and as a result the
drugs. Acamprosate, naltrexone, buprenorphine, VA mental health core staff has increased nation-
and methadone are just some of the therapeutic ally by almost 50 percent.
medications used to decrease the veteran’s crav- A policy document has also been developed,
ings for drugs and alcohol. the “Handbook on Uniform Mental Health Ser-
VA facilities have emphasized the importance vices in VA Medical Centers and Clinics,” stating
of utilizing some form of talk therapy in combi- the requirements of the MHSP and how it must
nation with medication to combat substance dis- apply to all veterans and VA facilities. The VA
orders. Cognitive behavioral therapy (CBT) has has established a national office for suicide pre-
had positive results by assisting veterans to learn vention, in partnership with the Substance Abuse
new coping methods and behaviors to avoid cer- and Mental Health Services Administration.
tain substances. In order for a change to occur, Currently, veterans have access to a national sui-
the veteran must want to make the change, so cide prevention hotline at 1-800-273-TALK. The
to assist them, the VA has utilized motivational VA has also added suicide support coordinators
enhancement therapy (MET). MET is designed to and staff at all of the VA medical centers and cer-
give the veteran the positive motivation, strength, tain large outpatient clinics. The responders at
and desire to want to overcome their substance the VA crisis center that administers the suicide
addiction. The VA also has residential treatment help line have access to veteran medical records
programs for substance abuse, where the veteran and can instantly notify emergency person-
can receive intensive treatment and care as an nel near the veteran. The crisis center can also
inpatient. instantly notify the veteran’s local suicide pre-
vention coordinator. The VA calls this the “hub
Suicide and spoke” network: the hub is the crisis center,
It is estimated that about 18 veterans commit and the spokes are the local suicide prevention
suicide every day in the United States. The VA coordinators around the country.
issued data in 2010 that veteran suicide rates The VA has also implemented policy requir-
had “increased by 26 percent between 2005 and ing the screening of all VA patients for suicide
2007.” There has been a growing awareness of and other mental health conditions on an annual
the need to identify veteran risk factors for suicide basis. Veterans who screen positive receive inten-
in order to design and implement effective pre- sive enhanced care and a personal safety plan. All
ventive programs. Certain risk factors that have veterans are provided the handbook, crisis line
been identified are physical injuries, prolonged number, and options for texting and Internet chat
combat, psychiatric conditions such as PTSD and with a crisis responder. The VA has no means in
depression, access to and knowledge of guns, and place to determine the amount of suicide in the
 Veterans’ Hospitals 937

general veteran population except among those report called “Strategies for Serving Our Women
who access VA health services. Data from 2011 Veterans.” The report was developed to determine
show a decline in suicide rates among known the current state of female benefits and services
veterans from 2001 to 2008. While in 2011, provided, and to access what can be improved
the number of suicides increased from 1,609 to through recommendations by the task force and
1,909, the suicide rate decreased over the previ- other gender-related experts within the VA sys-
ous year by 9 percent. This decrease was due to tem. Women who serve today share the battlefield
an increase in the number of veterans served by with their male counterparts and sustain the same
the VA from 4 million to 5.3 million. Much of injuries as men. In 1950, women comprised just 2
this decrease is attributed not to the MHSP, since percent of the overall military (active and reserve
the decrease began before implementation, but components); today, women comprise 32 per-
rather to the 1999 Veterans Millennium Health cent. In 2011, women were the largest increasing
Care Act (VMHCA) and the yellow ribbon effect. component of the veteran community. Currently,
The VMHCA has provided more services to vet- approximately 1.8 million out of 22.2 million
erans, including mental health and other benefits. veterans are female. This number is expected to
The yellow ribbon effect is known as more com- reach 2 million by 2020, and at that time, women
munity involvement and support toward veterans will comprise of about 10 percent of the veteran
because of the perception of how American soci- population.
ety values military members and their commit- Females make up an entirely different demo-
ment to service for their country. A strong social graphic of the veteran population. The average
bond between veterans and their communities has age of male veterans as of 2010 was 62, com-
been shown to strengthen a sense of belonging and pared to 48 for females. Females are diagnosed at
of being a valued member of society, thus possibly a greater proportion with mental health problems
reducing suicide rates among veterans. The VA is (mainly PTSD, depression, and hypertension)
continually monitoring the annual numbers, and than males. Research has shown that female vet-
making necessary adjustments in suicide preven- erans have increased rates of having both a medi-
tion programs. cal and a mental health condition, 31 percent,
compared with 24 percent for males. Females
Female Veterans have experienced higher incidences of military
Numbers of females in the armed services have sexual trauma (MST); about one in five female
grown dramatically since they were first allowed veterans tested positive for MST of those who uti-
to serve their country in the armed forces. New lize the VA for medical services. Women veterans
female military recruits accounted for 20 percent who have MST have an increased risk for PTSD,
of all new recruits in 1998, and as high as 30 per- depression, and substance disorders. The rate for
cent in 2013. The number of women who utilized mental health comorbid diagnosis increases six-
VA health care services in 2008 was 281,000, and fold for female veterans with MST. Females also
it is projected to increase to 330,000 by 2033. need access to gender-specific specialty doctors
This is a 17 percent increase, which VA health ser- (OB/GYN). There has also been a noted gap in
vices must prepare for by increasing gender-based gender services, while there is underutilization of
services oriented toward the needs of female vet- services that are provided. Many female veterans
erans. Males and females show differing effects seem to be unaware of their eligibility for services
from war trauma, with completely different diag- provided by the VA. Based on recommendations
noses between the genders. In 2010, the VA issued from the WVTF, the VA will continue to increase
new policies focused on meeting the health care capacity to provide coordinated and consistent
needs of women veterans and ensuring parity in access for the unique needs of female veterans for
services provided to both males and females. comprehensive services and benefits.
The Women Veterans Task Force (WVTF) was
created in July 2011 and was implemented by VA Homeless Veterans
Secretary Eric K. Shinseki. In 2012, the VA, along Many VA hospitals become shelters for veter-
with the Women Veterans Task Force, released a ans to escape the heat or cold of the streets. This
938 Veterans’ Hospitals

unexpected service has become a huge burden on assistance, and rehabilitation to homeless vet-
the VA hospitals’ limited resources. A report pub- erans, and continues to improve these services
lished by the Department of Housing and Urban as needed to reach the 2015 goal of eradicating
Development (HUD) in 2009 estimated that homelessness among veterans.
approximately 76,000 veterans are homeless. It
is estimated that veterans comprise roughly one- Post-Traumatic Stress Disorder
third of the homeless population in the United Traumatic events can occur in anyone’s life,
States. These homeless veterans deal with many of whether they have been in the military or not.
the same issues that people in the general home- PTSD does not discriminate between gender and
less population have to contend with, such as drug race; anyone who has experienced a traumatic
and alcohol addiction, mental illness, hunger, and life event has an increased risk for PTSD. Soldiers
lack of a sense of belonging. To address the issue who have experienced combat have a higher life-
of homelessness in the veteran population, the time prevalence rate, and female soldiers have a
VA implemented the Healthcare for Homeless higher incident rate than their male counterparts.
Veterans (HCHV) program to eradicate veteran Studies have suggested that female veterans are
homelessness by 2015. Veterans who live on the underdiagnosed and may have more of a predis-
streets require specific services to assist them in position for combat-related PTSD. The assump-
day-to-day living. The gender-specific needs of tion is that female soldiers have a higher exposure
individuals are also met through the VA HCHV rate than male soldiers to early childhood sexual
program. Support provided by HCHV comes and physical abuse. Premilitary sexual trauma has
from a broad range of services that the VA has been demonstrated by research studies to cause
to offer, including mental health, education and an increase in occurrence of PTSD in female sol-
job-skills training, housing resources, rehabilita- diers. Females in the general population have
tion services within the VA, and federal, state, and higher risk rates for lifetime PTSD prevalence
local organizations. than males—5 to 6 percent for men, and 10 to
Many large VA facilities currently maintain 12 percent for females. PTSD estimates are at 13
homeless veteran drop-in centers that provide to 35 percent for current veterans of the Iraq and
meals, bathing facilities, and job search assis- Afghanistan wars.
tance. It is also a policy of the HCHV to arrange PTSD is a chronic, recurring anxiety disorder,
temporary housing for the veteran “within three and comorbidity with other mental health dis-
days of shelter placement.” The HCHV has pro- orders is common. Depression, substance abuse,
vided outreach to veterans on the street and in somatization, attempted suicide, and anxiety
homeless shelters to inform them of services that are all comorbid disorders that may be pres-
the VA provides for them. The VA has also set ent in a veteran with PTSD. PTSD among war
up a national toll-free hotline for homeless vet- veterans of both sexes has an increase in medi-
erans at 1-877-4AID VET. Many homeless vet- cally unexplained physical symptoms (MUPS).
erans need special assistance with mental health When a diagnosis of PTSD is assigned, more
disorders, staying on medications, and abstaining often than not medication is prescribed, rather
from drugs and alcohol. Medical treatment for than “empirically validated psychological treat-
mental health and physical disorders is provided ments.” Many of these psychological treatment
to homeless veterans, including substance abuse studies have been performed on men, and women
treatment, at no cost. Homeless veterans usu- may require a different approach to treatment.
ally qualify for transportation assistance to and Psychotherapeutic interventions to treat PTSD
from their local VA medical center for scheduled are supported by the current literature. A com-
appointments. Many veteran drop-in centers may bination of therapy and psychopharmacologi-
also provide a monthly bus pass to the home- cal intervention can provide relief of symptoms
less veteran so that they may access the drop-in experienced by the veteran.
center, make scheduled medical appointments, The VA currently utilizes three proven effective
access temporary housing, and seek employment. therapy treatments for PTSD: cognitive behav-
The VA provides case management, long-term ioral therapy (CBT), cognitive processing therapy
 Veterans’ Hospitals 939

Petty Officer 3rd Class Pete Herrick, a patient at the James A. Haley Veterans Hospital in Tampa, Florida, talks about his experiences
in Iraq to a group of U.S. Air Force personnel, November 4, 2004. For current veterans of the Iraq and Afghanistan wars, estimates
of post-traumatic stress disorder (PTSD) are at 13 to 35 percent. The Veterans Administration utilizes three proven, effective therapy
treatments for PTSD: cognitive behavioral therapy, cognitive processing therapy, and prolonged exposure therapy.

(CPT), and prolonged exposure therapy (PE). CBT last weeks, months, and even years till the veteran
assists veterans to understand the relationship can manage their PTSD disorder.
interconnected between their thoughts, behav- The mental health of U.S. veterans is a top pri-
iors, and emotions. CBT assists the veteran with ority of the VA, and has been since Abraham Lin-
learning new, positive behavioral approaches and coln created the VA’s predecessor and stated, “To
patterns of thinking for situations. CPT places care for him that has borne the battle.” Today, the
emphasis on the veteran’s beliefs regarding the VA is a leading innovator in community mental
traumatic event. CPT allows the veteran to form health by allowing all veterans to have easy access
new schemas through accommodation and assim- “to the most up-to-date treatments, integrat-
ilation of past and present beliefs of the self. Ther- ing mental health with primary care, encourag-
apists who specialize and practice CPT help the ing care that is patient- and family-centered, and
veteran strive toward a balanced belief schema. working for the adoption of the recovery model.”
PE therapy came about from the “emotional pro- The VA has improved quality and care to over-
cessing theory” of PTSD and states that “amelio- come negative perceptions of mental health care
ration of PTSD symptoms occurs when trauma treatment that stems from the era of the return of
survivors emotionally process their traumatic combat-experienced Vietnam War veterans. The
experience.” PE-practicing therapists repeatedly VA is preparing its facilities to be able to handle
expose the veteran to their memories of the trau- the influx of both male and female combat-expe-
matic event in a safe treatment environment until rienced veterans returning from the wars in Iraq
the fear is overpowered. All these therapies may and Afghanistan. Many of these veterans will
940 Vietnam

suffer from PTSD, depression, and other mental by establishing an asylum close to a major city.
health related issues, for which the VA is ready The first mental asylum was established by the
to supply the best and most comprehensive men- French in grounds on the outskirts of Bien Hoa in
tal health care treatment with a recovery-oriented 1919, long after those founded by their colonial
approach for its veterans. counterparts in the region. Known as the Bien Hoa
Insane Asylum, it initially had a capacity of 140
Corey R. Carlson patients, with the idea that the gardens around
Prairie View A&M University the asylum would provide peace and solace to the
inmates, although many remained confined inside
See Also: Gender; Homelessness; Post-Traumatic the building. In spite of the asylum remaining
Stress Disorder; Suicide. small, during French colonial times, “he comes
from Bien Hoa” became used as a pejorative for
Further Readings somebody who was or might be mentally ill.
Department of Veterans Affairs. “VHA Directive In 1929, Dr. Sonn Mam, the nephew of the
2006–004: VHA Mental Health Intensive Case minister of justice in Cambodia (who had stud-
Management (MHICM).” Washington, DC: ied at the University of Paris), was appointed the
Veterans Health Administration, 2006. director of the Bien Hoa Asylum. He remained
Freedy, J. R., K. M. Magruder, A. G. Mainous, B. C. there until 1940, when he returned to Cambodia
Frueh, M. E. Geesey, and M. Carnemolla. “Gender and established the asylum at Takhmau, just out-
Differences in Traumatic Event Exposure and side Phnom Penh, which he ran until his death
Mental Health Among Veteran Primary Care in 1966.
Patients.” Military Medicine, v.175 (2010). During the 1930s, the facility at Bien Hoa was
Sullivan, G., K. Arlinghaus, C. Edlund, and M. Kauth. overstretched, and in 1933, another asylum was
“Guide to VA Mental Health Services for Veterans established at Voi, in Tonkin in northern Viet-
and Families” (2011). South Central Veterans nam. By 1937, there were 400 patients at Voi
Integrated Service Network. http://www.mental versus 700 at Bien Hoa. The asylum continued
health.va.gov/docs/MHG_English.pdf (Accessed to be used during the Vietnam War, but with the
May 2013). massive U.S. base at Bien Hoa, there was almost
U.S. Department of Housing and Urban constant fighting around the grounds of the asy-
Development, Office of Community Planning lum because it was on the outskirts of the town.
and Development. “Veteran Homelessness: A U.S. advisers and visiting journalists were also
Supplemental to the 2009 Annual Homeless shocked at the increasingly bad conditions at the
Assessment Report to Congress.” VA Research Bien Hoa asylum, which was subsequently closed.
Currents (January 2010). The Indochina War (1946–54) and the Vietnam
War (1960–75) resulted in much trauma in the
country. Many people witnessed atrocities, and
villagers suffered from mental problems emerging
from the massive bombing in parts of the country.
Vietnam Foreign soldiers serving there also suffered from
mental illnesses, and there is extensive litera-
During medieval and early modern times, there ture on the psychiatric care of U.S. soldiers who
were Vietnamese folklore tales that referred to returned home after the war. Abuse of narcotics
people suffering from mental illnesses, often has also exacerbated mental illnesses among both
about a weak ruler manipulated by an avaricious Vietnamese and foreigners involved in the fighting
adviser who took advantage of the problem. The in Vietnam.
abuse of opium also sometimes formed a part of In addition, psychiatry was used for politi-
the stories. cal purposes by the French and subsequent gov-
Modern psychiatric care dates from the French ernments in Vietnam. The preacher Huynh Phu
colonial period. The French followed the practice So was declared by the French to be insane in
of other European colonial powers in the tropics 1939. In the asylum, he converted his doctor to
 Violence 941

millenarianism. Upon his emergence, Huynh Phu Lauber, C. and W. Rossler. “Stigma Towards People
So established the powerful Hoa Hao sect. The With Mental Illness in Developing Countries in
revolutionary, Nguyen Ngoc Dien, was also con- Asia.” International Review of Psychiatry, v.19/2
fined to the asylum at Bien Hoa on three occasions; (2007).
and a woman antigovernment activist, Thieu Thi Niema, Maria, Huong T. Thanh, Tran Tuan, and
Tao, was transferred there in 1969 from the Tiger Torkel Falkenberg. “Mental Health Priorities in
Cages of Con Son after an outcry over the condi- Vietnam: A Mixed-Methods Analysis.” BMC
tions of the prison where she was previously held. Health Services Research, v.10 (2010).
Isolation of Vietnam after 1975 led to a severe
shortage of funds for all areas of health care, with
few resources devoted to psychiatric care. After
the cutting of aid from the Soviet Union, Vietnam
revised its mental health policies in 1989, and Violence
four years later, psychiatric services in the whole
of Vietnam were overhauled. The new system saw Cultures across the world experience violence,
the service based in provinces, with extended fam- which can have deleterious consequences for
ilies generally looking after family members, and mental health, including post-traumatic stress,
the payment of an allowance by the government depression, and anxiety. Violence is usually cat-
to encourage this practice to continue. Family egorized as sexual violence, intimate partner vio-
members are trained on problems, and this allows lence, and criminal violence. Sexual violence is
beds allocated in asylums to be used by people defined as forced or coerced sexual contact with
who would otherwise not receive care. John Wal- an individual. The majority of victims are female.
lace, an Irish doctor who visited Can Tho prov- Sexual violence statistics indicate that nearly one-
ince near Ho Chi Minh City in November 1996, quarter of women experience sexual assault of
found that there were only 25 acute inpatient psy- some form in the United States over the course
chiatric beds for a province that had a population of their lifetimes. Prevalence rates across different
of about 2 million. countries differ, but most indicate that sexual vio-
Gradually, through involvement with for- lence is a worldwide issue. Some countries, such
eign governments, charities, and foundations, as the Democratic Republic of the Congo, also
there have been major improvements in parts of have a high prevalence of systematic rape, which
Vietnam, with cities and towns and areas close refers to rape being used as a tool of warfare, eth-
to major cities much better covered than more nic cleansing, or political oppression.
remote regions of the country. The work in Viet- Interpersonal violence (IPV) occurs when an
nam is now coordinated by the National Institute individual inflicts abusive behavior on a domes-
of Mental Health. However, there are still major tic partner or spouse. It is viewed as a pattern of
problems with the mentally ill not having specific behaviors characterized by control, isolation, and
legal rights. abuse. The abuser often exhibits erratic behavior
as one moment he or she may act lovingly and
Justin Corfield the next emotionally or physically abusive. The
Independent Scholar inconsistencies of the relationship make it more
difficult for the victim to know what to expect
See Also: Asylums; Drug Abuse; National Institute of and how to act. Interpersonal violence is an issue
Mental Health; Veterans; War. in the United States and countries across the
world, although cultural differences on accept-
Further Readings able marital behavior and spousal roles should
Duong Anh Vuong, Ewout Van Ginneken, Jodi also be considered when examining prevalence
Morris, Son Thai Ha, and Reinhard Busse. statistics.
“Mental Health in Vietnam: Burden of Disease Other types of violent crime include robber-
and Availability of Services.” Asian Journal of ies and homicides. The prevalence rates of these
Psychiatry, v.4/1 (2011). types of crime also vary from country to country.
942 Violence

Research indicates that the majority of robberies been sexually assaulted after age 16 reported
involve some type of weapon. that the offender was a husband or partner, with
Circumstances behind homicides are related to 29 percent reporting that the offender was an
a range of issues, including sex, drugs, arguments, acquaintance. Prevalence rates for the United
or the workplace. In the United States, blacks and States are also similar to those in Australia, where
Hispanics have higher rates of homicide victim- 20 percent of women and 0.05 percent of men
ization and perpetration than whites. report that they have experienced sexual violence
Being a victim of violence is associated with after the age of 15.
numerous psychological issues and disorders. One Prevalence rates across Europe vary depending
of the most widely known responses to violence is on the country. For instance, 20 percent of girls
post-traumatic stress disorder, which is character- or women in Switzerland report that they have
ized by re-experiencing the trauma, withdrawal or experienced at least one instance of sexual vio-
numbing symptoms, and hyperarousal and hyper- lence, and 25 percent of women in Norway report
vigilance. Depression is also a common reaction that they have experienced physical and/or sexual
to violence, and suicidal thoughts and behaviors abuse by their husband or partner, which are sim-
sometimes occur in victims of violence. Other ilar to the rates found in the United States. In east-
psychological disorders that have been associated ern Europe, 2 to 6 percent of women report being
with experiencing various types of violence are the victim of sexual assault in Albania, Hungary,
anger problems, substance abuse, dissociative dis- and Lithuania. This rate was slightly higher in
orders, sexual disorders, anxiety disorders, and the Czech Republic, with 11.6 percent of women
eating disorders. reporting that they had experienced forced sexual
contact sometime during their lifetime.
Sexual Violence Rates and Effects In the examination of rape prevalence, there is
In 2010, nearly one in five women (18.3 percent) an important distinction between systematic and
and one in 71 men (1.4 percent) in the United nonsystematic rape. Systematic rape refers to rape
States reported that they had been forced into being used as method of ethnic cleansing, war-
completed or noncompleted sexual penetration or fare, or political oppression. Rape is often used as
completed, substance-facilitated penetration. For a way of destroying an ethnic group by ensuring
women, 51.5 percent reported that the offender that victims leave the area or by impregnating a
was an intimate partner, and 40.8 percent woman to bear a child of the offender’s ethnic-
reported that the offender was an acquaintance. ity. This type of rape occurred during the Bosnian
Findings for men were similar in that 52.4 percent War, for example, as Bosnian Muslim and Croat
reported that the offender was an acquaintance women were raped for ethnic cleansing purposes.
and 15.1 percent that the offender was a stranger. Another purpose of systematic rape is to inflict
Broken down by self-reported ethnicity, the fol- terror and suffering during warfare. For instance,
lowing percentages of women reported that they the systematic rape in the Democratic Republic of
had experienced rape during their lifetime: 22 the Congo has earned it the title of “rape capital
percent of women who identified as black, 18.8 of the world.” Exact statistics are difficult to find,
percent of women who identified as non-Hispanic but one study found that 7 percent of women
white, 14.6 percent of women who identified as were raped at least once between 2006 and 2007
Hispanic, 26.9 percent of women who identified in North Kivu, a province rife with conflict. Rape
as American Indian or Alaska Native, and 33.5 is also often employed as a method of repressing
percent of women who identified as multiracial political opposition and silencing dissidence. For
non-Hispanic. example, political leaders losing power during
Prevalence rates are similar in the United King- the Arab Spring in the Middle East used rape to
dom (UK). Approximately 24 percent of women intimidate, dishonor, and discredit activist women
and 5 percent of men report that they have expe- and their families.
rienced some type of sexual victimization at least In addition, physical consequences such as
once during their lifetime. Similar to the United injuries, sexually transmitted diseases, and
States, over half of women (54 percent) who had pregnancy can have many negative effects on
 Violence 943

mental health. Approximately 33 percent of were as follows: 39.7 to 41.7 percent for urban
sexual assault survivors experience at least one and provincial Bangladesh, 27.2 to 33.8 percent
major depressive episode during their lifetime. for urban and provincial Brazil, 48.7 percent
Suicidal thoughts and behavior are common, for provincial Ethiopia, 30.6 percent for urban
with 33 percent of sexual assault victims con- Namibia, 48.6 percent for urban Peru, 40.5 per-
templating suicide and 17 percent attempting cent for Samoa, 22.8 percent for urban Serbia and
suicide. Another common reaction to sexual Montenegro, 22.9 to 33.8 percent for urban and
assault is post-traumatic stress disorder (PTSD), provincial Thailand, and 32.9 to 46.7 percent for
which is characterized by involuntarily re-expe- urban and provincial United Republic of Tanza-
riencing the trauma (such as flashbacks), avoid- nia. However, when examining domestic violence
ance of behaviors or situations associated with rates across other cultures, it is important to con-
the trauma, emotional numbing and/or social sider differences in views toward marriage and
withdrawal, and hypervigilance toward possible the marital roles that are expected from husbands
danger cues. Approximately 33 percent of sexual and wives. Behaviors that are considered abusive
assault victims develop PTSD. Other psychologi- in one culture may not be considered abusive in
cal conditions associated with sexual assault are another, which may result in different reporting
substance abuse, anger issues, eating disorders, methods.
sexual disorders, dissociative disorders, and bor- The psychological effects of IPV are often doc-
derline personality disorder. umented in the research. As with sexual assault,
PTSD is a common response. Rates of PTSD in
Intimate Partner Violence Rates and Effects women with a history of IPV victimization range
IPV, often called domestic violence or abuse, from 33 to 88 percent. Depression is also seen in
refers to a pattern of abusive behaviors inflicted victims of IPV; rates range from 17 to 72 percent.
by an intimate partner such as a spouse. The Other psychological reactions include eating dis-
majority of IPV victims are female. In 2010 in orders, substance abuse, anger issues, and sex-
the United States, 32.9 percent of women and ual disorders. Psychotic episodes have also been
28.2 percent of men reported that they had expe- observed. Women who remain in relationships
rienced physical violence by an intimate partner with IPV may also develop a condition called
during their lifetime. Furthermore, 1,247 women “battered woman syndrome” (BWS). A woman
and 440 men were murdered by an intimate part- with BWS believes that the IPV is her fault, fears
ner in 2000. Black females encounter IPV at a for her and her children’s lives, and believes that
rate 35 percent higher than white females, and the abuser is always present and knows every-
2.5 times that of women of other ethnicities. thing she does. However, the concept of BWS is
Black males also encounter IPV at a rate 62 per- controversial, and not all experts accept it as a
cent higher than white males and 2.5 times that valid psychological condition.
of men of other ethnicities. Women in households
with the lowest annual income category (less Criminal Violence Rates and Effects
than $7,500) experienced an IPV rate that was Criminal violence encompasses robberies and
seven times higher than that of women with the murders. In 2010 in the United States, 29.5 per-
highest income category ($75,000 and higher). cent of violent crimes were robberies and 1.2
These numbers were similar to those in the UK, percent were murders. Per every 100,000 inhabit-
where 45 percent of women and 26 percent of ants, there were 4.8 murders and 119.1 robber-
men reported that they had experienced domestic ies. The rates of both homicide victimization and
violence. perpetration were six times higher for blacks than
In a study examining rates across 10 coun- for whites. Circumstances for homicides included
tries at 15 sites that were provincial or urban, the those related to sex, drugs, gangs, arguments,
World Health Organization found the lowest rate or the workplace. For whites, the majority of
of IPV in Japan, at 12.9 percent, and the highest homicides were sex related, whereas for blacks,
in the Peruvian province, at 60.8 percent. Lifetime the majority were drug related. For whites, the
prevalence rates for the other countries studied offender/victim relationship in homicides tended
944 Violence

to be family (60.7 percent), whereas for blacks other segments of the population and less able to
it was split between intimate (41.2 percent) and cope with the trauma of victimization.
infanticide (41.6 percent).
Western and central Europe have a lower inten- April Bradley
tional homicide rate at 1.2 murders per 100,000 Katie Miller
inhabitants, as does Asia at four murders per University of North Dakota
100,000. Rates in South America at 21 and Africa
at 32 are higher than in the United States. One See Also: Congo, Democratic Republic of the; Cross-
study examined robbery rates across different National Prevalence Estimates; Cultural Prevalence;
countries, using the definition of “taking property Dangerousness; Dissociative Disorders; Eugenics;
from an individual via force or overcoming resis- Gender; Human Rights; Hypersexuality; Incidence and
tance.” The study found that southern Africa had Prevalence; Insanity Defense; Labeling; Lay Conception
rates of approximately 200 robberies per every of Illness; Mass Media; Movies and Madness; Popular
100,000 inhabitants. Western and central Europe Conceptions; Post-Traumatic Stress Disorder; Race;
had rates of approximately 75, and eastern and Race and Ethnic Groups, American; Self-Injury; Shell
southeastern Europe had higher rates of approxi- Shock; Suicide; Television; Trauma: Patient’s View;
mately 90. Southern and southeastern Asia had Trauma, Psychology of; Veterans; War; Women.
rates of approximately 25.
The effects of criminal violence are similar to Further Readings
those seen in IPV and sexual assault victims. They Alvarez, A. and R. Bachman. Violence: The Enduring
include depression, anxiety or fear, anger, sleep Problem. Thousand Oaks, CA: Sage, 2008.
difficulties, and frustration. Victims may also Black, M. C., K. C. Basile, M. J. Breiding, S. G.
develop PTSD if the incident involved a threat to Smith, M. L. Walters, M. T. Merrick, J. Chen, and
their life or the lives of a loved one. Families of M. R. Stevens. “The National Intimate Partner and
murder victims often experience bereavement and Sexual Violence Survey (NISVS): 2010 Summary
adjustment issues, which can eventually turn into Report.” Atlanta, GA: National Center for Injury
depression. Prevention and Control, Centers for Disease
Control and Prevention, 2011.
Violence and Mental Illness Federal Bureau of Investigation. “Violence Crime
Public perceptions of the link between mental ill- Statistics, 2010.” FBI Uniform Crime Reports
ness and violence are greatly distorted, primarily (January 19, 2010). http://www.fbi.gov/about-us/
because of media attention given to a few high- cjis/ucr/crime-in-the-u.s/2010/crime-in-the-u.s.
profile cases and general negative portrayal of -2010/violent-crime (Accessed July 2012).
the mentally ill in movies and television shows. Hiday, V. A., M. S. Swartz, and J. W. Swanson, et al.
Unfortunately, this distorted view continues to “Criminal Victimization of Persons With Severe
increase. Between 1950 and 1996, the percep- Mental Illness.” Psychiatric Services, v.50 (1999).
tion of mental illness being associated with crime Pescosolido, B. A., J. Monahan, B. G. Link, A.
and dangerous behavior nearly doubled. How- Stueve, and S. Kikuzawa. “The Public’s View of
ever, the overwhelming majority of violence is the Competence, Dangerousness, and Need for
not committed by those with a chronic or seri- Legal Coercion of Persons With Mental Health
ous mental illness. Of people with a mental ill- Problems.” American Journal of Public Health,
ness, violent crime is quite low, and when it does v.89 (1999).
occur, it is most likely to be focused on family Reyes, G., J. D. Elhai, and J. D. Ford. The
members. Encyclopedia of Psychological Trauma. Hoboken,
In contrast, however, people with serious men- NJ: John Wiley & Sons, 2008.
tal illness are 2.5 times more likely to be victims World Health Organization (WHO). “WHO Multi-
of violence than those without mental illness. Country Study on Women’s Health and Domestic
Poverty, inadequate housing, and lack of engage- Violence Against Women” (2005). http://www.
ment in social and community supports makes who.int/gender/violence/who_multicountry_study/
the chronically mentally ill more vulnerable than en (Accessed July 2012).
 Visual Arts 945

World Health Organization (WHO). “World Report consumption of the visual arts is through televi-
on Violence and Health.” Geneva: WHO, 2002. sion and film, which exacerbates such negative
views of those with mental illness. The pur-
ported links between mental illness, dangerous-
ness, and crime have repeatedly been exploited
via the theme of the “mad murderer” that is so
Visual Arts salient among film and television works. Alfred
Hitchcock’s film Psycho in 1960 set a stage for
Historically, there has been a strong connection succeeding films that also portrayed psychotic
between the visual arts and mental illness. Public murderers in which the killing is accounted for
conceptions of mental illness have some founda- by their mental illness. Other similar films that
tional roots in the visual arts that originate from followed include titles such as Homicidal (1961),
the artist’s rendering of what mental illness looks Maniac (1963), Paranoiac (1963), and Night-
like externally, reflecting the belief that individuals mare (1963). In the late 1970s and 1980s, psy-
with mental illness look different than others in cho-killer movies were popular, spurring mov-
society. Hence, early artists attempted to visually ies such as Halloween (1978), Friday the 13th
depict unobservable mental phenomenon. This (1980), and Nightmare on Elm Street (1984),
occurred by depiction of outward symbols via which were so popular that they had numerous
art that was associated with insanity. Such early sequels spanning decades. These types of films
iconic renderings in the 14th century depicted the have continued into present day (e.g., The Silence
mentally ill as outcast and dirty, having matted of the Lambs, 1991; Red Dragon, 2002), making
disheveled hair and tattered clothing. Illustrations large profits for Hollywood filmmakers. Current
of melancholy (depression) showed individuals television shows reflect this continuing trend, and
posed with downcast eyes, little muscular tension, psychotic killers repeatedly surface as the sub-
and dark complexions (in accordance with views jects of prime-time broadcasting (e.g., CSI and
of Hippocrates, a Greek physician, that melan- Law and Order).
choly was a result of black bile in one’s body). Beginning in the mid-19th century, artistic ren-
Muscular tension, an arched back, and dishevel- derings of mental illness also sought to represent
ment characterized psychosis, while depictions of the disordered inner mental processes that char-
manic features included wide eyes, bodily contor- acterize many forms of mental illness. A combi-
tions, nakedness, dishevelment, and restraints. nation of the work of the newly emerging profes-
Other depictions of mental illness combined sion of psychiatry and 19th-century Romanticism
such aspects with silly facial features, odd clothes, created a growing fascination and interest in the
and unusual props such as a balloon or fool’s inner emotional life of those with mental illness.
staff. Such illustrations are not accurate or literal In these circles, it was thought that the art of the
characterizations of those who experience men- mentally ill could provide privileged insights into
tal illness but highlight more extensively the felt the experience of madness. In some circles, there
need for artists to visually render what the art was were suggestions that insanity was a higher plane
meant to portray. of awareness and was connected to genius and
creativity, an idea that can be traced as far back
Portrayal of the Mentally Ill and as the time of the ancient Greeks. Plato believed
the “Mad Genius” in this connection and projected that the outcome
Modern-day depiction of those with mental ill- of such creativity by those with mental illness was
ness reflects similar conventional thinking that productive rather than pathological. Ambroise-
individuals with mental illness look distinctively Auguste Tardieu, a psychiatrist, in 1872 led the
different than the rest of the public, and this is way to use of the art renderings of those with
reflected in all types of medium in the visual arts, mental illness as a way to reconstruct their per-
such as through the works of painters, sculp- spectives on reality; later in that decade, the art
tors, filmmakers, and television producers in of the mentally ill began to be used to aid in dis-
the 20th century. The majority of modern-day tinguishing between diagnoses of melancholia,
946 Visual Arts

general paralysis, dementia, imbecility, megalo- sand; and Edvard Munch’s The Scream (1893), a
mania, and chronic mania. Skilled artists such as desolate troubled individual, mouth opened in a
Vincent van Gogh, Wassily Kandinsky, and Albre- silent scream, set against a tumultuous sky.
cht Durer were used as examples to provide foun- Such in-depth historical depictions and charac-
dation for the belief of the “mad genius,” giving terizations of those with mental illness through
way to encouragement by asylum doctors of art visual arts have contributed to the stereotypes
production by individuals who had schizophre- and stigma of mental illness.
nia. By the mid-20th century, the Prinzhorn col- One of the most salient examples of this phe-
lection in Germany and the Collection of Outsider nomenon is the experience of hysteria in the late
Art in Switzerland were renowned as prodigious 19th century, which included symptoms such as
collections of artworks produced by the insane. fainting, paralysis of limbs and voice, and pain,
This time period also included representations of though no obvious evidence of an organic eti-
mental states by professional artists, leading to art ology. The popular characterization of an indi-
movements such as expressionism and surrealism, vidual with hysteria during this era was a young
which were influenced in turn by Freudian psy- female with rolling eyes, twisted limbs, disor-
choanalysis. Such art illustrated inner emotional dered hair, and a contorted body. The newly
states, psychopathology, and dreams. Examples developed medium of photography presented
include Salvador Dali’s Persistence of Memory images of hysteric sufferers with the character-
(1931), a rendering of melting clocks and lonely ized distorted symptoms, which became guides
on how to display such symptoms. Jean-Martin
Charcot, a renowned physician, demonstrated
hysteric patients in front of attuned audiences
and rewarded patients who publicly displayed
these symptoms with attention and treatment.
The widespread pervasiveness of hysteria in the
late 19th century was followed by its virtual dis-
appearance in the early 20th century. The rise
and fall of this phenomenon indicates the power
of suggestion and characterization through the
visual arts, affecting how the culture is socialized
to view mental illness and symptoms.

Visual Art by Those Who Experience

Mental Illness
Some studies have documented high rates of men-
tal illness among creative artists, which raises the
question of whether creativity and mental illness
are correlated. The current consensus is that they
are not necessarily related but that creative art-
ists draw on their personal and subjective experi-
ences, which can be funneled in the outlet of the
visual arts; hence, the visual arts may draw indi-
viduals who have mental illness to it as a way of
expressing themselves. The connection is thus not
between mental illness and creativity, but between
Vincent van Gogh’s “At Eternity’s Gate” (1890) was completed the presence or absence of mental illness and par-
during the artist’s relapse of poor health and about two months ticular forms of creative expression. Many suggest
before his death, generally attributed to suicide. The “mad that the “madness-genius” connection is nothing
genius” of artists such as van Gogh was used by asylum doctors more than a prevalent stereotype of mental illness.
as a basis for art production therapy for schizophrenics. Art production by those who have mental illness
 Voluntary Commitment 947

has appeared in public at an increasing rate over Rosen, Alan. “Return From the Vanishing Point: A
the last century in galleries, media, and publica- Clinician’s Perspective on Art and Mental Illness,
tions. Some see this as positive, and that this can and Particularly Schizophrenia.” Epidemiologia e
be an avenue for individuals to reintegrate into Psichiatria Sociale, v.16 (2007).
society; however, others view this as an avenue to Schoeneman, Thomas J., Carly M. Henderson, and
emphasize the difference between those who have Vaunne M. Weathers. “Interior Landscapes of
mental illness and the general public, adding to Mental Disorder: Visual Representations of the
the stereotype of the “mad artist.” Experience of Madness.” American Journal of
Early experiences with the art of the mentally Orthopsychiatry, v.75 (2005).
ill included use of their art for diagnostic or inter- Wahl, Otto F. Media Madness: Public Images of
pretative purposes. In the 20th century, exhibits Mental Illness. New Brunswick, NJ: Rutgers
of such work began to appear, labeled as “out- University Press, 2006.
sider art” or “schizophrenic art.” Some of the
largest collections of art created by those who had
mental illness are unattributed work by hospital-
ized patients who were killed by the Nazi regime.
However, many modern artists who experience Voluntary Commitment
mental illness join cooperative ventures that com-
bat stigma and are in line with a recovery orienta- Voluntary commitment takes place when a per-
tion, providing people opportunities for empow- son provides informed consent to be admitted to
erment, emotional expression, social inclusion, a psychiatric hospital or residential mental health
and personal agency as they add to the culture of unit for the purposes of psychiatric assessment
visual arts. and treatment. Criteria for admission as a volun-
Visual arts are also used in modern therapeutic tary patient vary between jurisdictions, but often
environments, and many modalities of psychiatric include some or all of the following: the person
treatment include some version of art therapy. A is diagnosed as having a mental disorder, the
new therapeutic movement includes the use of art person is considered suitable for voluntary com-
designed to focus on the therapeutic relationship mitment and/or has the potential to benefit from
and the process of art creation and communica- treatment, the person understands the nature and
tion. These art programs are designed as part of implications of the request for voluntary commit-
psychosocial rehabilitation, and those participat- ment, the person is willing to sign a voluntary
ing in these programs have indicated that involve- admission form or to consent verbally to admis-
ment has had a positive effect on their recovery. sion, and the person must be capable of request-
Research indicates that involvement with creative ing discharge. As an additional criterion, in some
expression can be useful, increasing a sense of jurisdictions, the patient must be at risk of harm
empowerment and self-validation. to self or others.
Persons who are under voluntary commitment
Erika Carr are free to withdraw consent to admission, refuse
Memphis VA Medical Center consent to different treatments, and/or leave the
facility at any time. However, different legal or
See Also: Art and Artists; Creativity; Movies and administrative policies may delay this process or
Madness; Stereotypes. usurp this right. The person’s capacity to consent
may have an impact on their ability or their sub-
Further Readings stitute decision maker’s ability to consent to vol-
Horwitz, Allan V. Creating Mental Illness. Chicago: untary admission. Applications for involuntary
University of Chicago Press, 2002. commitment may be used to detain persons who
Lloyd, Chris, Su Ren Wong, and Leon Petchkovsky. lack capacity or withdraw consent to admission
“Art and Recovery in Mental Health: A and treatment prior to any attempt to leave the
Qualitative Investigation.” British Journal of facility. In some jurisdictions, voluntary commit-
Occupational Therapy, v.70 (2007). ment is defined within mental health legislation,
948 Voluntary Commitment

whereas in many jurisdictions it is not, although decision makers are able to sign them in as vol-
jurisdictions are moving in the direction of untary patients on their behalf. In other jurisdic-
embedding such definitions within statutes. The tions, patients who present themselves for volun-
vast majority of psychiatric inpatients are vol- tary commitment, and are deemed to require such
untary. Voluntary commitment is preferred and treatment, are not assessed for capacity unless
encouraged by most hospitals and practitioners they refuse or withdraw consent at some point
over involuntary commitment, although any ben- during their admission.
efits to patient agreement may be outweighed by Children, who are deemed unable to consent
the experiences of coercion and lack of legislative because of age, with specific age limits varying
safeguards attached to voluntary commitment. between jurisdictions, can be voluntarily admitted
by parents, guardians, or care givers. In Austra-
Treatment lia, this voluntary committal of children by those
Once voluntary commitment takes place, the with parental rights is allowable only if the child
inpatient may be subjected to a variety of forms does not actively resist admission, thus allowing
of treatment, usually psychotropic medication, children to refuse consent (but not to consent) to
but also electroshock (ECT), individual therapy, voluntary admission.
and group therapy. Voluntary patients maintain
the right to stop any of these treatments by with- Withdrawal or Refusal of Consent
drawing consent, or to refuse some or all forms and Request for Discharge
of treatment at any time. Consenting to voluntary Voluntary patients in principle retain the right to
admission to hospital does not serve as blanket withdraw their consent to admission and/or treat-
consent to all treatment. Voluntary patients must ment, or to refuse consent to treatment at any
be given the right to consent or refuse consent, time. As such, the request to be discharged is an
or withdraw consent after giving consent, to dif- inherent right of all voluntary patients, regardless
ferent forms of treatment. Varying between juris- of jurisdiction. However, there are various differ-
dictions, voluntary patients may or may not be ences between jurisdictions in terms of the amount
subjected to restraint. of time it may take to be released once a request
In order to be able to agree to admission and for discharge is made and the steps needed to be
treatment, a person who is voluntarily commit- released, if release takes place at all. For exam-
ted must be informed and aware of their volun- ple, most facilities maintain the right to detain a
tary status and must be informed of their right to voluntary patient requesting discharge from four
withdraw consent and leave the hospital at any hours in some jurisdictions up to 72 hours in oth-
time, as an ethical standard. In addition, informa- ers. This delay allows time for assessment and
tion must be given to the person that details their change of status application to involuntary com-
assessment and treatment, and they must be given mitment or facilitating aftercare planning prior
the opportunity to ask and receive answer to any to the patient leaving. However, in some juris-
questions they may have about the committal. dictions where the detainment allowance time is
In order for informed consent to be considered very short, such as in New Zealand, practitioners
genuinely voluntary, it must be free of coercion may fill in involuntary admissions forms at the
or constraints, including force, pressure, duress, time that patients are undergoing voluntary com-
deceit, and fraud. If these elements of informed mitment, in order to help speed up the involun-
and noncoerced consent are not all present, the tary committal process if the voluntary patient
commitment represents an infringement on per- attempts to discharge him- or herself.
sonal and civil liberties and is involuntary. This process, although expedient, is unethi-
In some jurisdictions, patients who are assessed cal and counter to involuntary commitment
to lack capacity to consent are not permitted rules, which generally require current, rather
to commit themselves voluntarily, as they are than post-dated assessments. Other administra-
understood to be unable to agree to admission tive rules, varying between jurisdictions, include
or to make well-reasoned decisions for them- filling out request for discharge forms, signing
selves. However, in some jurisdictions, substitute discharge against medical advice (AMA) forms,
 Voluntary Commitment 949

obtaining passes, obtaining leaves of absence, served up by nurse demand or insistence, and acts
being assigned particular privilege levels, and/or of persuasion, forceful arguments, and emotional
obtaining permission from practitioners. These guilt trips may be used to gain consent to engage
administrative rules may be embedded in statute in group work—a few examples of the arsenal of
or may simply be based on local facility policy. coercive techniques used by practitioners to gain
The signing of forms, and in particular the AMA compliance to treatment and to ensure that the
forms, is designed to limit liability of the hospital person does not leave the hospital. This is in addi-
and practitioners if the discharged patient causes tion to the coercion or “persuasive powers” that
harm to self or others after discharge. In some may be used to obtain consent to voluntary com-
jurisdictions, voluntary patients who discharge mitment in the first instance. This attests to the
themselves without following the administra- need to understand both voluntary and involun-
tive rules or without informing practitioners are tary committal as consisting of blurred forms of
deemed to have absconded and will be returned psychiatric coercion, rather than understanding
to the facility by police. As such, although request them as dichotomous instances of noncoercive
for discharge is a right of voluntary patients, and coercive forms of commitment.
the administrative rules and delays in being dis- The research literature demonstrates that many
charged ensures that patients deemed to require voluntarily committed patients regard their status
treatment are not allowed to leave. as one that has involved coercive force rather than
In some jurisdictions, refusing treatment as a being genuinely voluntary. However, what consti-
voluntary patient may be sufficient grounds to tutes coercion or undue pressure is not understood
change a patient’s status from voluntary to invol- or experienced the same by all voluntarily com-
untary; however, in most jurisdictions, the criteria mitted patients. Not all patients feel forced at the
are more exacting and may include all or some same points within the process of admission and
of the following: the person is diagnosed with treatment as others. There is a great variability
a mental disorder, the person is deemed lacking in experiences of coercion as voluntary patients.
capacity to consent, the person is a danger to self Some strategies and forms of the experiences of
or others, the person is at risk of serious physi- coercion, ranging from at the point of referral,
cal impairment or substantial mental or physical at the point of admission, and after admission,
deterioration, the person demonstrated improve- include threat of involuntary commitment, overt
ments from treatment in the past, and the person force, gentle persuasion, threat of incarceration,
is deemed unsuitable for voluntary commitment. threat of apprehension of children, outright or
Involuntary patients may become voluntary implicit deceit, punishments, constraints, verbal
patients upon request and in meeting the criteria, persuasion, not being listened to, not being given
or in some jurisdictions, this may automatically adequate information about treatment and alter-
happen once the timeline of their involuntary natives and instead having their treatment decided
admission expires. for them, not being told if they were voluntarily
or involuntarily admitted and leaving them with
Coercion no knowledge of their status or their rights, being
Coercion may be defined as any threat of action denied permission to leave, enforced medication,
or actual action that compels someone to conduct physical force, and physical restraint. All of these
themselves in a way that is inconsistent with their issues raise questions regarding ethical standards,
wishes. Although there is the illusion of choice social control, power relations, and accountabil-
attached to voluntary commitment, many volun- ity within psychiatric institutions when people are
tary patients will attest to the many elements of under voluntary commitment.
forced admission and forced treatment attached to In many jurisdictions, voluntary commitment
their “voluntary” inpatient experiences. Attempts lacks the safeguards that are attached to the due
to be discharged may be met with threats of invol- process protections of involuntary commitment
untary commitment, absconding may be met with status. However, it remains the preferred mode of
police involvement in being forcibly returned to admission to hospital, with its benefits proffered as
hospital, pro re nata (PRN) medication is often being less coercive, stigmatizing, and adversarial;
950 Vulnerability

more participatory, timely, and respectful of Vulnerability

autonomy, decision making, and choice, as well
as leading to more successful treatment outcomes. Vulnerability considers the susceptibility, or frag-
Critics of voluntary commitment remain uncon- ile state or condition, of a population group in
vinced by these claims. Instead, the downside of regard to a social impact or health condition. Vul-
voluntary commitment is understood to outweigh nerability can be based on race, gender, income,
any possible benefits. These include lack of safe- education, or geographic region (i.e., nation, or
guards against coercion, abuse, and assault; lack urban versus rural). Vulnerable populations may
of legal representation or judiciary review; fewer be more at risk because of social limitations such
opportunities for release; fewer procedural rights; as poverty and lack of education, and because of
no means of external redress; and the overriding certain social and environmental factors such as
threat of involuntary detainment. The lack of a pollution, community violence, health impacts
legal safety net for voluntary patients is seen to such as obesity, and other behavioral and mental
leave people vulnerable to the coercion that is health outcomes. Vulnerable populations are also
known to accompany voluntary commitment. more likely to be susceptible to a range of social
By choosing voluntary over involuntary commit- conditions that predict health and well-being as a
ment, the hospitals benefit from removal of the result of social inequality.
adversarial nature of legal system involvement in Although vulnerability to certain health condi-
the committal and treatment process. tions and outcomes may be genetic or inherited,
such as schizophrenia, oftentimes vulnerable
Brenda A. LeFrançois populations experience lower social status (based
Memorial University of Newfoundland on education or resources) and have less or lim-
ited access to power. Populations may experience
See Also: Commitment Laws; Compulsory vulnerability in various social arenas such as in
Treatment; Informed Consent; Patient Rights; Right education, politics, safety and crime, and health.
to Refuse Treatment. Racial or ethnic populations, women, sexual
minorities, and populations residing in certain
Further Readings regions may experience more vulnerability based
Bingham, Rachel. “The Gap Between Voluntary on their social situation.
Admission and Detention in Mental Health Units.” Overall, vulnerability reflects the social status of
Journal of Medical Ethics, v.38 (2012). a group of people that experience a range of poor
Farrow, Tony L., Brian G. McKenna, and Anthony J. health and social outcomes as a result of their low
O’Brien. “Initiating Committal Proceedings ‘Just social and socioeconomic status. Because there
in Case’ With Voluntary Patients: A Critique of is a high correlation between race and ethnicity
Nursing Practice. Nursing Praxis in New Zealand, and gender and socioeconomic status and power,
v.18/2 (2002). minorities and women are more likely vulnerable
Katsakou, Christina, Stamatina Maroougka, to social conditions (i.e., poverty and lower edu-
Jonathan Garabette, Felicitas Rost, Ksenija Yeeles, cation) and adverse health outcomes than other
and Stefan Priebe. “Why Do Some Voluntary populations.
Patients Feel Coerced Into Hospitalisation? A
Mixed-Methods Study.” Psychiatric Research, Race
v.187 (2011). Racial ethnic minority groups are often more
Stone, Donald H. “The Benefits of Voluntary vulnerable to a range of social and health effects.
Inpatient Psychiatric Hospitalization: Myth or Research has explored different outcomes for
Reality?” Public Interest Law Journal, v.9 (2000). racial and ethnic groups across a range of indi-
Wallsten, Tuula and Lars Kjellin. “Involuntarily cators compared to whites. Outcomes often vary
and Voluntarily Admitted Patients’ Experiences across health, crime rates (including victimization
of Psychiatric Admission and Treatment—A from crime and criminal charges), educational
Comparison Before and After Changed Legislation level, economic well-being, and access to political
in Sweden.” European Psychiatry, v.19 (2004). power. Also, racial ethnic minorities, particularly
 Vulnerability 951

those who are more susceptible to economic vul-

nerability, may experience poor health. Overall
life expectancy among racial ethnic minorities
is lower than for white populations. Racial eth-
nic groups often experience greater disability
and death from a number of stress-induced and
behavior-related health conditions, including high
blood pressure and heart disease, diabetes, kidney
disease, cancers, HIV/AIDS, and violence. African
Americans, Latinos, and Native Americans expe-
rience some of the worst health outcomes in the
nation.
Racial ethnic minority groups are more likely to
be victims of both violent and nonviolent crimes.
Racial ethnic minorities also have disproportion-
ate rates of arrests and sentences for crimes com-
pared to whites.
The “achievement gap” between racial ethnic
groups, or the disparity in academic achievement,
graduation rates, and attendance in four-year
colleges, is also significant with regard to popu-
lation vulnerability. Education correlates with
multiple quality of life indicators such as literacy,
income, and access to increased social mobility.
Also, worldwide, educational level correlates
with improved health outcomes. This has been A street man resting on a sidewalk in Sarasota, Florida, in
explained in part by access to behavior through January 2013 meets numerous criteria for vulnerability: living
health literacy and to income and resources, both in a crowded urban area and being African American, poor, and
of which decrease population vulnerability. handicapped. However, males are less vulnerable than females.
Economic factors are significant to population
vulnerability. Wealth (assets, e.g., a home, stocks,
bonds, and savings) and income (wages from
employment) allow populations access to needed In a democracy such as the United States, polit-
resources such as food, clothing, and shelter, but ical power may be gained through the support of
also to other technologies, services, and supports the masses. Although the masses have access to
that have the potential to improve the quality of vote and to influence the outcomes of political
life for population groups, such as health insur- processes, oftentimes the distance of disenfran-
ance, preventative health care and treatments, chised and vulnerable populations from avenues
leisure time physical activity, safe and clean hous- of political power keeps vulnerable communities
ing, transportation, and health-enhancing foods. in a lower social standing. The hallmark of vul-
Socioeconomic status refers to the combined nerable populations is that they are typically kept
standing of an individual, group, or population, out of the political process and away from oppor-
based on any combination of level of education, tunities and access to power.
income, and assets. Socioeconomic status is a
social determinant that indicates how one group Gender
may fare relative to another. As social economic Although women have overall better health than
status increases, individuals and groups have men, women are more likely than men to suffer
greater access to more resources of life and other from disability over the life course. Women are
materials. Increased social standing also coordi- also more vulnerable to certain health concerns
nates with access to political power. than men, including certain forms of mental illness.
952 Vulnerability

Women are less likely to commit crime than and improve their communities, such as adequate
men. Further, women also represent a significantly police protection and quality schools.
smaller number of arrests and represent less of
the nation’s inmates than men. Women, however, Vulnerability of Mentally Ill Populations
are more likely to fall victim to certain types of The mentally ill can also be a vulnerable popula-
crimes, including assault and battery. tion group. They often face social stigma because
Women exceed men in academic achievement of a diagnosis, as well as face targeted risks if they
and in the pursuit of higher education. Education experience limited cognitive ability or mental
has become one of the avenues through which awareness, or if they are suffering from emotional
women are able to increase their social standing trauma, mental lapse, or disconnection from an
and to secure higher-paying jobs. illness or diagnosis.
Regardless of the increase in women securing Although mental illness is common, it may
higher education, women continue to make less occur in conjunction with other health condi-
than men, with the same and sometimes with less tions. At times, uncontrolled mental illness (i.e.,
education. Women of color make even less, com- anxiety disorder) may display symptoms of other
pared to white women, than their male counter- serious health conditions (heart attack). Further,
parts. This is important because women of color mental health sufferers may not always receive
are also more likely to raise children alone as the the appropriate care and concern for health con-
head of household. ditions outside of their mental health diagnoses.
Untreated mental illness may lead to socially
Region deviant and criminal behaviors. Depending on
There are also regional differences in experiences the severity of mental illness, those living with
that populations face. Often, rural populations are chronic mental illness may experience a difficult
vulnerable to issues of service access because of lim- time maintaining employment. Advocacy for
ited transportation systems and the distance from mental illness is important to increase awareness
urban centers. Conversely, while urban popula- about the needs of mental health sufferers, reduce
tions may have access to certain resources, includ- stigma, and increase services.
ing transportation systems, urban populations also A number of theories have been purported to
face social and health concerns because of urban explain why various groups experience vulner-
conditions such as crowding, crime, and poverty. ability differently than others. While some theo-
Populations may be vulnerable to health out- ries explore individual-level factors such as the
comes based on place of residence. Urban popu- ability of individuals to control their destinies
lations may deal with different health risks than and to master their environments, other theories
rural groups, including pollution, violence, and acknowledge the limitations that populations
noise pollution. However, rural areas often face a face in changing their environments and everyday
lack of access to health and other social services hurdles that populations may endure that prevent
and health resources that might be found in larger them from changing their circumstance. Still oth-
urban centers. ers focus on the systemic limitations and oppres-
Urban areas are often described as experiencing sive politics that exploit some populations and
greater crime because there are more people liv- allow others to benefit. Historical considerations
ing within closer contact as opposed to less people are also important. Minorities and women, for
spread out over more land in rural areas. Resources example, were not always granted equal access to
for schools vary based on place of region. Further, resources and politics as men. Although such de
regions offer different opportunities, such as lower jure laws are currently prohibited, there are still de
teacher-to-student ratio. Where people reside may facto practices and forms of exclusion that prevail
be an indication of the economic security of a com- that affect how racial ethnic minorities and women
munity. Low-income and high-income neighbor- are able to combat discriminatory practices.
hoods possess different resources. Political power
is important in order for regional areas in order to Raja Staggers-Hakim
benefit from appropriate resources to help build Eastern Connecticut State University
 Vulnerability 953

See Also: Exclusion; Gender; Homelessness; Chen, J., S. S. Rathore, M. J. Radford, Y. Wang, and
Marginalization; Neighborhood Quality; Race; H. M. Krumholz. “Racial Differences in the Use of
Race and Ethnic Groups, American; Social Isolation; Cardiac Catheterization After Acute Myocardial
Stigma; Welfare; Women. Infarction.” New England Journal of Medicine,
v.344 (2001).
Further Readings Epstein, A. M. and J. Z. Ayanian. “Racial Disparities
Brown, E. R., V. D. Ojeda, R. Wyn, and R. Levan. in Medical Care.” New England Journal of
Racial and Ethnic Disparities in Access to Health Medicine, v.344 (2001).
Insurance and Health Care. Los Angeles: Hogue, C., M. Hargraves, and K. Scott-Collins, eds.
UCLA Center for Health Policy Research and the Minority Health in America. Baltimore, MD: Johns
Henry J. Kaiser Family Foundation, 2000. Hopkins University Press, 2000.
 W
War soldiers were inexcusable cowards, not fulfilling
their duty to serve their country. Good men, doc-
Today, doctors generally accept that war can have tors believed, were not afraid to fight and easily
severe psychological costs, but doctors were less forgot the mutilation and death that happened
sympathetic in the past. This is because psychia- on the battlefield. Shell-shocked soldiers were
trists are influenced by the ideas and prejudices too effeminate, and the best therapy was “manly
of their societies. Now Western psychiatrists tend guidance.” This guidance included stringent mili-
to believe that war traumatizes all people in the tary discipline, manual labor, electrical shock,
same way, diagnosed as post-traumatic stress dis- and harsh scolding.
order (PTSD). The PTSD diagnosis is a product During World War II (1939–45), for the most
of Western cultural values and has moral impor- part, military doctors remained unsympathetic to
tance. Because of the diagnosis, war survivors traumatized soldiers. During the war, high rates
receive care that they might not have received of U.S. soldiers were discharged from the mili-
otherwise, but the diagnosis has also been used tary for psychiatric causes, but it was not until
as a weapon for condemning war and advancing the 1980s that American psychiatrists began to
human rights. Paradoxically, however, the diag- agree that the war had caused psychological prob-
nosis can also prevent healing, quiet antiwar poli- lems for veterans. Likewise, in Germany, doctors
tics, advance violence, and dehumanize people in debated whether camp syndrome was real, but
war-torn countries. most doctors did not think that the mental disor-
Doctors first became widely concerned with ders of Nazi victims were the result of concentra-
war trauma during World War I (1914–18), tion camp experiences.
when they began seeing a large number of sol- However, in the 1960s, West Germans began
diers with shell shock. Most of these soldiers had newly expressing collective guilt for the Holo-
escaped physical injury but displayed strange caust. The West German government was also
behaviors: temporary blindness or deafness, attempting to maintain good standing with other
stutters or muteness, paralysis in isolated limbs, Western countries and, as a result, the govern-
startle, and odd postures and gaits. Deeply influ- ment became more lenient in awarding disability
enced by nationalism and ideas about masculin- pensions to Nazi victims seeking help with psy-
ity, military doctors saw traumatized soldiers as chological troubles. Collective guilt and govern-
morally weak. They thought that shell-shocked ment acceptance of camp syndrome changed the

955
956 War

English prisoner of war (POW) Horace Greasley (right) demands more food for prisoners during Heinrich Himmler’s inspection of a
POW camp, circa 1940 to 1941. During World War II, military doctors for the most part were unsympathetic to traumatized soldiers.
In Germany, doctors debated the validity of camp syndrome and many did not think that Nazi victims suffering from mental disorders
had these symptoms as a result of living in concentration camps.

way that doctors thought about trauma and the the emotional and psychological costs of a war
Holocaust, and doctors opened up to the idea that what Lifton called an “absurd evil.”
that the Holocaust came with deep psychological Their struggles were successful in the context
consequences for Nazi victims. However, collec- of changes in the way Americans thought about
tive guilt and political pressures have prevented the war. Americans felt they had not properly
doctors from ever recognizing that the camps and honored the veterans when they came back from
war might have also traumatized Nazis. Vietnam, and at the end of the 1970s, the govern-
The landmark moment in the diagnosis of war ment was trying to fix this. In 1979, for exam-
trauma came in 1980. That year, post-traumatic ple, U.S. president Jimmy Carter said during the
stress disorder (PTSD) was placed in the Diag- newly established Vietnam Veterans Week that
nostic and Statistical Manual of Mental Disor- “the nation has not done enough to respect, to
ders (DSM)—America’s official listing of mental honor, to recognize and to reward [Vietnam vet-
illnesses. Prior to that, there was no commonly erans’] special heroism.”
accepted diagnosis of war trauma. In the early Post-Vietnam syndrome became PTSD because
1970s, psychiatrics who opposed the war, such as to get a diagnosis into the DSM, Lifton, Shatan,
Robert Jay Lifton and Chaim Shatan, identified and their supporters had to accommodate oth-
veterans as suffering from “post-Vietnam syn- ers interested in psychological trauma, such as
drome.” These psychiatrists fought to have the psychiatrists treating Holocaust and rape survi-
disorder placed in the DSM as a way to recognize vors. Consequently, the diagnosis was changed to
 War 957

PTSD to recognize that someone living through psychiatry mixes medicine and politics. When
any life-threatening event could be traumatized. Western doctors enter war zones, they are not
In terms of war, the PTSD diagnosis applies to only trying to care for trauma survivors; they are
both soldiers and civilians. also often trying to document war atrocities. The
PTSD diagnosis is a scientific way of recording
War as an Individual Issue the suffering caused by war, and in diagnosing
The 1980 DSM states that PTSD occurs because and treating war trauma, mental health profes-
a person has experienced a stressor event, “a sionals are also trying to uncover the stories of
psychologically distressing event that is outside atrocity, stories of the stressor event. The PTSD
the range of usual human experience,” followed diagnosis is a way to bear witness to suffering and
by disruptive symptoms. The symptoms include becomes justification for further humanitarian
painful memories of the experience, uncontrol- aid or military intervention, evidence for the trial
lable flashbacks to the event, depression, anxiety, of war crimes, and proof that victimized groups
loneliness, aggressive behaviors, and difficulty deserve asylum in other countries.
concentrating. Some details and wording have The PTSD diagnosis has particular power in
changed, but newer versions of the DSM present advancing human rights and in claiming the inhu-
PTSD in basically the same way. manity of war. As humanitarian psychiatrists carry
The PTSD diagnosis reflects Western individu- the PTSD diagnosis around the globe, they show
alism. Westerners tend to see society as made up that armed conflict takes a common human toll,
of isolated individuals, and the PTSD diagnosis even among people fighting against each other.
defines trauma in individualistic terms: PTSD is However, observers and former humanitarian
a disruption in the individual’s psychology and workers worry that humanitarian medical orga-
personal life. nizations take sides in armed conflicts, and armed
Because of the diagnosis, many veterans have actors have increasingly targeted humanitarian
care that was not available in the past, but the medical workers based on the same worries. By
diagnosis also draws attention away from the taking sides, the suffering that humanitarian psy-
political controversies that surround war. War, chiatry discovers is guided by politics, not science.
a gruesome beast shot through with moral and Medical aid can be a way for the organization
political dilemmas, is reduced to the sterile medi- to condemn whom it sees as the oppressor, and
cal language of “stressor event.” Furthermore, rather than witnessing the suffering war causes
PTSD defines war as a personal problem. How- for all, humanitarian psychiatry can devalue the
ever, war is not an individual problem; it is a suffering of those on the wrong side of the con-
social problem. Today in the West, governments flict. In this way, humanitarian psychiatry contra-
and voters choose war, and that political choice dicts its commitment to alleviating suffering and
is what creates war trauma: no war means no its notion of human rights, a sense of equality and
war trauma. In other words, the PTSD diagno- safety for all human beings.
sis silences the fact that war trauma is ultimately Furthermore, the PTSD diagnosis can dehu-
about the political decision to go to war. Conse- manize individuals by not respecting global diver-
quently, the diagnosis as it relates to antiwar poli- sity. Among humanitarian organizations, PTSD
tics is contradictory. Antiwar politics contributed is becoming an official common language to
to the acceptance of the diagnosis, but the diag- describe suffering. However, it describes suffering
nosis also neutralizes antiwar positions that ques- in Western terms and ignores cultural difference.
tion the collective choice to wage war. For example, in some cultures, trauma leads to
physical ailments, not psychological troubles such
Humanitarian Psychiatry as distressing memories and anxiety. In other cul-
War trauma has become a major humanitarian tures, people may show symptoms of PTSD but
concern for organizations such as UNICEF and not find them distressing or worthy of mention.
Doctors Without Borders, and Western doctors When war survivors tell of atrocity and men-
wielding the PTSD diagnosis have led the human- tion psychological troubles, it is sometimes only
itarian psychiatry movement. Humanitarian because the war survivors hope that they will be
958 Welfare

more likely to receive food or shelter if they tell Fassin, Didier and Richard Rechtman. The Empire
aid workers what they want to hear. Also, the vio- of Trauma: An Inquiry Into the Condition of
lence—such as seeing a family member killed— Victimhood. Princeton, NJ: Princeton University
might be minor to other factors for people in Press, 2009.
some societies. Cambodian refugees, for example, Shephard, Ben. A War of Nerves: Soldiers and
who suffered horrible terror and violence by the Psychiatrists in the Twentieth Century. Cambridge,
Pol Pot regime (1975–79), see poverty as the most MA: Harvard University Press, 2001.
devastating aspect of their ordeal. Furthermore, Summerfield, Derek. “The Social Experience of War
people in collectivist cultures often see suffering and Some Issues for the Humanitarian Field.” In
in collective terms, not in individual terms. In Rethinking the Trauma of War, Patrick Bracken
these cultures, war survivors might list the break- and Celia Petty, eds. London: Free Association
up of their community as most troublesome. For Books, 1998.
these people, leaving their group for individual Withuis, Jolande and Annet Mooij, eds. The Politics
therapy might not help them heal; healing hap- of War Trauma: The Aftermath of World War II
pens by rebuilding the community and returning in Eleven European Countries. Amsterdam:
to old social duties. Aksant, 2010.

PTSD and Torture

One consequence of the PTSD diagnosis is that
Western militaries are more sensitive to trauma
and are preparing soldiers for traumatic experi- Welfare
ences as part of their training. For this reason, U.S.,
UK, and other NATO soldiers are prepared for Social policies are collective public forms of soli-
torture situations. This is called R2I: resistance to darity, aimed at ensuring the welfare of a coun-
interrogation training. R2I training involves mock try’s population. However, they cannot be sepa-
tortures, where soldiers are exposed to nakedness, rated from the question of social control because
darkness (sometimes by hooding), and coldness allocating resources requires a system to identify,
for prolonged periods. In these mock tortures, regulate, and deal with deviant groups. Social
soldiers are deprived of sleep and taunted about policies include mental health policies, therefore
their sexuality. While R2I might make soldiers affecting each other. In this way, a narrow con-
resilient to torture, it also teaches them to trau- ception of the welfare system (assistance) coexists
matize. For example, between 2004 and 2006, with a broader conception (protection) alongside
11 U.S. soldiers were sentenced for human rights two major broad historical trends in social poli-
violations because they tortured Iraqis in the Abu cies regarding mental health: integration of the
Ghraib prison. Their torture techniques included mentally ill and promotion of well-being.
those taught in R2I, such as hooding, prolonged In its narrowest sense, the term welfare sys-
nakedness, sleep deprivation, ridicule, and sexual tem designates systems of social aid for a specific
humiliation. population: the poor. For example, the U.S. wel-
fare system offers provision of minimum income
Justin Snyder such as Temporary Assistance for Needy Fami-
Saint Francis University lies (TANF), the Food Stamp Program (FSP), and
Medicaid. Because the mentally ill are among the
See Also: Human Rights; Military Psychiatry; most vulnerable people in society, they are gener-
Nazi Extermination Policies; Policy: Military; Post- ally the victims of social exclusion, and there is
Traumatic Stress Disorder; Trauma: Patient’s View; therefore a strong correlation between inequality,
Trauma, Psychology of; Veterans; Violence. poverty, and mental illness. The field of psychiatry
thus overlaps to a certain extent with health and
Further Readings social care services. In this narrow framework,
Edkins, Jenny. Trauma and the Memory of Politics. individual responsibility prevails over the idea of
Cambridge: Cambridge University Press, 2003. solidarity, and it proves difficult to extend these
 Welfare 959

systems so that they constitute an initial level of Conducting happiness studies was the second
wider-reaching social protection. major trend. Its inception dates back to the 1950s,
In a broader sense, the welfare system designates but it developed during the particularly conducive
systems of social protection that allow individuals context of the 1990s, when positive (or hedonic)
and groups to deal with the risks of life, such as psychology met with the economy of well-being in
the needs of childbearing, health care and handi- a new politico-administrative knowledge of inter-
caps, unemployment, or retirement. In this case, it national scope carried forward in various forms
is a question of rights extended across the board to by organizations such as the Organisation for Eco-
a country’s general population, in the context of a nomic Co-operation and Development (OECD),
welfare state that puts in place the necessary social the World Health Organization (WHO), and the
services for the well-being of all its citizens, and United Nations Children’s Fund (UNICEF). From
also attempts to regulate the negative effects of this perspective, it was a question of extending
market forces. For example, in the wake of World positive mental health by making health care ser-
War II, the British welfare state aimed to afford vices more accessible and promoting well-being
protection to its population “from the cradle to within the general population by emphasizing a
the grave.” The founding of the National Health series of necessary skills. The economic meaning
Service was the leading measure in this endeavor. of welfare was formerly equated with measures
of wealth, using gross domestic product (GDP) as
Major Trends an indicator to evaluate the condition of an entire
The first defining trend in contemporary mental country or economy.
health policies was born in the 1920s. Mecha- However, as the well-being of individuals could
nisms were developed for integrating and reha- now be quantified and measured using quality of
bilitating mentally ill people within society (e.g., life and life satisfaction scales, welfare took on
related to housing, occupation, and personal sup- a psychological meaning referring to well-being
port), in stark opposition to the 19th-century asy- and focused on individual subjectivity, while it
lum model of segregation and isolation. The idea was also efficiently applied to a variety of differ-
was to develop early prevention of mental illness ent areas in society in the form of mental health
and suicide. norms: well-being at school, in the workplace,
Nonetheless, it was only at the end of World and in hospital. More widely, the ideas of “life
War II that the mental health movement really skills” and “psychosocial competencies” devel-
developed as it met with the movement for care in oped around the expected moral components of a
and by the community, the desire to destigmatize normal personality, such as empathy, self-esteem,
patients, the spread of psychoactive medication, optimism, resilience, coping, and social integra-
and the drastic reduction in the cost of health care tion. In this current context, in which autonomy
services leading to public psychiatry moving out of is part of what defines citizenship and positivity
the hospital context. This heightened the private is a cardinal virtue, psychiatry is positioned as a
market of psychiatric care and led to an increase in negative pole, and it becomes difficult to consider
homeless mentally ill people, but it also gave rise irresponsibility from any point of view other than
to two positive extensions of the boundaries of that of the potential dangerousness of people suf-
mental health. On the one hand, certain diagno- fering from a severe mental disorder. The prin-
ses such as post-traumatic stress disorder (PTSD), ciple of protection is thus radically reversed, and
rather than leading to stigma, gave legal status the onus shifts from protecting the mentally ill to
and compensation to victims of war trauma. Sim- being protected from them.
ilarly, many other diagnoses allowed the existence
of a handicap to be established, thus giving people Samuel Lézé
access to social aid or specialist help. On the other Ecole Normale Superieure de Lyon
hand, in this new political space of mental health,
different associations—for families, patients, con- See Also: Economics; Legislation; Medicare and
sumers, ex-patients, or survivors—came to play Medicaid; Patient Rights; Right to Treatment; Social
an increasingly important role within psychiatry. Control; Social Security; State Budgets.
960 Women

Further Readings women and poverty rather than examining how

Diener, Ed and Richard Lucas, eds. Wellbeing for the intersections of race, ethnicity, social class,
Public Policy. Oxford: Oxford University Press, gender, religion, and sexual orientation interact to
2009. produce certain mental health problems. Recip-
MacMahon, Darin. The Pursuit of Happiness: A rocal relationships often exist between socioeco-
History From the Greeks to the Present. London: nomic and occupational status; the presence of
Penguin, 2007. lifestyle and behavioral risk factors such as unsafe
Mechanic, David. Mental Health and Social Policy: sex, violence, smoking, alcohol consumption,
Beyond Managed Care. Boston: Allyn & Bacon, lack of exercise, and poor diet; health; residential
2008. location; exposure to health and safety risks; past
and present life stressors; community and social
support; and the availability of health services.
Other stressors include the “double shift” of
paid (often low-paid) work and unpaid labor in
Women the home; lower wages; workplace discrimination
and sexual harassment; physical, emotional, and
The traditional biomedical view of mental illness sexual violence; and the psychological demands
has been primarily concerned with biological fac- of child care and other forms of caregiving pre-
tors in the production of illness and disease and dominantly performed by women. It is essential
with ways of improving diagnosis and treatment to examine women’s mental health within a social
once illness and disease have occurred. The social model, which gives an account of the physical and
model of mental health, while acknowledging bio- mental health effects of life stressors that are dis-
logical contributions for a limited subset of disor- proportionately experienced by women.
ders, calls attention to both individual behavioral Poor women who often have experienced mul-
risk factors as well as economic, legal, and envi- tiple negative life events are at higher risk for
ronmental factors and their complex reciprocal developing psychiatric conditions. Poor women’s
relationships that affect women’s lives and limit powerlessness interacts with environmental fac-
their ability to control the determinants of their tors such as neighborhood safety, job market
health. Even when biological factors contribute to forces (unemployment, fluctuating employment,
particular disorders in women (such as postpar- or underemployment), racism, and discrimina-
tum depression), social factors mediate the risk tion. The majority of poor women are also moth-
of actually developing a mental disorder. Social ers, whose stress increases with age and number
change directed at factors that negatively affect of children. Women also engage in more care-
women’s mental health offers the possibility of giving than men, often providing care for their
primary prevention, reducing the incidence of cer- own children, other family members (often aging
tain mental disorders. For purposes of this review, and ill parents), and friends. Multiple-role strain
the focus is on women in the United States. Major often results in feelings of depression, stress,
social risk factors are considered first, followed frustration, and helplessness, placing women
by information on rates of women’s mental illness at an additional disadvantage for mental health
and their utilization of psychiatric medications. problems.
According to the World Health Organization
Gendered Inequality, Poverty, and Racism (WHO), there is strong evidence that globaliza-
It has been reported consistently in research that tion and large-scale restructuring have increased
socially disadvantaged groups (such as women, income inequalities and adverse life events and dif-
racial minorities, and the poor) can have mental ficulties, particularly for women. If gender-based
health difficulties based on their disadvantaged income inequalities are not reduced, the numbers
status. A gendered, social determinants model of girls and women who are forced to rely on
offers the only viable framework for understand- harmful and/or illegal activities for income, such
ing all relevant factors related to women’s mental as work in the sex industry and human traffick-
health. Most research takes a generic approach to ing, will continue to escalate.
 Women 961

Racism has been a ubiquitous social reality in their partners, and women are at extremely high
the United States and has the potential to make risk of murder when they attempt to leave an abu-
everyday life events more difficult and extreme sive relationship.
life difficulties catastrophic. Institutional racism Violence in the home tends to be repetitive,
continues to be embedded in many social institu- escalates in severity over time, and encapsulates
tions, including an everyday climate of social hos- all three features identified in social research on
tility, patterned injustice, or extended hardship depression in women: humiliation, enforced infe-
resulting in chronic stress, contributing to mental rior ranking and subordination, and blocked
health vulnerability. escape or entrapment. Domestic violence com-
monly includes physical abuse as well as sexual
Gender-Based Interpersonal Violence abuse and, in particular, rape.
The high incidence of sexual violence against girls Women are often reluctant to disclose a history
and women has prompted researchers to sug- of violent victimization, and undetected victim-
gest that female victims make up the single larg- ization results in high and costly rates of utiliza-
est group of those suffering from post-traumatic tion of the health and mental health care system.
stress disorder (PTSD). Interpersonal violence At least one in five women experience rape or
disproportionately affects women and includes attempted rape in their lifetime. A nationwide sur-
child sexual abuse, rape, and domestic violence. vey of rape in the United States found 31 percent
Women who have been victims of any kind of vio- of rape victims developed PTSD at some point in
lence at any age are at greater risk of developing their lives compared with 5 percent of nonvictims.
a mental disorder. They are also more likely to PTSD also persists longer in women than in men.
attempt and complete suicide, have poor overall The National Women’s Study produced dramatic
health, and are more likely to suffer from other confirmation of the mental health impact of rape.
types of abuse throughout their lives. Violence— The study determined comparative rates of several
physical, sexual, and psychological—is related to mental health problems among rape victims and
high rates of depression and comorbid psychopa- nonvictims. The study ascertained whether rape
thology, including PTSD, dissociative disorders, victims were more likely than nonvictims to expe-
phobias, and substance use and suicidality. rience these devastating mental health problems.
Moreover, psychological disorders are accom- Thirty percent of rape victims had experi-
panied by somatization, altered health behaviors, enced at least one major depressive episode in
changed patterns of health care utilization, and their lifetimes, and 21 percent of all rape victims
health problems affecting many body systems. were experiencing a major depressive episode
Being subjected to the exercise of coercive control at the time of assessment. Rape victims were 13
leads to diminished self-esteem and coping abil- times more likely than noncrime victims to have
ity. Violent victimization increases women’s risk attempted suicide (13 percent versus 1 percent,
for unemployment, reduced income, and divorce. respectively).
Thus, gender-based violence further weakens There is substantial evidence that rape victims
women’s social position by operating on the have higher rates of drug and alcohol consumption
structural determinants of health while it simulta- than nonvictims, as well as a greater likelihood of
neously increases vulnerability to depression and having drug- and alcohol-related problems.
other psychological disorders. National surveys of adults suggest that 9 to 32
Domestic violence is a mental health issue that percent of women and 5 to 10 percent of men
affects all women, spanning economic class and report that they were victims of sexual abuse and/
educational level and occurring throughout the or assault during their childhood. It is well known
life span, including in adolescent dating relation- that many more girls than boys are the victims
ships. Risk factors for intimate partner violence of sexual abuse. The effects of child sexual abuse
include economic inequality, no option of divorce can include depression, suicidality, PTSD, dissoci-
for women, and men having greater decision-mak- ation, anxiety, substance abuse, eating disorders,
ing authority in the home or family. Pregnancy is and higher risk of further victimization in adult-
a time of increased violence against women from hood. Research has shown that traumatic stress,
962 Women

including stress caused by sexual abuse, causes psychological outcomes, even when other
structural neurologic changes in brain function- potentially significant factors have been
ing and development that can affect intelligence statistically controlled in data analysis.
and memory and create increased vulnerability to This has been found in studies on the
subsequent anxiety disorders, particularly PTSD. mental health impact of domestic vio-
lence and childhood sexual abuse.
Gender Bias • There are marked reductions in the level
Gender bias occurs in the assessment, diagnosis, of depression and anxiety once women
and treatment of mental disorders and derives stop experiencing violence and feel safe,
from multiple sources. compared with increases in depression
Physicians are more likely to diagnose depres- and anxiety when violence continues.
sion in women compared with men, even when
they present with equivalent scores on standard Overall rates of mental disorders in men and
measures or with identical symptoms. Depressed women are quite similar, although there are gen-
men may present with anger, irritability, anti- der differences in rates across different disorders.
social behavior, and substance abuse masking Gender rates are equivalent for several severe
depression, which may partially contribute to mental illnesses known to have a stronger degree
their underdiagnosis. of biological causation, such as bipolar disorder
Criteria for some personality disorders corre- (0.4 percent) and schizophrenia (0.4 percent).
spond to gendered, role-scripted behaviors and There are significant gender differences in preva-
gender stereotypes that may affect both the pre- lence rates in many other mental disorders.
sentation of distress and the likelihood of diagno- Major depression is twice as common in
sis. These include dependent personality disorder, women. Women predominate in rates of depres-
histrionic personality disorder, and borderline sion, anxiety disorders, and somatic disorders.
personality disorder. In addition, behaviors char- Women are twice as likely than men to develop
acteristic of these particular disorders are also PTSD after a stressful event. Disability associated
typical of complex PTSD caused by interpersonal with mental illness falls most heavily on those
trauma, and it has been argued that many women who experience three or more comorbid disor-
suffering from complex PTSD are inappropriately ders, where women predominate.
diagnosed with personality disorders and thus fail The evidence indicates that the predominance
to receive effective treatment. of depression and other disorders in women
Women are more likely to seek help and dis- reflects their greater exposure to a range of stress-
close psychological distress and symptoms to ors and risks to their mental health, rather than
their health providers. While gender bias and gender bias in diagnosis or a biologically based
help-seeking may contribute to gender differ- vulnerability to psychological disorders.
ences observed in rates of mental disorders to
some degree, gender differences in these rates are Culture-Bound Syndromes:
robust phenomena related to the social and con- Depression and Eating Disorders
textual forces described above. According to the Major depression is the most common of all men-
WHO, the likely causal role of violence in depres- tal disorders in Western populations. According
sion, anxiety, and other disorders such as PTSD is to the WHO, unipolar depression (major depres-
suggested by the following: sive disorder) is predicted to be the second lead-
ing cause of global disability burden by 2020
• A three- to four-fold increase occurs and is twice as common in women. The lifetime
in rates of depression and anxiety in prevalence in the United States is 21.3 percent for
large community samples among those women and 12.7 percent for men. This difference
exposed to violence compared with those in risk begins in adolescence and remains through
not exposed. midlife. Depression is not only the most common
• Severity and duration of violence pre- women’s mental health problem but also may be
dicts the severity and number of adverse more persistent in women than men. According
 Women 963

to the WHO, reducing the overrepresentation of Medicalization of Women’s Mental Illness

women who are depressed would contribute sig- More than one in five adult Americans took at least
nificantly to lessening the global burden of disabil- one medication commonly used to treat a psychi-
ity caused by psychological disorders. Depression atric or behavioral disorder in 2010. Women’s use
is also a major risk factor for suicide. Considering was even higher, with one in four using a mental
that women suffer from depression at twice the health–related drug in 2011. Treating symptoms
rate of men, this makes suicide a significant issue of mental disorders with medication may provide
for women. temporary relief and even facilitate the patient’s
In the United States, conservative estimates indi- utilization of psychotherapy and better address
cate that after puberty, 5 to 10 million girls and their individual issues. However, medicalizing the
women in the United States (5 to 10 percent) and result of social conditions such as inequality, vio-
1 million boys and men are struggling with eating lence, and injustice diverts attention from needed
disorders including anorexia, bulimia, binge eat- social change and individualizes mental illness.
ing disorder, or borderline conditions. The Alli- In addition, the medicalization of mental illness
ance for Eating Disorders Awareness states that results in significant profits for the pharmaceutical
over one person’s lifetime, at least 50,000 indi- industry, which relies on the continued existence
viduals will die as a direct result of their eating of mental illness and its causes to maintain a profit
disorder. Because of the secretiveness and shame margin. For these reasons, it is important to criti-
associated with eating disorders, many cases are cally examine the marketing of new psychoactive
likely not reported. In addition, many individuals medications, and women are its largest market.
struggle with body dissatisfaction and subclinical The pharmaceutical industry has participated
eating disorder attitudes and behaviors. in developing and creating new diagnoses for
Eating disorders are sometimes classified as women by funding research, clinical trials, con-
a culture-bound syndrome because they occur ferences, and individual experts with the goal of
almost exclusively in wealthy, industrialized creating new markets for its products. Examples
nations. For example, 80 percent of American include Eli Lilly’s heavily funded sales campaign
women are dissatisfied with their appearance. in 2001 for Sarafem (fluoxetine), formerly trade-
The drive for thinness is culturally and histori- marked as Prozac, for treatment of its newly coined
cally specific, socially determined, and seen as “premenstrual dysphoric disorder” (PMDD) Its
etiologic of the high rate of eating disorders in overinclusive criteria was targeted at millions of
women and girls. Most often, eating disorders in women with the marketing tagline: “Think it’s
boys and men develop as a function of trying to PMS? Think again . . . it could be PMDD.” Lilly
meet weight limits in competitive sports. claimed that PMDD was “a distinctive medical
Thinness is strongly associated with social value condition” but did little to distinguish it from
and becomes associated with self-worth in young most women’s typical premenstrual symptoms.
girls, reinforced by social pressures and inunda- Although Lilly claimed that only 3 to 5 percent
tion with nonrepresentative depictions of women of women experience PMDD, based on its vague
across all media. The objectification and sexual- diagnosis, almost every menstruating woman
ization of women and girls have been seen as lay- could potentially suffer from this mental disor-
ing the groundwork for eating disorders. Sexual der. Sarafem promised to make its target market
objectification, or sexualization, is a precursor “more like the woman you are.” By renaming this
to self-objectification, which leads to self-sur- drug and funding the creation of a new diagnosis
veillance and body shame. Sexualization teaches and subsequent market, Lilly extended its patent
women that attracting a man, which requires sex on fluoxetine, avoided generic sales, and thus pro-
appeal and conformity to current standards of tected corporate profit.
thinness, will ensure financial stability and per- From 1997 to 2004, Pfizer engaged in similar
sonal safety. Thus, prevention lies in changing the practices to build a market for experimental medi-
stakes and the social structure that creates this cations targeted at a catchall, company-created
system of rewards and punishments rather than in diagnosis of “female sexual dysfunction” (FSD).
pathologizing the affected individuals. Starting with a disease “awareness” program,
964 Women

Pfizer trumpeted findings that 43 percent of women risks. Consequently, it is urged that a rights frame-
suffer from some type of sexual dysfunction (based work be adopted to guide research, mental health
on findings that many women are sexually unful- care practice, and policy. The WHO report states
filled) but then marketing their new medications that research indicates three main factors that are
as a cure, when the predominant causes of lack of highly protective against the development of men-
female sexual response are based on a relational tal problems, especially depression. These include
context. These new medications had dangerous the following:
side effects and were only defeated through strong
consumer-based and feminist activist efforts. • Having sufficient autonomy to exercise
When corporations influence the develop- some control in response to severe events
ment of diagnoses and the marketing of cures for • Access to material resources that allow
women, it is important to question the validity the possibility of making choices in the
of these created diagnoses, question whether a face of severe events
medical “cure” is appropriate for what may be • Psychological support from family,
socially based problems in living, and consider friends, or health providers
that many medications have unwanted and dan-
gerous side effects. Finally, the importance of trauma, violence, and
abuse must be recognized by providers, research-
Greater Use of Psychiatric ers, policy makers, and the general public. These
Medications by Women factors are far more prevalent in the lives of girls
A report by Medco Health Solutions, Inc., pro- and women than commonly thought. They may
vided an analysis of trends in mental health lead to serious, long-standing physical ailments,
medication usage, comparing utilization of anti- co-occurring conditions, and risky behaviors that,
depressants, antipsychotics, attention deficit if left unrecognized and untreated, can compro-
hyperactivity disorder (ADHD) drugs, and anti- mise women’s health. With removal from unsafe
anxiety treatments from 2001 to 2010. The report and violent settings and with appropriate treat-
found that more than a quarter of American ment, recovery from mental disorders or from the
women of all ages (26 percent) take such drugs, effects of trauma, violence, and abuse is possible.
compared to 15 percent for their male counter-
parts. Antidepressants are by far the most com- Wendy Ellen Stock
monly utilized, with over 20 percent of women Independent Scholar
on a drug typically prescribed to treat depression.
Women are also more likely than men to take See Also: Antipsychiatry; Children; Clinical
antipsychotic drugs such as Zyprexa, Risperdal, Trials; Diagnosis; Eating Disorders; Employment;
and Abilify, which treat disorders such as bipolar Family Support; Gender; Globalization; Hysteria;
disorder and schizophrenia. Anxiety treatments Inequality; Law and Mental Illness; Marital Status;
are also widely used by women and at almost Medicalization, Sociology of; Pharmaceutical
twice the rate of men; the greatest use is found Industry; Post-Traumatic Stress Disorder; Prozac;
among middle-aged women (45 to 65 years of Race; Race and Ethnic Groups, American; Role
age), 11 percent of whom were on an antianxiety Strains; Self-Esteem; Self-Help; Sex; Somatization of
drug in the previous year of the study. Distress; Suicide; Violence; Vulnerability.

Policy and Prevention Further Readings

A 1998 WHO report states that effective strate- Belle, D. “Poverty and Women’s Mental Health.”
gies to address women’s mental health risk cannot American Psychologist, v.45 (1990).
be neutral while the risks themselves are gender Breslau N., R. C. Kessler, and H. D. Chilcoat, et al.
specific, and women’s status and life opportunities “Trauma and Post-Traumatic Stress Disorder in
remain “tragically low.” As noted in the report, the Community: The 1996 Detroit Area Survey
low status, poverty, interpersonal violence, and of Trauma.” Archives of General Psychiatry, v.55
human rights violations are potent mental health (1998).
 Work–Family Balance 965

Byrne, C. A., H. S. Resnick, D. G. Kilpatrick, C. L. Lundberg-Love, Paula K., Kevin L. Nadal, and
Best, and B. E. Saunders. “The Socioeconomic Michele A. Paludi, eds. Women and Mental
Impact of Interpersonal Violence on Women.” Disorders. Santa Barbara, CA: Praeger, 2011.
Journal of Consulting and Clinical Psychology, Mellin, L., S. McNutt, Y. Hu, G. B. Schreiber, P.
v.67 (1999). Crawford, and E. Obarzanek. “A Longitudinal
Campbell, J. and L. Lewandowski. “Mental and Study of the Dietary Practices of Black and White
Physical Health Effects of Intimate Partner Girls 9 and 10 Years Old at Enrollment: The
Violence on Women and Children.” Psychiatric NHLBI Growth and Health Study.” Journal of
Clinics of North America, v.20 (1997). Adolescent Health, v.20/1 (1991).
Collins, M. E. “Body Figure Perceptions and National Eating Disorders Association. “Fact Sheet
Preferences Among Pre-Adolescent Children.” on Eating Disorders” (May 2008). http://www
International Journal of Eating Disorders (1991). .nationaleatingdisorders.org/uploads/file/in-the
Douglas, E. and D. Finkelhor. “Child Sexual Abuse -news/NEDA-In-the-News-Fact-Sheet%282%29
Fact Sheet.” http://www.unh.edu/ccrc/factsheet/pdf/ .pdf (Accessed August 2012).
CSA-FS20.pdf (Accessed August 2012). Rebensdorf, A. Sarafem. “The Pimping of Prozac for
Felitti, V. J., R. F. Anda, D. Nordenburg, D. F. PMS.” Alternet (June 11, 2001). http://www.alter
Williamson, A. M. Spitz, V. Edwards, M. P. Koss, net.org/story/11004/sarafem%3A_the_pimping
and J. S. Marks. “Relationship of Childhood _of_prozac_for_pms (Accessed August 2012).
Abuse and Household Dysfunction to Many of Resnick, H. S., R. Acierno, and D. G. Kilpatrick.
the Leading Causes of Death in Adults.” American “Health Impact of Interpersonal Violence.”
Journal of Preventive Medicine, v.14 (1998). Behavioural Medicine, v.23 (1997).
Fredrickson, B. L. and T. A. Roberts. “Objectification Roberts, G. L., J. M. Lawrence, G. M. Williams, and
Theory: Toward Understanding Women’s Lived B. Raphael. “The Impact of Domestic Violence on
Experiences and Mental Health Risks.” Psychology Women’s Mental Health.” Australian and New
of Women Quarterly, v.21 (1997). Zealand Journal of Public Health, v.22 (1998).
Kendler, K. S., C. M. Bulik, J. Silberg, J. M. Hettema, Shisslak, C. M., M. Crago, and L. S. Estes. “The
J. Myers, and C. A. Prescott. “Childhood Sexual Spectrum of Eating Disturbances.” International
Abuse and Adult Psychiatric and Substance Use Journal of Eating Disorders, v.18/3 (1995).
Disorders in Women: An Epidemiological and Slater, L., A. Banks, and J. Daniel, eds. The Complete
Cotwin Control Analysis.” Archives of General Guide to Mental Health for Women. Boston:
Psychiatry, v.57/10 (October 2000). Beacon Press, 2003.
Kessler, R. C., P. Berglund, O. Demler, R. Jin, K. Sutherland, C., D. Bybee, and C. Sutherland. “The
R. Merikangas, and E. E. Walters. “Lifetime Long-Term Effects of Battering on Women’s
Prevalence and Age-of-Onset Distributions of Health.” Women’s Health, v.4 (1998).
DSM–IV Disorders in the National Comorbidity World Health Organization. “Women’s Mental
Survey Replication.” Archives of General Health: An Evidence Based Review: Gender and
Psychiatry, v.62 (2005). Women’s Mental Health” (2000). http://www.who
Kilbourne, J. “Can’t Buy My Love: How Advertising .int/mental_health/prevention/genderwomen/en
Changes the Way We Think and Feel.” New York: (Accessed August 2012).
Touchstone, 2000.
Kilpatrick, Dean G. “The Mental Health Impact
of Rape” (2000). University of South Carolina.
http://www.musc.edu/vawprevention/research/
mentalimpact.shtml (Accessed August 2012). Work–Family Balance
Levine, M. P. and L. Smolak. “Media as a Context
for the Development of Disordered Eating.” In Prior to the late 1880s, most work in the United
The Developmental Psychopathology of Eating States was conducted within the context of the
Disorders: Implications for Research, Prevention, family. Agrarian work required participation
and Treatment, L. Smolak and M. Levine, eds. of most members of the family in the process
Hillsdale, NJ: Lawrence Erlbaum, 1996. of planting, harvesting, and animal care. Retail
966 Work–Family Balance

businesses were often housed within a family of women entered the workforce and when male
home or near a family home, making the training roles adopted greater participation in parenting.
and work of the shop part of the life of the fam- A model of integrated work and family roles
ily. Tradesmen worked from their home shop and evolved to explain the increase in satisfaction
apprenticed family members in their work. and performance that some individuals reported,
It was only as a result of the Industrial Rev- despite an increase in the number of activities
olution that the issue of work and life balance they undertook. Role variety has been found to
began to arise. As manufacturing centers created increase feelings of well-being, and it is specu-
a demand for workers to live removed from their lated that this benefit derives from having mul-
home, workers were separated from their family tiple channels of support. If stress is experienced
in order to obtain employment. As the develop- within one domain (work) there is availability
ment within industrial and post-industrial com- of support and efficacy within the other domain
munities increased, the time demands on the (family). There are some limitations to this model,
worker changed. In some ways, these changes however, with men and women generally report-
have led to greater separation of family and ing different levels of household responsibility
work life, whereas the digital age has decreased within their family life, which impacts the amount
the distinction. Unions, child labor laws, com- of leisure and work time available to them. There
pulsory education laws, and other legislative are differences in this “second shift” phenom-
policies taken up within developed nations have enon across cultures. In general, the greater the
created a distinction between work and family distinction of gender roles within a culture, the
life that has been challenged by technology and more likely there is to be a difference in women’s
economic factors occurring within the digital reports of satisfaction with their balance between
age. Mental well-being has been linked to feel- work and family life. Greater egalitarianism has
ings of efficacy within family and work domains, been shown to increase women’s life satisfaction
and different theories have emerged to predict and reduce their experience of work and family
and explain well-being derived from work and dissatisfaction.
family life.
Technology
Gender Roles and Work Demands The integration of work and family roles became
Segregation of domains, with clear distinctions increasingly common as technological develop-
between one’s work experience and one’s fam- ments enabled greater access to work efforts from
ily experience, was a dominant model within one’s home. In the same way that the Industrial
the post–World War II era of manufacturing and Revolution relocated the center of one’s work, the
business. There was a cultural shift in a return digital or information revolution recentered work.
to traditional gender roles and divisions of labor Many creative and technology workers have been
for men returning from World War II, and as a able to conduct some part of their work functions
result, there was a great deal of emphasis placed from their home computer, or increasingly from
on the male worker as the breadwinner and key their smartphone. While most manufacturing and
economic contributor. Although active in the industrial work remains centered within a physi-
workforce prior to World War II, women’s roles cal work location, workers are able and expected
were idealized as homemakers. This gender and to communicate with colleagues, respond to cus-
role division also served to separate the role of tomers, or share information within their teams
worker and the role of family member. Some whether they are physically within the work envi-
research findings have reported that well-being ronment or not. The demands of the information
is high among those who report a high degree age can create a sense of disconnection from the
of distinction between their family and work relationships within one’s physical world, and a
demands. Other research affirms that satisfaction preoccupation with task monitoring that had pre-
is often high among individuals who endorse a viously been reserved only for those workers with
clear division between gender roles. The segrega- high-level positions (e.g., surgeon, financial ana-
tion model was challenged when greater numbers lyst, or plant manager). Today, even an entry-level
 Work–Family Balance 967

worker can be charged with being available underrepresented within their community, and
because of e-mail, social media, cloud computing, those without partners often report greater daily
and telephone capabilities. hassles and adverse life events, which cumula-
tively result in illness associated with long-term
Impact on Health and Well-Being stress, ranging from heart disease to depression.
Perhaps because of this integration between work Just as the Industrial Revolution altered the
and family life and the availability of the worker distinctions between work and family, changes
to the work environment, there has been greater in communities have also revealed work/life
interest in the effects on the worker and the work- tensions. As suburban development increased
place. Research investigating physical health out- throughout the United States, the average
comes of workers has shown that workers with length of time a worker spent traveling to work
greater work demands, less autonomy in execut- increased. With the proliferation of car owner-
ing those demands, and greater gender role adop- ship and the investment in highway development,
tion report more physical illness. Mental well- the length of the commute required to arrive at
being has also been demonstrated to be affected work also lengthened. Recent research has indi-
by stresses between work and family roles. Those cated that longer commutes, those greater than
with less social power appear to be dispropor- 20 minutes from the worker’s home, decrease sat-
tionately affected by the tension between fam- isfaction scores and also decrease the amount of
ily and work demands; the poor, those who are community engagement reported by the worker.

Thursday evening rush-hour commuters head home from work on a New York City subway train, October 18, 2007. In the United
States, work/home commuter time has increased along with suburban development. Longer commutes negatively affect mental well-
being. Recent research has indicated that longer commutes (greater than 20 minutes from the worker’s home) decrease a worker’s
satisfaction scores as well as community engagement. Increased commute times also compromise family relationships.
968 World Health Organization

Longer commutes contribute deleteriously to Further Readings

well-being. More time in a car often leaves less Ford, M. T., B. A. Heinen, and K. L. Langkamer.
time for physical activity. Physical activity is “Work and Family Satisfaction and Conflict:
known to assist in regulating the stress hormones A Meta-Analysis of Cross-Domain Relations.”
associated with cardiovascular functioning and Journal of Applied Psychology, v.92/1 (2007).
mental health. Also, the time spent commuting Hobson, C. J., L. Delunas, and D. Kesic. “Compelling
detracts from time spent cultivating personal Evidence of the Need for Corporate Work/Life
interests or relationships. Balance Initiatives: Results From a National Survey
of Stressful Life-Event.” Journal of Employment
Workplace Response Counseling, v.38/1 (2001).
Workplaces have sought to respond to such find- Kalliath, Thomas and Paula Brough. “Work-
ings to improve the well-being of their workplace Life Balance: A Review of the Meaning of the
environment and to retain workers, decrease Balance Construct.” Journal of Management &
health care costs, and improve the image of their Organization, v.14 (2008).
company to the public and potential workers. As
more women entered the workforce and as more
men adopted active roles in parenting, workplaces
added on-site day care, child care subsidy, lacta-
tion rooms, and even elder care services to sup- World Health
port the role demands faced by employees within
their family life. Newer workers report access to Organization
social media, a digital space they use to connect
and interact with peers and family members, as an The World Health Organization (WHO) has been
important factor in their selection of employers. a leader in bringing attention to the global men-
Flexible work arrangements, including job shar- tal health crisis and the urgent mental health care
ing, telecommuting, split shifts, and compressed needs of persons living in all corners of the world.
work weeks are useful in retaining workers who The WHO position on mental health is based on
also have family demands. its widely recognized definition of health that has
While the arrangements between work and been in place since its adoption in 1948: “Health
family life have looked different over the past 100 is a state of complete physical, mental, and social
years, there has been a consistent set of ingredi- well-being and not merely the absence of disease
ents that seem to promote worker satisfaction or infirmity.” The WHO framing of the meaning
and family well-being. Workers who feel engaged of health was revolutionary because it established
in their tasks, supported by managers, experience the relationship of health to mental well-being
a sense of autonomy in how they execute their and the overall health and well-being of the whole
responsibilities, and have flexibility when family person as situated in a cultural social ecology.
demands increase will report greater satisfaction The WHO’s stance embeds health and mental
in their work and less stress when demands in health in public health, prevention, and the social
either sphere increase. These findings suggest that determinants of health. Social structural factors
there are ways to structure many work environ- such as income, housing, neighborhood, educa-
ments to contribute to well-being and that doing tion, violence, armed conflict, resources, and
so will result in fewer physical and mental health equitable access to adequate resources influence
problems. population health and health outcomes, includ-
ing mental well-being. Integrating public heath
Loretta L. C. Brady strategies for improving mental health and well-
Saint Anselm College being at all levels of society calls for promotion of
policy development, drug availability, education
See Also: Business and Workplace Issues; Children; and training, and implementation. Even in light
Family Support; Gender; Role Strains; Stress; of limited knowledge about the etiology of mental
Unemployment; Women. health disorders and the adequacy of treatment
 World Health Organization 969

interventions, there is some evidence to support least restrictive type of mental health care, (5)
the effectiveness of mental health treatments in self-determination, and (6) the right to be assisted
developing countries for such disorders as depres- in the exercise of self-determination.
sion and schizophrenia. More research on scaling A snapshot of the most recent data on global
up such treatments and interventions is necessary mental health burden demonstrates that public
for all types of mental disorders. health goals for the attainment of mental well-
This approach is also rooted in the recognition being remain aspirational in many countries. Over
of the right to mental health as a human right, 450 million people worldwide are reported to have
just as the right to health has been affirmed as a mental disorders. This number may even be higher
fundamental human right in the United Nations if people with disabilities are included. In terms of
Universal Declaration of Human Rights. It is now disease burden in low- and middle-income coun-
well understood that mental health is integral tries, it is estimated that mental health conditions
to health. The normative content of the right to account for between roughly 9 and 17 percent of
health includes the right to a system of mental the total disease burden related to health.
health protection to enjoy the highest attainable WHO’s response to the global mental health
level of mental well-being. crisis has been to work with governments and
societies to strengthen mental health systems. In
Public Information the WHO “Mental Health Atlas of 2011” report,
In providing information to the public about men- WHO reports on the status of mental health in
tal health, WHO explains in its announcements many countries. According to WHO, this is the
and disseminations of information to the pub- most comprehensive mapping of global mental
lic that mental health describes a wide range of health resources for the three purposes identified
human activities that fall under the mental well- in the report: to prevent and treat mental disor-
being domain in the WHO definition of health. ders, provide rehabilitation, and protect human
More specifically, it identifies three public health rights. This 2011 edition, which is an update to
goals for mental health: promotion of mental the 2005 report, includes more quantitative mea-
well-being, prevention of mental disorders, and sures that are consistent with those in the WHO
treatment and rehabilitation of people suffer- Assessment Instrument for Mental Health Sys-
ing from mental disorders. In 1996, the WHO tems (WHO-AIMS). This tool was developed for
issued a statement identifying 10 basic principles the purpose of conducting an in-depth assessment
of mental health care law that help to clarify the of a country’s mental health system.
right to mental health and attainment of the high- The evidence presented in the 2011 report makes
est standards of mental well-being. clear that there are both insufficient resources to
While this document was not a formal publica- prevent and treat mental health disorders and sig-
tion of WHO, it does provide reference bench- nificant inequities in access to resources across the
marks in the fields of global mental health, mental world. For example, WHO reports that between
health care, and human rights as well as impor- 76 and 85 percent of people with severe mental
tant annotations regarding implementation. The disorders in low- and middle-income countries
document does include a statement of aims that are receiving no treatment for their disorders. The
makes explicit that development was intended to situation is still far below acceptable ranges for
describe basic legal principles that were generally high-income countries, where numbers remain
not influenced by culture or were culture-bound. high in the 35 to 50 percent range.
Enumeration of certain of these aims helps to lay Other differences that are correlated to income
a foundation for understanding the work that are sharper, including global spending on mental
WHO has carried out in the period following health, which is reported to be less than $2 per per-
their development. They include (1) promotion of son per year and less than 25 cents in low-income
mental health and prevention of mental disorders, countries. While 60 percent of reporting member
(2) access to basic mental health care, (3) mental states had a mental health policy (98 percent of
health assessments in accordance with interna- world population), high-income countries allo-
tionally accepted principles, (4) provision of the cate higher levels of human resources to mental
970 World Health Organization

health. In practical terms, for example, this trans- Further Readings

lates into nearly 50 percent of the world’s popula- Cohen, A. The Effectiveness of Mental Health Services
tion living in a country that is reported to have an in Primary Care: The View From the Developing
average of one psychiatrist available per 200,000 World. Geneva: World Health Organization, 2001.
people. Facilities are scarcer in low-income coun- Hosman, C., E. Jane-Llopis, and S. Saxena, eds.
tries, particularly outpatient mental health facili- Prevention of Mental Disorders: Effective
ties, which are reportedly 58 times more preva- Interventions and Policy Options. Oxford: Oxford
lent in high-income countries than in low-income University Press, 2005.
countries. Perhaps the most shocking pattern Mann, Jonathan, et al. “Health and Human Rights.”
uncovered by the report is in the area of mental In Health and Human Rights: A Reader, Jonathan
health legislation, which covers only 36 percent Mann, et al., eds. New York: Routledge, 1999.
of people in low-income countries as opposed to Patel, V., et al. “Treatment and Prevention of Mental
92 percent in high-income countries. Disorders in Low-Income and Middle-Income
Countries.” The Lancet, v.370/9591 (September
Conclusion 2007).
Significant barriers to effective mental health Patel, V., A. Kleinman, and B. Saraceno. “Beyond
care persist worldwide. In developing an agenda Evidence: The Moral Case for International Mental
for action, WHO identifies investment in public Health.” American Journal of Psychiatry, v.163
health; more effective delivery of mental health (2006).
care, especially within primary care; allocation Sen, Amartya. “Why and How Is Health a Human
of adequate human resources for mental health; Right?” The Lancet, v.372 (2008).
and development of public mental health leader- World Health Organization (WHO). “Mental Health
ship as the priority concerns on the world stage Atlas 2011.” Geneva: WHO, 2011.
if the global mental health crisis is to be urgently World Health Organization (WHO). “mhGAP
addressed. These broad humanistic concerns are Intervention Guide for Mental, Neurological, and
of a seriousness and magnitude that demand Substance Abuse Disorders in Non-Specialized
the attention of all peoples and persons who are Health Settings.” Geneva: WHO, 2010.
attuned to the welfare of human beings. World Health Organization (WHO). “WHO
Definition of Health.” (1948). http://www.who.int/
Mary Beth Morrissey about/definition/en/print.html (Accessed June 2013).
Fordham Graduate School of Social Service World Health Organization (WHO). “World Health
Organization Assessment Instrument for Mental
See Also: Disability; Epidemiology; Global Mental Health Systems: WHO-AIMS Version 2.2.”
Health Movement; Globalization; Human Rights; Geneva: WHO, 2005.
Inequality; International Comparisons; Legislation; World Health Organization (WHO). “The World
Life Expectancy Trends; Mortality; Public Education Health Report 2001: Mental Health: New
Campaigns; Racial Categorization; Vulnerability. Understanding, New Hope.” Geneva: WHO, 2001.
 Glossary

Access to care: The ability of someone who needs or “mass psychogenic illnesses,” in which individ-
medical, psychiatric, or psychological treatment uals complain of physical symptoms and/or dis-
to receive that treatment. Access includes both the play behaviors associated with physical illnesses
ability to get to treatment (a particular problem but without an identifiable physical cause.
for people living in rural areas) and the ability to
pay for the services or have someone else, such as Addiction: Physical or psychological dependence
an insurance company, pay for them. Access to on a chemical substance (such as alcohol, tobacco,
care for mental health services has been a much- heroin) or activity (such as gambling, sex) so that
contested issue in the United States, as some insur- the person feels a compulsion or craving to repeat
ance plans provide less coverage for mental health the activity or access the substance and may suffer
services than for medical services. withdrawal symptoms if it is not available.

Acculturation: The process of becoming familiar ADHD: Attention deficit/hyperactivity disorder, a

with a new culture or environment and becom- disorder characterized by impulsivity, inattention,
ing able to function effectively in it. Acculturation and hyperactivity. ADHD is one of the more com-
is often discussed in relation to people emigrat- monly diagnosed disorders in school-age children,
ing from one country to another or to people in perhaps because it impairs their ability to func-
a minority culture within a country (for instance, tion in a typical classroom. Diagnosis of ADHD
Mexican Americans in the United States). has greatly increased in some countries (including
the United States) in recent years, and the disease
ACT: Assertive community treatment, an inte- itself, as well as methods to treat it, is a frequent
grated approach to community mental health source of controversy.
care, including treatment, rehabilitation, and
continuing support. ACT is typically provided by Adjustment disorders: Emotional and/or behav-
a multidisciplinary team of professionals and is ioral symptoms that are triggered by an identi-
particularly recommended for individuals with fiable stressor (such as the end of a marriage),
persistent, severe mental illness. are clinically significant, and arise within three
months after the stressor occurs. The American
Acute somatoform illnesses: The technical name Psychological Association’s definition of adjust-
for what are sometimes called “hysterical illnesses” ment disorders includes several different ways an

971
972 Glossary

adjustment disorder may be identified, including Anorexia nervosa: An eating disorder character-
anxiety, depressed mood, and disturbed emotions ized by disordered body image (the belief that one
or conduct. is fat when one is in fact quite thin) and severely
restricted food consumption.
Adult day care centers: A service offered in some
countries, often through nonprofit agencies or Antabuse: The proprietary name for disulfiram, a
nursing homes, that allows dementia patients to drug used to treat alcoholics by creating an aver-
eat and participate in daily activities at a care cen- sion to alcohol. Because Antabuse interferes with
ter, then return home to sleep. the body’s ability to metabolize alcohol, when a
person taking Antabuse consumes alcohol, they
Affective disorders: See Mood disorders. suffer unpleasant symptoms such as vomiting,
headache, and breathing difficulties.
Ageism: Discrimination by someone on the basis
of age; the term is most commonly applied to dis- Antipsychiatry movement: A movement led by
crimination against older people. Although age American psychiatrist Thomas Szasz that pos-
discrimination in employment is against the law ited that mental illness was a “myth,” that is,
in the United States and some other countries, not descriptions of real illnesses but rather labels
many believe it still takes place because it is diffi- applied to deviant, disapproved behaviors.
cult to prove age discrimination in a court of law.
Antisocial personality disorder: A disorder char-
Agoraphobia: The fear of being in open, public acterized by a refusal or inability to acknowledge
places. Agoraphobia is often linked with panic dis- the rights and feelings of others and behave in a
order, in which a person may experience attacks socially acceptable manner. While some people
of overwhelming anxiety. The inability to control with antisocial personality disorder engage in
these attacks may contribute to an agoraphobic’s criminal behavior, certain characteristics of the
fear of being in a public place. disorder may also promote success in business,
finance, or other fields.
Alcoholism: A condition characterized by alco-
hol consumption at a level such that it causes Anxiety disorders: Disorders characterized by
problems for the individual. The designation an unusual degree of tension or apprehensive-
of alcoholism as a mental disorder or disease is ness in response to a perceived danger. Anxiety
controversial because some consider alcohol con- disorders are one of the more common mental
sumption a voluntary behavior, and the definition illnesses; according to the American Psychiatric
of when the consumption of alcohol becomes a Association, approximately 20 million Americans
problem depends in part on social and cultural are affected by anxiety disorders. These disorders
factors. include phobias, post-traumatic stress disorder
(PTSD), and panic disorder.
Amok: A culturally specific behavior observed in
some Asian and south Pacific countries, including Asperger’s syndrome: An autism spectrum disor-
Polynesia, Papua New Guinea, the Philippines, der characterized by difficulties in social interac-
Malaysia, and Laos. Episodes of amok are char- tion and intense interest in a small set of activities.
acterized by aggressive behavior and dissociation, Individuals with Asperger’s syndrome do not usu-
and these episodes are more common in men than ally have language or cognitive delays, and some
women. argue that with appropriate educational and
social support, they have particular aptitude for
Anhedonia: The inability to feel enjoyment or the some professions (such as engineering and com-
diminished ability to feel enjoyment. Anhedonia puter programming).
has been identified in people suffering from sev-
eral types of mental illness, including depression, Barbiturates: Drugs that depress the central ner-
schizophrenia, and neurosis. vous system and may be used to treat anxiety and
 Glossary 973

insomnia. Today, barbiturates are used less to law enforcement officers trained in de-escalation
treat these conditions because they are toxic and techniques respond to mental disturbance calls
addictive and can worsen insomnia if used over a such as suicide attempts. CIT has been successfully
period of time. replicated in other U.S. cities, including Durham,
North Carolina; Albuquerque, New Mexico;
Blood-brain barrier: A physiological barrier that Seattle, Washington; and San Jose, California.
prevents chemicals formed of large molecules from
passing from the bloodstream into the brain. This Club drugs: A number of drugs whose use is asso-
mechanism protects the brain from substances ciated with young people, night clubs, and dance
that might harm it but also poses a barrier to diag- parties, although they may also have legitimate
nosis, as it makes it difficult to create blood tests medical uses. Examples of club drugs include
to identify many specific mental disorders. MDMA (Ecstasy), ketamine, GHB, and flunitraz-
epan (Rohypnol).
Body image: Beliefs a person holds about his or
her appearance and body, which may or may not Community mental health: The practice of pro-
correspond to reality. For instance, people with viding mental health services within a commu-
eating disorders may believe themselves to be fat nity setting, with patients living independently
while in reality they are abnormally thin. or in supported circumstances (such as halfway
houses) and receiving treatment on an outpa-
Brain imaging: Computer techniques to visualize tient basis rather than being confined to a mental
images of the brain without performing surgery. hospital.
Examples of brain imaging techniques include
magnetic resonance imaging (MRI), computer- Co-occurring disorders: Also known as dual diag-
ized axial tomography (CAT), and positron emis- nosis disorders or comorbidities, two or more dis-
sion tomography (PET). orders occurring simultaneously in a patient. The
term is most often applied to the co-occurrence of
Brainwashing: A set of psychological techniques mental health and substance abuse disorders but
used to control or indoctrinate individuals so that can apply to any co-occurring disorders.
they seem to have no ability to think for them-
selves. Brainwashing first came to worldwide Conduct disorder: A personality disorder charac-
attention during the Korean War but has also terized by behaviors such as truancy, vandalism,
been cited in the methods used by religious or and substance abuse, most commonly diagnosed
other cults to indoctrinate their followers. in children and adolescents.

Bulimia nervosa: An eating disorder character- Decompensation: In psychology, the return to a

ized by a distorted body image and a pattern of lower level of functioning and adaptation, often
bingeing (eating large quantities of food in a short when an individual is placed under severe stress.
amount of time) followed by purging (vomiting or
using laxatives) so that the food does not remain Deinstitutionalization: The process of moving
in the body long enough to cause weight gain. mental patients out of large state mental hospi-
tals, presumably into less restrictive care provided
Case management: Coordination of care and in a community setting, and the consequent clos-
services for mental and/or physical care. A case ing of many state mental hospitals.
manager is often placed in charge of coordinating
services for an individual, which are provided by Depression: A mood disorder characterized by
a number of specialists such as physicians, coun- feelings such as sadness, hopelessness, lethargy,
selors, and social workers. and helplessness. Although depression can occur
with anyone and at any age, it is more common
CIT: Crisis Intervention Team, an approach devel- in women than in men and is also associated with
oped in Memphis, Tennessee, in which a team of particular age groups (for men, major depressive
974 Glossary

episodes peak between the ages of 50 and 75, ECT: Electroconvulsive therapy, a treatment
while for women, they peak between the ages of for depression involving passing a low-voltage
20 to 45). current through a person’s brain while they are
sedated. ECT is also known as electroshock ther-
Deviant behavior: Behavior that violates role apy and was introduced into psychiatric treat-
expectations and other norms of a particular ment in 1938.
society, in particular if such behaviors are disap-
proved of by the society. Deviant behavior can EMDR: Eye-movement desensitization and repro-
include anything from criminal behavior (such cessing, a therapeutic technique developed in the
as committing murder) to violations of cultural 1990s to treat post-traumatic stress disorder,
expectations (such as refusing to get married to a eating disorders, and other conditions. EMDR
member of the opposite sex). involves the patient moving their eyes in response
to movement of a light manipulated by the thera-
Dissociative disorders: Disorders characterized by pist and may also involve tapping on the hands
the disruption of identity, consciousness, memory, or face.
and perception. There are several types of disso-
ciative disorders, including dissociative fugue, Epidemiologic Catchment Area (ECA) Survey of
in which a person suddenly leaves familiar sur- Mental Disorders: A series of surveys initiated in
roundings and is confused about their identity or the United States in 1977 as part of a program to
takes on a new identity; depersonalization disor- collect research data on the prevalence of mental
der, in which a person feels detached from their disorders and the need for mental health services.
body or mental processes; and dissociative amne- The first ECA survey was conducted from 1980 to
sia, in which a person is unable to recall personal 1985 and at the time was the largest survey relat-
information. ing to mental health conducted in the country.

Diversion program: A law enforcement program Epidemiology: The study of disease occurrence
that allows some individuals to avoid criminal jus- in populations (descriptive epidemiology), the
tice penalties if they agree to treatment. Diversion correlates of the occurrence of disease (analytic
programs are often used in the United States to epidemiology), and the results of interventions
offer options to minor drug offenders and the intended to change population health (experi-
mentally ill. mental epidemiology).

Down syndrome: A type of mental retardation in Family therapy: Psychotherapy focused on the
which an individual is born with an extra copy family as a unit rather than on members of the
of the 21st chromosome (Trisomy 21). People family as individuals. Family therapy is particu-
with Down syndrome have a distinctive physi- larly popular when dealing with the psychologi-
cal appearance and often suffer from physical cal issues of children and adolescents because the
difficulties such as heart defects, cataracts, and family provides much of the context for their lives.
digestive problems. Prenatal screening tests can
indicate the probability of a baby being born First-generation antipsychotic: Also known as
with Down syndrome, and diagnostic tests such typical antipsychotics or traditional antipsychot-
as amniocentesis can be used to follow up if the ics, a number of drugs developed in the 1950s to
screening test indicates a high probability of treat schizophrenia and other psychotic disorders;
Down syndrome. examples include haloperidol and chlorproma-
zine. Because first-generation antipsychotics often
DTs: Delirium tremens, symptoms often seen in produce serious side effects, they have largely
severe alcoholics or after withdrawal from alco- been replaced by less dangerous drugs.
hol. Symptoms of the DTs include rapid pulse,
excessive perspiration, high temperature, delu- Gender identity disorder: A disorder in which an
sions, and hallucinations. individual’s anatomical gender is inconsistent with
 Glossary 975

their psychological gender identification. According MMPI: The Minnesota Multiphasic Personality
to the American Psychiatric Association, a diagno- Inventory, a commonly used self-rating assess-
sis of gender identity disorder must include strong ment of personality. Originally developed in
and persistent cross-gender identification, persis- 1942, the MMPI is used in psychiatric settings
tent discomfort with one’s anatomical gender, and but also for other purposes, including screen-
impairment in social or other important areas of ing individuals for high-risk employment and in
functioning. counseling.

Iatrogenic disorder: A disorder caused by medi- MMSE: The Mini-Mental State Examination,
cal care or treatment. In psychiatry, the term a brief method of evaluating a person’s cogni-
often refers to psychiatric symptoms caused by an tive functioning. The MMSE is often used with
unexpected reaction to medication prescribed for elderly patients to assess their orientation, recall,
another purpose. language, and ability to follow commands based
on simple questions such as, “What is the day of
Inhalant abuse: The use of inhalable chemi- the week?” and tasks such as counting backward
cal vapors, such as solvents or aerosols, to pro- by fives.
duce intoxication. The intoxication effect occurs
because the inhalants starve the brain of oxygen Mood disorders: Disorders characterized by
and may produce hallucinations, slurred speech, a change in mood sufficient to require clinical
dizziness, and other symptoms. attention. Mood disorders are differentiated by
thought disorders such as schizophrenia because
Labeling theory: A theory explaining mental ill- mood disorders do not typically involve disor-
ness as a product of labeling. As some deviant dered thought processes but instead are character-
behavior is identified and labeled by others as an ized by extremes of sadness or elation. Examples
indication of mental illness, the deviant individual of mood disorders include bipolar disease (manic-
accepts the label as part of their identity and tends depressive disease), major depression, cyclothy-
to act in accordance with the label. mia, and dysthymia.

Learned helplessness: A term coined by Martin Munchausen syndrome: A disorder in which a

Seligman to describe a response adopted by some person complains of physical symptoms that do
individuals who feel they have no control over a not in fact exist or that are self-inflicted. Also
situation. These individuals, who typically have known as factitious disorder, Munchausen syn-
been hindered in their ability to initiate behavior, drome is generally attributed to a need for atten-
often lose motivation, become passive, and may tion and may result in a person receiving medical
become depressed. tests and even treatments that they do not need.

Lithium: An element used since the 1940s to treat Munchausen syndrome by proxy: Presenting a
manic and manic-depressive patients. Adoption child for medical treatment and describing symp-
of lithium as a treatment was slowed by the fact toms that have been induced by the caretaker
that it is a toxic substance and could produce side or do not exist. The motivation of Munchausen
effects, including death. However, the availability syndrome by proxy (MSbP) is believed to be the
of methods to monitor the blood levels of lithium desire of the adult to assume the sick role by
in patients, particularly since the 1970s, has facil- proxy. MSbP is considered child abuse because
itated its increased use to treat bipolar disorder. it can harm the child, either through the induced
symptoms or by causing the child to undergo
Medical model: A model for mental disorders unnecessary medical procedures.
based on the assumption that they have a chemi-
cal, genetic, or physiological basis like any physi- Neurodiverse: A term applied to people who are
cal disease and can be treated in a similar manner neurologically different from so-called neuro-
to physical diseases. typicals or normal. Examples of conditions that
976 Glossary

might qualify someone as neurodiverse (the term Psychoanalysis: A method of treating mental ill-
is contested) include Asperger’s syndrome, atten- ness developed by Sigmund Freud and practiced
tion deficit hyperactivity disorder (ADHD), and by individuals who have undergone specialized
dyslexia. training. Psychoanalysis is a talk-based therapy
intended to increase self-understanding, and psy-
OCD: Obsessive-compulsive disorder, an anxi- choanalysts use techniques such as free associa-
ety disorder characterized by repeated, intrusive tion and dream analysis in their work.
thoughts and compulsive, ritualized behavior
such as repeatedly washing one’s hands. OCD PTSD: Post-traumatic stress disorder, an anxiety
may make it impossible for an individual to live disorder caused by a stressful event such as mili-
a normal life because so much time and energy tary combat or physical assault. PTSD may also
must be devoted to their rituals. be caused by witnessing a stressful event such as
a crime. Symptoms of PTSD, which may occur
Opioids: Substances derived from the opium long after the precipitating event, include re-expe-
poppy, or synthetic derivatives or completely syn- riencing the trauma, insomnia, emotional numb-
thesized substances that deliver similar effects. ness, and avoidance of activities associated with
Natural opioids include morphine and codeine, the trauma.
synthetic derivatives include heroin and oxyco-
done, and completely synthetic opioids include Refrigerator mother: A term popularized in the
meperidine (Demerone), methadone, and dextro- 1950s by Bruno Bettelheim to characterize moth-
propoxyphene hydrochloride (Darvon). ers of autistic children. The implication was that
the mothers acted in a “frigid” manner toward
Phobia: A type of anxiety disorder characterized their children and thus were responsible for the
by an intense, persistent, and unrealistic fear of children’s disorders; this term has been largely
something. Many types of phobias have been iden- discarded.
tified, from phobias triggered by specific objects
(such as dogs and spiders) or situations (such as Respite care: Short-term care provided to some-
flying) to more generalized phobias such as social one with a serious mental disorder or an elderly
phobia and agoraphobia. A person with a pho- person in order to allow the usual caretakers
bia may try to avoid the object or situation that (often relatives of the person requiring care) to
triggers it and may suffer a panic attack or other take a break from providing the care. Respite care
anxiety responses if exposed to it. is considered an important factor in relieving the
stress of taking care of a difficult or demanding
Pibloktoq: A culture-related syndrome seen pri- individual and preventing burnout of caretakers.
marily in arctic and subarctic Inuit communities.
Pibloktoq is characterized by an abrupt and brief Ritalin: Methylphenidate hydrochloride, a stim-
dissociative episode followed by convulsions or a ulant used to treat some children with atten-
coma. During the dissociative episode, the indi- tion deficit hyperactivity disorder (ADHD) and
vidual may tear their clothing, destroy property, increase their ability to perform well in school.
or perform other violent acts but will have no The use of Ritalin and other stimulants for this
memory of these behaviors after the attack. purpose is controversial and has been banned in
some countries.
Postpartum depression: Depression in a woman
following the birth of her child. Many factors are Role occupancy theory of depression: A theory
thought to contribute to postpartum depression, suggested by Walter Gove and others, beginning
including hormonal changes following pregnancy, in the 1970s, explaining the fact that women suf-
sleep deprivation caused by the need to attend to fer more from depression than men as a product
the baby, fear of the responsibilities of mother- of the relatively small number of roles available to
hood, and confusion from the changes in routine adult women in Western society and the resulting
and loss of status based on employment. stress caused by the lack of fit to one’s role.
 Glossary 977

SAD: Seasonal affective disorder, a mood disor- means such as cutting or burning one’s skin, pull-
der believed to be triggered by less exposure to ing one’s hair out, or ingesting toxic substances.
sunlight during certain seasons of the year, such
as winter in the Northern Hemisphere. It may be SES: Socioeconomic status, a method of iden-
relieved by using a lamp that creates bright light tifying a person’s social position on the basis of
similar to the sun’s rays. factors such as income, type of occupation, and
educational level. Many studies have found rela-
Sandwich generation: A term used to describe tionships between SES and mental health, with the
adults who find themselves caring for children typical finding that persons in lower SES catego-
or grandchildren while at the same time caring ries are more likely to suffer from mental illness.
for aging parents. The term was popularized in
the 2000s, as it was noted that many who found Sick role: A concept developed by the American
themselves in this situation suffered many anxi- sociologist Talcott Parsons, which defines the
eties and role confusions due to the conflicting obligations (trying to get well, seeking competent
demands placed on them. medical help, and following medical advice) and
the rights (exemption from blame for sickness,
Schizophrenia: A group of chronic mental disor- exemption from normal social roles) of a sick
ders characterized by distortions of thought, per- person.
ception, and speech. Schizophrenia can manifest
itself in many ways, including fears of persecution Social causation hypothesis: A hypothesis explain-
(paranoid schizophrenia), hallucinations, distur- ing the relationship between socioeconomic sta-
bances in affect, and withdrawal from reality. tus (SES) and mental illness as being due to the
greater stress, vulnerability to threats, and lack
Second-generation antipsychotics: Also known as of resources common among people in lower SES
atypical antipsychotics, this group includes drugs categories as compared to those in higher SES
such as dibenzoxazepine (Clozapine), benzisox- categories.
azole (Risperidone), and thienbenzodiazepine
(Olanzapine) that are more effective and have SSRI: Selective serotonin reuptake inhibitors,
fewer side effects than first-generation antipsy- a class of drugs used since the 1980s to treat
chotic drugs. depression. Examples of SSRIs include fluoxetine
(Prozac), citalopram (Celexa), sertraline (Zoloft),
Selection/drift hypothesis: A hypothesis explain- and paroxetine (Paxil).
ing the relationship between socioeconomic sta-
tus and mental illness by suggesting that mental Substance abuse: Use of a drug, alcohol, or other
illness causes people to occupy lower rungs on substance to the point that it causes difficulties for
the socioeconomic ladder, as they are less able to a person. Substance abuse is at least partially cul-
compete for good jobs or finish their education turally defined because the same substance may
because of their illness. be outlawed, and thus problematic for that rea-
son alone, in one country and yet may be used
Self-efficacy: A term popularized in the 1970s freely in another country. In addition, different
by the Canadian American psychologist Albert cultures place different values on states such as
Bandura, referring to beliefs or expectations an intoxication, and what is accepted in one culture
individual may hold about their ability to perform may be considered problematic in another.
some task or behavior. Bandura believed that one
goal of counseling should be to increase an individ- Systematic desensitization: A method used to
ual’s self-efficacy in targeted areas through vicari- treat phobias by training an individual in relax-
ous learning and experience with the behavior. ation techniques and then gradually introduc-
ing stimuli related to the phobia, or having the
Self-injury: Deliberately causing harm to oneself, person imagine the situation that triggers the
but without the intention to commit suicide, by phobia.
978 Glossary

Tardive dyskinesia: A disorder characterized by World Health Organization intended to increase

delayed onset of involuntary and repetitive body services for people suffering from mental, neuro-
movements. Tardive dyskinesia is a known side logical, and substance use disorders, with particu-
effect of first-generation antipsychotic drugs. lar emphasis on low- and middle-income countries.

Valium: The brand name for diazepam, a ben- World Mental Health Day: A day each year
zodiazepine drug that is used to treat conditions (October 10) designated by the World Health
such as anxiety disorders, muscle spasms, and Organization to raise global awareness of mental
withdrawal from alcohol. health issues.

World Health Organization Mental Health Gap Sarah Boslaugh

Action Program (mhGAP): A program by the Kennesaw State University
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 Appendix

Federal Reports on Mental Illness

Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report:
Mental Illness Surveillance Among Adults in the United States...................................................... 987
National Center for Health Statistics, Data Brief: Antidepressant Use in Persons
Aged 12 and Over, United States, 2005 to 2008........................................................................... 1019
Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report:
Attitudes Toward Mental Illness—35 States, District of Columbia, and Puerto Rico, 2007.......... 1029
 Appendix 987

Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report
September 2, 2011

Mental Illness Surveillance Among Adults

in the United States
988 Appendix

The MMWR series of publications is published by the Office of Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention (CDC),
U.S. Department of Health and Human Services, Atlanta, GA 30333.
Suggested citation: Centers for Disease Control and Prevention. [Article title]. MMWR 2011;60(Suppl):[inclusive page numbers].
Centers for Disease Control and Prevention
Thomas R. Frieden, MD, MPH, Director
Harold W. Jaffe, MD, MA, Associate Director for Science
James W. Stephens, PhD, Director, Office of Science Quality
Stephen B. Thacker, MD, MSc, Deputy Director for Surveillance, Epidemiology, and Laboratory Services
Stephanie Zaza, MD, MPH, Director, Epidemiology and Analysis Program Office
MMWR Editorial and Production Staff
Ronald L. Moolenaar, MD, MPH, Editor, MMWR Series Martha F. Boyd, Lead Visual Information Specialist
Christine G. Casey, MD, Deputy Editor, MMWR Series Julia C. Martinroe, Stephen R. Spriggs, Terraye M. Starr
Frederic E. Shaw, MD, JD, Guest Editor Teresa Visual Information Specialists
F. Rutledge, Managing Editor, MMWR Series David C. Quang M. Doan, MBA, Phyllis H. King
Johnson, Lead Technical Writer-Editor Catherine B. Lansd- Information Technology Specialists
owne, MS, Project Editor

MMWR Editorial Board

William L. Roper, MD, MPH, Chapel Hill, NC, Chairman
Virginia A. Caine, MD, Indianapolis, IN Patricia Quinlisk, MD, MPH, Des Moines, IA
Jonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA Patrick L. Remington, MD, MPH, Madison, WI
David W. Fleming, MD, Seattle, WA Barbara K. Rimer, DrPH, Chapel Hill, NC
William E. Halperin, MD, DrPH, MPH, Newark, NJ John V. Rullan, MD, MPH, San Juan, PR
King K. Holmes, MD, PhD, Seattle, WA William Schaffner, MD, Nashville, TN
Deborah Holtzman, PhD, Atlanta, GA Anne Schuchat, MD, Atlanta, GA
John K. Iglehart, Bethesda, MD Dixie E. Snider, MD, MPH, Atlanta, GA
Dennis G. Maki, MD, Madison, WI John W. Ward, MD, Atlanta, GA
 Appendix 989

Supplement

Mental Illness Surveillance Among Adults in the United States

William C. Reeves, MD1
Tara W. Strine, PhD1
Laura A. Pratt, PhD2
William Thompson, PhD3
Indu Ahluwalia, PhD3
Satvinder S. Dhingra, MPH4
Lela R. McKnight-Eily, PhD3
Leslie Harrison, MPH 3
Denise V. D’Angelo, MPH3
Letitia Williams, MPH3
Brian Morrow, MA3
Deborah Gould, PhD1
Marc A. Safran, MD5
1Public Health Surveillance Program Office
2National Center for Health Statistics
3National Center for Chronic Disease Prevention and Health Promotion
4Northrop Grumman
5 National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Summary

Mental illnesses account for a larger proportion of disability in developed countries than any other group of illnesses, including
cancer and heart disease. In 2004, an estimated 25% of adults in the United States reported having a mental illness in the previ-
ous year. The economic cost of mental illness in the United States is substantial, approximately $300 billion in 2002. Population
surveys and surveys of health-care use measure the occurrence of mental illness, associated risk behaviors (e.g., alcohol and drug
abuse) and chronic conditions, and use of mental health–related care and clinical services. Population-based surveys and surveil-
lance systems provide much of the evidence needed to guide effective mental health promotion, mental illness prevention, and
treatment programs.
This report summarizes data from selected CDC surveillance systems that measure the prevalence and impact of mental ill-
ness in the U.S. adult population. CDC surveillance systems provide several types of mental health information: estimates of the
prevalence of diagnosed mental illness from self-report or recorded diagnosis, estimates of the prevalence of symptoms associated with
mental illness, and estimates of the impact of mental illness on health and well-being. Data from the CDC 2005–2008 National
Health and Nutrition Examination Survey indicate that 6.8% of adults had moderate to severe depression in the 2 weeks before
completing the survey. State-specific data from the CDC 2006 Behavioral Risk Factor Surveillance System (BRFSS), the most
recent BRFSS data available, indicate that the prevalence of moderate to severe depression was generally higher in southeastern
states compared with other states. Two other CDC surveys on ambulatory care services, the National Ambulatory Medical Care
Survey and the National Hospital Ambulatory Medical Care Survey, indicate that during 2007–2008, approximately 5% of
ambulatory care visits involved patients with a diagnosis of a mental health disorder, and most of these were classified as depres-
sion, psychoses, or anxiety disorders.
Future surveillance should pay particular attention to changes in the prevalence of depression both nationwide and at the state
and county levels. In addition, national and state-level mental illness surveillance should measure a wider range of psychiatric
conditions and should include anxiety disorders. Many mental illnesses can be managed successfully, and increasing access to and
use of mental health treatment services could substantially reduce the associated morbidity.

Corresponding author: William C. Reeves, MD, Public Health

Surveillance Program Office, CDC, 1600 Clifton Rd., N.E., MS E-97,
Atlanta, GA 30333. Telephone: 404-498-6521; Fax: 404-498-1177;
E-mail: [email protected].

MMWR / September 2, 2011 / Vol. 60 1

990 Appendix
Supplement

Introduction Background
Mental illness refers collectively to all diagnosable mental
disorders and is characterized by sustained, abnormal altera-
Role of Surveillance in Reducing
tions in thinking, mood, or behavior associated with distress Morbidity and Mortality Associated with
and impaired functioning (1). Mental illness is an important Mental Illness
public health problem, both in its own right and because the Public health surveillance is the ongoing and systematic col-
condition is associated with other chronic diseases and their lection, analysis, interpretation, and dissemination of data used
resulting morbidity and mortality. According to the World to develop public health interventions that reduce morbidity
Health Organization (WHO), mental illnesses account for and mortality and improve health (24). Surveillance for a
more disability in developed countries than any other group of particular condition might depend either on collection of new
illnesses, including cancer and heart disease (2). Approximately data or use of data obtained from existing health information
one fourth of adults in the United States have a mental illness, systems (e.g., from vital statistics or public health surveys).
and nearly half will develop at least one mental illness during Surveillance data have numerous uses in public health: 1)
their lifetime (3–5). The most common mental illnesses in determination of the distribution and spread of disease, 2)
adults are anxiety and mood disorders (4). The effects of mental estimation of the impact of a disease or injury, 3) generation
illness range from minor disruptions in daily functioning to of hypotheses and stimulation of research, 4) development of
incapacitating personal, social, and occupational impairments public health interventions, 5) description of the history of a
and premature death (6–9). In 2002 and 2003, mental illness health condition and the impact of treatments on outcomes, 6)
cost the United States an estimated $300 billion annually, evaluation of prevention and control measures, and 7) facilita-
which included approximately $193 billion from lost earnings tion of program planning (25). Because a single surveillance
and wages and $24 billion in disability benefits in 2002 (10) system typically cannot accomplish all of these tasks, use of
and $100 billion in health-care expenditures in 2003 (11). multiple surveillance systems often provides a more complete
Mental illness exacerbates morbidity from the multiple assessment of a particular disease or condition.
chronic diseases with which it is associated, including car- Surveillance data are essential to the public health goals of
diovascular disease, diabetes, obesity, asthma, epilepsy, and reducing the incidence, prevalence, severity, and economic
cancer (12–16). This increased morbidity is a result of lower impact of mental illnesses. Public health officials, academi-
use of medical care and treatment adherence for concurrent cians, health-care providers, and advocacy groups need accu-
chronic diseases and higher risk for adverse health outcomes rate and timely information on the prevalence and effects
(17–20). Rates for injuries, both intentional (e.g., homicide of mental illness to detect and characterize trends in mental
and suicide) and unintentional (e.g., motor vehicle), are 2–6 illness prevalence and severity (26); assess associations between
times higher among persons with a mental illness than in the mental illness and other chronic medical conditions (e.g., obe-
overall population (21,22). Mental illness also is associated sity, diabetes, heart disease, and alcohol and substance abuse);
with use of tobacco products and alcohol abuse (23). identify populations at high risk for mental illness and target
This report summarizes data from selected CDC surveil- interventions, treatment, and prevention measures; and provide
lance and information systems that measure mental illness and outcome measures for evaluating mental illness interventions.
the associated effects in the U.S. adult population. The data For example, officials have used metal illness surveillance data
presented include 1) the occurrence and associated effects of to track trends in mental illness and psychological distress
mental illness among adults in the United States as measured associated with exposure to military combat or large-scale
through selected CDC surveillance and information systems, disasters (27).
2) the CDC systems involved in the collection of mental ill-
ness data for adults and the associated public access databases,
and 3) estimates from other studies and surveys, particularly Diagnostic Classification of Mental Illness
those conducted by the Substance Abuse and Mental Health Population surveys can be used to estimate accurately the
Services Administration (SAMHSA), compared with CDC prevalence of certain mental illness symptoms across popula-
system estimates. tions, and by repeating surveys over time, they can be used to
detect and characterize trends. Surveys generally cannot be used
to diagnose mental disorders with the same level of specificity as
an individual clinical examination conducted by an experienced
psychiatrist or other mental health professional. Instead, they

2 MMWR / September 2, 2011 / Vol. 60

 Appendix 991
Supplement

collect information on a range of subjective manifestations of mental illness criteria. CIDI also is intended for use in epide-
alterations in thinking, mood, behavior, and associated distress miological, clinical, and research studies. CIDI is lengthy, like
that correspond with clinical disorders. Surveys collect this SCID, but may be administered by trained lay interviewers
information using participant questionnaires that have been (32). SCID and CIDI identify overlapping but not necessar-
validated empirically to distinguish between persons with ily identical populations because they are based on different
and without specific mental illnesses or general psychological classification systems.
distress. Estimates from these surveys vary according to the
symptoms being collected and the way they correspond with Screening Instruments
various defined mental illnesses. Survey estimates usually are Large surveys that focus on a wide range of health topics
based on carefully defined patterns of symptoms. The most typically can include only a limited number of mental health
commonly used patterns correspond with diagnostic criteria questions and often rely on SCID- or CIDI-validated screen-
agreed on by mental health professionals. ing instruments to provide indicators of psychiatric-related
The symptom patterns used for surveys vary according to symptoms; in some cases, statistical models are used to predict
the classification of mental illness under study; changes in the likelihood of specific mental illness in the respondent
these classifications over time have increased the complexity based on rating scales. Several standardized and validated
of matching symptom patterns to specific illnesses. New clas- screening instruments can be used to identify persons with
sifications have been identified, and certain classifications have mental illnesses such as depression and psychological distress,
been removed. Even for relatively stable diagnostic categories with varying degrees of diagnostic sensitivity and specificity
(e.g., depression), subcategories and terminology have varied (33–35). CDC surveys use these screening instruments, as well
over time. For example, terms used to describe depression have as other standardized questions, to assess mental illness and
included major and minor depression, psychotic depression, other measures, such as impaired quality of life (e.g., mentally
depression not otherwise specified, bipolar disorder, dysthy- unhealthy days) and health-related disability associated with
mia, moderate to severe depression, and mild depression. mental illness.
However, the relationship among the disorders described by
Depression (Patient Health Questionnaire-8 and
these different terms often is unclear. The American Psychiatric
Association (APA) developed mental illness diagnostic catego- Patient Health Questionnaire-9)
ries based on symptoms observed by a health professional or Depression is a major focus of population surveys of mental
reported by the patient; the Diagnostic and Statistical Manual of illness. To meet the DSM-IV-TR definition of major depressive
Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) disorder, a person must have either a depressed mood or a loss
is the current version of this system (28). Another system, the of interest or pleasure in daily activities consistently for at least
WHO International Classification of Diseases, 10th Revision, 2 weeks. This mood must represent a change from the person’s
Clinical Modification (ICD-10-CM), defines mental illness normal mood; social, occupational, educational, or other
categories that are similar but not identical to those in the important functioning also must be impaired by the change
DSM-IV-TR (29). Previous DSM and ICD versions have in mood. Under the DSM-IV-TR, a depressed mood that is
not been completely congruent, and APA is developing a fifth caused by substances (e.g., drugs, alcohol, or medications) or
edition of the DSM (DSM-V) that will coordinate better with that is part of a general medical condition is not considered
future editions of ICD (30). to be major depressive disorder (28).
One of the most widely used and validated instruments for
measuring depression in population surveys is the nine-item
Methods for Measuring Prevalence and
Patient Health Questionnaire (PHQ-9). The PHQ-9 screens
Public Health Impact of Mental Illness for the presence of the nine DSM-IV-TR criteria for acute and
Research Instruments clinically significant depressive disorders (36). A PHQ-9 score
of ≥10 has high sensitivity (88%) and specificity (88%) when
The Structured Clinical Interview for DSM Disorders validated against SCID (37) and effectively detects depressive
(SCID) Research Version (31) is considered to be the standard symptoms among persons of various races and ethnicities
among psychiatric research instruments based on DSM-IV-TR (38,39). The PHQ-9 has been used as a self-administered
criteria; however, SCID takes 30–60 minutes and must be module in many clinical studies and telephone-administered
conducted by a trained mental health professional. Another surveys (38,40–43).
instrument, the Composite International Diagnostic Interview Other telephone surveys have used a slightly shorter instru-
(CIDI), was developed by WHO and is based on ICD-10 ment, the eight-item Patient Health Questionnaire (PHQ-8),

MMWR / September 2, 2011 / Vol. 60 3

992 Appendix
Supplement

which omits the PHQ-9 question concerning suicidal or self- Mentally Unhealthy Days
injurious ideation because survey administrators might not be Health-related quality of life (HRQOL) is a multidimen-
able to offer appropriate follow-up interventions. Omitting sional concept that includes physical, mental, emotional, and
this question in population-based surveys has only a minor social domains and reflects perceived physical and mental
effect on the usefulness of PHQ as a screen for depression (36). health (46,47). HRQOL often is used to characterize certain
The standard PHQ-8 and PHQ-9 have the following pri- aspects of disease impact, disability, and injury and to identify
mary question: “Over the last 2 weeks, how often have you unmet health needs and disparities among various sociodemo-
been bothered by any of the following problems?” The follow- graphic populations (48). A core set of four questions (i.e.,
ing problems are listed: 1) little interest or pleasure in doing the Healthy Days Core Module, or HRQOL-4) has been
things; 2) feeling down, depressed, or hopeless; 3) trouble standardized and validated for public health survey purposes.
falling/staying asleep, sleeping too much; 4) feeling tired or HRQOL-4 asks respondents about self-rated general health,
having little energy; 5) poor appetite or overeating; 6) feeling physical health, mental health, and activity limitations result-
bad about yourself or that you are a failure or have let yourself ing from poor physical or mental health during the previous
or your family down; 7) trouble concentrating on things, such 30 days (48). One indicator often used to measure HRQOL
as reading the newspaper or watching television; 8) moving is the number of mentally unhealthy days experienced by a
or speaking so slowly that other people could have noticed, person. Typically, the question asks: “Now thinking about your
or the opposite — being so fidgety or restless that you have mental health, which includes stress, depression, and problems
been moving around a lot more than usual; and 9) (PHQ-9 with emotions, for how many days during the past 30 days
only) thoughts that you would be better off dead or of hurt- was your mental health not good?” Respondents who report
ing yourself in some way. Response categories are “not at all,” ≥14 mentally unhealthy days over the past month are defined
“several days,” “more than half the days,” and “nearly every day.” as having frequent mental distress. The mentally unhealthy
PHQ-8 and PHQ-9 answers are scored using one of two days question has acceptable criterion validity and test-retest
algorithms, and the scores are used to assign depression catego- reliability (48–50). In a large prospective study, this question
ries. One algorithm is based on the DSM-IV and categorizes predicted 1-month and 12-month physician visits, hospitaliza-
depressed respondents as having a major depressive disorder or tions, and mortality outcomes (51).
other depression. The other algorithm categorizes respondents
according to the severity of depressive symptoms (i.e., no sig- Health-Care Surveys
nificant depressive symptoms or mild, moderate, moderately Data from health-care providers and insurers provide an
severe, or severe depressive symptoms) (36,37). additional important source of information on the prevalence
Psychological Distress (Kessler-6 Psychological of mental illness in the United States. Coding systems used by
hospitals and medical providers for billing purposes typically use
Distress Scale)
the ICD-9 coding system, which, as mentioned previously, is not
Surveys use the Kessler-6 psychological distress scale to screen completely congruent with the DSM-IV-TR. In addition, men-
for psychological distress experienced by persons with anxiety tal health professionals generally use the DSM-IV-TR nomen-
and mood disorders (44). The Kessler-6 scale asks respondents clature, whereas primary care providers use other terminology. In
about the frequency with which they have experienced six practice, regardless of the diagnostic system used, diagnoses vary
manifestations of psychological distress, which include feel- according to the training of the coder, local practice, availability
ing 1) nervous, 2) hopeless, 3) restless or fidgety, 4) so sad or of treatment resources, and reimbursement codes.
depressed that nothing could cheer the respondent up, 5) that
everything is an effort, and 6) worthless. Responses are “all of
the time,” “most of the time,” “some of the time,” “a little of CDC Surveillance Systems and
the time,” and “none of the time.” Scoring of individual items
is based on a 4-point scale according to increased frequency Surveys that Measure Prevalence and
of the problem, yielding a total six-item score ranging from Impact of Mental Illness
0–24. A score of ≥13 indicates serious psychological distress CDC systems for measuring the prevalence and impact
(45). Serious psychological distress as defined by the Kessler-6 of mental illness in the U.S. adult population fall into two
score is highly associated with anxiety disorders and depression categories: 1) population surveys, which are used to estimate
but does not identify a specific mental illness (44). mental illness prevalence, and 2) national health-care surveys
that include a diagnosed psychiatric condition based on ICD-9

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codes, which are used to estimate outpatient visits and hospital- for the probability of selection of a telephone number, the
izations and reflect access to and use of health care by persons number of adults in a household, and the number of landline
with mental illness (Table 1). Both of these systems provide telephone numbers that reach a household. Data are then
public access data sets that allow researchers to address specific stratified to adjust for nonresponse, to adjust for noncover-
queries or conduct specific analyses. In combination with age of households without telephones, and to force the sum
information from other studies and surveys, notably surveys of the weighted frequencies to equal the adult population in
conducted by SAMHSA, data from these CDC systems can each state.
be used to plan, implement, and evaluate mental illness pre- Every year, the core BRFSS includes a question on number
vention strategies and to explore ways to protect and promote of mentally unhealthy days as a measure of HRQOL. States
mental health. Proper interpretation of mental health surveil- also may administer BRFSS optional modules (conducted
lance statistics requires an understanding of 1) the reason the through a collaboration between CDC and SAMHSA) that
data were collected (e.g., to identify prevalence or for program address other mental health topics in depth. In 2006, 2008, and
planning); 2) the survey population (e.g., representative of state 2010, an optional BRFSS module on anxiety and depression
or national population, sample frame, and time conducted); contained the PHQ-8, one question on lifetime diagnosis of
3) survey methods (e.g., telephone vs. in-person interviews, anxiety, and one question on lifetime diagnosis of depression.
record reviews or abstracts, and vital statistics); 4) question- In 2007 and 2009, an optional BRFSS module on mental
naires and questions used (e.g., standardization, validity, and illness and stigma included the Kessler-6 scale (past 30 days),
reliability); 5) parameters measured (population prevalence and one question on activity limitations associated with a mental
effects of the illness); and 6) appropriate analyses (adjustment health condition or emotional problem, one question on treat-
and weighting for survey designs and response rates, rates, ment, and two questions on attitudes toward mental illness that
proportions, and continuous measures). might underlie stigma. Because certain individual states do not
use these optional modules, BRFSS cannot provide national
Population Surveys estimates of depression or psychological distress.
CDC provides public online access to the following summary
BRFSS statistics from various BRFSS modules:
BRFSS is a state-based telephone survey that was established • Prevalence and trends data: prevalence estimates for core
in 1984.* BRFSS is the largest ongoing telephone health survey variables by year and by state from 1995 to the present†
in the world, with approximately 450,000 adult interviews • Selected metropolitan/micropolitan area risk trends
completed each year. BRFSS collects standardized, state- (SMART) city and county data: CDC information on all
specific data concerning preventive health practices and risk health risk data for metropolitan and micropolitan statisti-
behaviors associated with infectious diseases, chronic diseases, cal areas (MMSAs) by year and category, with users able
and injuries in the adult population. Data are collected in all 50 to generate reports that compare statistics by MMSA and
states, the District of Columbia, Puerto Rico, the U.S. Virgin to use SMART to produce charts that show state, MMSA,
Islands, and Guam. The large size of the survey permits calcu- and county data for a limited set of health risk factors
lation of state-specific estimates (and in some cases, substate (2002–2008)§,¶
estimates) and aggregated nationwide estimates. States use • BRFSS maps: MMSA maps for many core variables (2002–
BRFSS data to identify emerging health problems, establish present)** and annual BRFSS survey data and technical
and track health objectives, and develop and evaluate public documentation so that researchers can conduct their own
health policies and programs. For many states, BRFSS is the analyses
only source of timely, accurate, state-based data on health- • Yearly state-based survey data sets and technical documen-
related behaviors. tation (1984–present)††
BRFSS interviews consist of three parts: 1) core questions
asked in all states and territories (e.g., demographics, HRQOL, † Additional information available at http://apps.nccd.cdc.gov/brfss.
§
access to health care, disability, chronic conditions, and risk Additional information available at http://apps.nccd.cdc.gov/brfss-smart/
index.asp.
behaviors); 2) optional modules with questions on specific ¶ Additional information available at http://apps.nccd.cdc.gov/brfss-smart/
topics (for mental illness: the anxiety and depression module selquickviewchart.asp.
and the mental illness and stigma module); and 3) questions ** Additional information available at http://apps.nccd.cdc.gov/gisbrfss/default.aspx.
†† Additional information available at http://www.cdc.gov/brfss/technical_
added by individual states. BRFSS data are directly weighted infodata/surveydata.htm.

*Additional information available at http://www.cdc.gov/brfss/index.htm.

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• Yearly data sets and technical documentation for counties NHIS sample weights, which account for the differential
and MMSAs with ≥500 respondents (2002–present)§§ probabilities of selection, nonresponse, and noncoverage, must
• Yearly data and technical documentation for state and MMSA be used for all analyses. Methods that incorporate the complex
geographic information system data files (2002–present)¶¶ sample design and weights (e.g., Taylor series linearization)
must be used to calculate appropriate standard errors.
National Health Interview Survey Since 1997, NHIS has used the Kessler-6 scale (past 30
The National Health Interview Survey (NHIS) is a con- days) to identify serious psychological distress among adults.
tinuous cross-sectional survey of the civilian U.S. household National rates for psychological distress by age, sex, and race are
population. NHIS monitors the health of the U.S. population produced quarterly through the NHIS Early Release Program
through the collection and analysis of data on a broad range and are available online. In 2007, the NHIS included three
of health topics.*** Data are collected through an in-person questions on lifetime diagnoses: “Have you EVER been told
household interview. The basic module, which remains largely by a doctor or other health professional that you had bipolar
unchanged from year to year, includes three components: a disorder? Schizophrenia? Mania or psychoses?”
family core questionnaire, a sample adult core questionnaire,
and a sample child core questionnaire. The family core col- National Health and Nutrition Examination
lects information on everyone in the family and serves as the Survey
sampling frame for additional integrated surveys. This core The National Health and Nutrition Examination Survey
includes information concerning household composition (NHANES) is a continuous survey of the health and nutritional
and sociodemographic characteristics, tracking information, status of the U.S. civilian noninstitutionalized population.§§§
information for linkage to administrative databases, indicators Although NHANES uses a multistage probability household
of health status, activity limitations, injuries, health insurance sampling design to obtain a nationally representative sample,
coverage, and access to and use of health-care services. One the sample is not sufficient for state- or local-level analyses.
adult and one child (if any children aged <18 years are present) NHANES sample weights, which account for the differential
are selected randomly from each family, and information on probabilities of selection, nonresponse, and noncoverage,
each is collected with the sample adult core and sample child must be used for all analyses. Survey participants complete an
core questionnaires. Because certain health issues are different interview administered in their home and then are invited to
for adults and children, certain items on these two question- participate in an examination conducted in a mobile examina-
naires differ; however, both collect basic data on health status, tion center. This includes a private interview, a standardized
health-care services, and behavior. These sections of the survey physical examination, and collection of biological specimens
yield the sample adult and the sample child data files. for laboratory testing. NHANES collects data on the prevalence
NHIS uses a multistage area probability design to identify of 1) chronic diseases and conditions (including undiagnosed
representative U.S. households. The sample is redesigned and conditions detected through the examination or laboratory
redrawn approximately every 10 years to more accurately testing) and risk factors (e.g., obesity, smoking, serum choles-
measure the changing population and to meet new survey terol levels, hypertension, and diet and nutritional status), 2)
objectives. NHIS oversamples blacks, Hispanics, and Asians vaccination status, 3) infectious disease prevalence, 4) health
(especially those aged ≥65 years) to allow for more precise insurance, and 5) measures of environmental exposures. Other
estimation of health characteristics in these growing minority topics include hearing, vision, anemia, diabetes, cardiovascular
populations. The NHIS sample size (approximately 10,000) is disease, osteoporosis, oral health, pharmaceuticals and dietary
not sufficient to provide reliable state-level estimates for most supplements, physical fitness, HRQOL, and health-care use.
states. Although the database does not identify respondents’ In the private mobile examination center interview, NHANES
state of residence, state-level estimates can be produced for uses the PHQ-9 to measure depression, and since 2000, this
more populous states by requesting state identifiers through the NHANES interview also has included the question on number
CDC National Center for Health Statistics (NCHS) Research of mentally unhealthy days. The examination and laboratory
Data Centers.††† data collected allow researchers to examine the relationships
between depression and health variables not available on other
§§
Additional information available at http://www.cdc.gov/brfss/smart/ national surveys.
technical_infodata.htm.
¶¶
Additional information available at http://www.cdc.gov/brfss/maps/gis_data.htm.
*** Additional information available at http://www.cdc.gov/nchs/nhis.htm. §§§ Demographic, questionnaire, examination, and laboratory data sets are available
††† Additional information available at http://www.cdc.gov/rdc. at http://www.cdc.gov/nchs/nhanes/nhanes2007-2008/nhanes07_08.htm.

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Pregnancy Risk Assessment Monitoring System to examine factors that influence use of health-care resources,
The Pregnancy Risk Assessment Monitoring System quality of health care, and disparities in health-care services in
(PRAMS) was established in 1987 and is a state-based, cross- population subgroups. In addition, because the surveys col-
sectional survey of women who have recently delivered a live- lect core information from a sample of providers that remains
born infant. PRAMS provides population-based data that can relatively stable over time, trends in the types of care delivered
be used to develop maternal and infant health programs and in each setting can be monitored and examined in relation to
policies.¶¶¶ The survey uses a mixed-mode data collection the characteristics of providers, patients, and clinical manage-
method. Each month, randomly selected women who have ment of patient care.
delivered a live-born infant are requested to complete a mail National Ambulatory Medical Care Survey
questionnaire; follow-up with nonresponders occurs by phone.
The National Ambulatory Medical Care Survey
Data are collected in 37 states and New York City, representing
(NAMCS)†††† collects information on the use of ambulatory
approximately 75% of the births in the United States. Data
care services in the United States. NAMCS uses a multistage
are weighted to adjust for survey design, nonresponse, and
probability sample of visits to office-based physicians and
noncoverage.
health-care providers in community health centers and collects
PRAMS collects information on maternal behaviors, atti-
data on provider characteristics. Sample data are weighted to
tudes, and experiences before, during, and after pregnancy.
produce national estimates that describe the provision and
Survey responses are linked to birth certificate data. The
use of ambulatory medical care services in the United States.
questionnaire includes core questions asked of all participants
Public use data files are released annually and include a visit
in all states, optional standard questions pretested by CDC,
statistical weight and (since 2005) a physician statistical weight.
and state-developed questions. PRAMS provides estimates of
Information on mental health and mental illness available
postpartum depression by using two questions similar to those
from NAMCS includes reasons for visit, physician diagnosis,
included in the PHQ-8: 1) “Since your new baby was born,
medications, treatment, referrals, and one item on comorbid
how often have you felt down, depressed, or hopeless?” and
depression. Physician diagnoses are recorded as written by the
2) “Since your new baby was born, how often have you had
physician (text or ICD-9 codes). Nosologists convert text to
little interest in doing things?” Possible responses are “never,”
ICD-9 codes for the data files.
“rarely,” “sometimes,” “often,” and “always.” Women who
answer “often” or “always” to either question or both questions National Hospital Ambulatory Medical
are categorized as having postpartum depression. Care Survey
CDC provides access to PRAMS data electronically through
The National Hospital Ambulatory Medical Care Survey
CPONDER (CDC’s PRAMS On-line Data for Epidemiologic
(NHAMCS)†††† collects data on the use of ambulatory care
Research).**** CPONDER provides access to prevalence
services in hospital emergency and outpatient departments.
estimates by state and by year (2000–2008). In addition,
NHAMCS involves a multistage probability sample of visits to
CPONDER indexes 54 variables by topic for selection as the
the emergency and outpatient departments of noninstitutional,
outcome variable in cross-tabular analyses. Twelve control
general, and short-stay hospitals in the United States. Federal,
variables may be used to stratify these outcomes in an analysis.
military, and U.S. Department of Veterans Affairs hospitals are
Analyses may include a single state and all available years or
not included. Data collected from outpatient departments are
all available states and a single year.
similar to those collected by NAMCS. Data from emergency
department visits are slightly different from the outpatient
National Health-Care Surveys department data and include whether the patient was admitted
CDC conducts surveys of health-care providers, and the data to a mental health unit or transferred to a psychiatric hospi-
from these surveys complement data from the population- tal. Sample data are weighted to produce national estimates.
based surveys to provide a more complete representation of Public-use data files are released annually.
the occurrence of mental illness in the United States. For
the health-care surveys, CDC collects data from a sample of
National Hospital Discharge Survey
organizations that provide health care (e.g., nursing homes, The National Hospital Discharge Survey (NHDS)§§§§
inpatient hospitals, or physician offices). The data can be used obtains national-level information on characteristics of
¶¶¶ Additional information available at http://www.cdc.gov/prams. †††† Additional information available at http://www.cdc.gov/nchs/ahcd.htm.
**** Additional information available at http://www.cdc.gov/prams/ §§§§ Additional information available at http://www.cdc.gov/nchs/nhds.htm.
CPONDER.htm.

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inpatients discharged from nonfederal, short-stay (<30 days) Population Surveys

hospitals in the United States. Only hospitals with an average
length of stay of <30 days, general hospitals, and children’s gen- Current Depression
eral hospitals are included in the survey. Psychiatric hospitals Two CDC surveillance systems provide estimates for cur-
with an average length of stay of <30 days are eligible. NHDS rent depression: NHANES (national estimates) and BRFSS
does not include federal, military, U.S. Department of Veterans (state estimates). These systems use the PHQ-9 (NHANES)
Affairs hospitals, prison hospitals, or hospitals with fewer than or PHQ-8 (BRFSS) to estimate the occurrence of depression
six beds. Hospitals are selected by using a three-stage stratified in the last 2 weeks. For example, using continuously collected
design. Patient information collected includes demographics, data from 2005–2008 (the most recent data available), results
length of stay, diagnoses, and procedures. Hospital characteris- from NHANES indicate that 6.8% of U.S. adults had depres-
tics collected include region, ownership, and number of beds. sion (measured by the PHQ-9) during the 2 weeks before the
NHDS sample statistical weights account for nonresponse and survey (Table 2).
must be used for all analyses. Methods that incorporate the Results from BRFSS for current depression (measured by the
complex sample design and weights, such as Taylor series linear- PHQ-8) vary according to the year conducted because in differ-
ization, must be used to calculate appropriate standard errors. ent years, a varying number of states might have administered
the optional modules containing the mental illness–related
National Nursing Home Survey
questions. Results from 2006 (in 38 states, the District of
The National Nursing Home Survey (NNHS)¶¶¶¶ is a con- Columbia, Puerto Rico, and the U.S. Virgin Islands) using
tinuous series of national sample surveys of nursing homes and the PHQ-8 indicate that approximately 8.7% of respondents
their residents and staff members. NNHS provides information had current depression. Results from 2008 in 16 states using
on nursing homes from the perspectives of the provider and the optional BRFSS anxiety and depression module indicate
recipient of services. Data on facilities include characteristics that 8.2% had current depression. Prevalence estimates were
such as number of beds, ownership, affiliation, Medicare and higher among women and non-Hispanic blacks compared with
Medicaid certification, specialty units, services offered, number other groups (Table 3).
and characteristics of staff, expenses, and charges. Data on Using the PHQ-8 algorithm for major depressive disorder
current residents include demographic characteristics, health (36), the 2006 BRFSS prevalence estimate of major depression
status, up to 16 current diagnoses, level of assistance needed during the previous 2 weeks was 3.5% (95% confidence inter-
with activities of daily living, vision and hearing impairment, val [CI]: 3.3–3.7) and in 2008 was 3.0% (95% CI: 2.8–3.3).
continence, services received, and sources of payment. The BRFSS state-specific prevalence estimates for depression in
survey uses a stratified two-stage probability design. The first 2006 and 2008 show marked variations from state to state,
stage is the selection of facilities, and the second stage is selec- with prevalences ranging from 4.3% in North Dakota to 13.7%
tion of residents. in Mississippi and West Virginia (Table 4). The prevalence
of depression was generally highest in the southeastern states
(Figure 1).
Findings from CDC Surveillance
Postpartum Depression
Systems and Surveys
During 2004–2008, a total of 14.5% of PRAMS respondents
Through the surveys and surveillance systems described in reported symptoms of postpartum depression (i.e., answered
this report, CDC provides prevalence estimates on current “often” or “always” to either or both of the following questions):
depression, postpartum depression, psychological distress, 1) “Since your new baby was born, how often have you felt
number of mentally unhealthy days, and lifetime diagnosis of down, depressed, or hopeless?” and 2) “Since your new baby
depression, anxiety, bipolar disorder, and schizophrenia in the was born, how often have you had little interest in doing
U.S. adult population. CDC health-care surveys provide health things?”) (Table 5). The prevalence of postpartum depression
services information about physician, hospital outpatient, and varied by age, ranging from 10.3% among women aged 30–39
emergency department visits related to mental illness. All of years to 23.3% among women aged ≤19 years. Prevalence also
these CDC systems can provide data for national-level (or varied by race/ethnicity: 16.8% among Hispanic women,
nationwide) estimates by sex, age, race, and ethnicity. BRFSS 11.9% among non-Hispanic white women, and 21.5% among
and PRAMS data also can be used for state-level estimates. non-Hispanic black women. Among 22 states, the prevalence
of postpartum depression ranged from 9.8% in Minnesota to
¶¶¶¶ Additional information available at http://www.cdc.gov/nchs/nnhs.htm. 21.3% in Tennessee (Table 6).

8 MMWR / September 2, 2011 / Vol. 60

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Psychological Distress National Health-Care Surveys

Both NHIS and optional modules of BRFSS use the
NAMCS and NHAMCS
Kessler-6 scale to identify persons who experienced psycho-
logical distress during the 30 days before the survey. NHIS During 2007–2008, an estimated 47.8 million ambula-
data indicate that in 2009, 3.2% of respondents experienced tory care visits were made by patients with primary mental
serious psychological distress (Table 7). BRFSS included the health diagnoses, which constituted approximately 5% of all
Kessler-6 in the optional mental illness and stigma module dur- ambulatory care visits made in the United States during those
ing 2007 (administered in 35 states, the District of Columbia, 2 years (Tables 17 and 18). Women made 29.4 million of the
and Puerto Rico) and 2009 (16 states). Among participating visits, compared with 18.5 million for men. Of all mental
states, prevalence estimates were similar in 2007 (4.0%) and illness–related visits, the greatest proportion of visits (31%)
2009 (3.9%) (Table 8). These BRFSS estimates are higher were made by patients with any depressive disorder, followed
than NHIS estimates, which might be a result of the limited by 23% of visits among those with schizophrenia and other
geographical coverage of BRFSS, differences in survey design psychotic disorders. The proportion of visits related to alco-
and methods, question placement, and context. As in NHIS, hol and drug use that occurred in emergency and outpatient
women were more likely to have serious psychological distress departments was higher than the proportion of visits for other
than men, and rates were highest among adults aged 45–54 mental illness diagnoses.
years and non-Hispanic blacks. BRFSS data for state-specific NHDS
prevalences of serious psychological distress during 2007 and
2009 indicate that, like depression, prevalence varied among Among patients discharged from nonfederal, short-stay
states, ranging from 1.9% in Utah to 9.4% in Tennessee hospitals, mental illness was a primary diagnosis for 97.9 dis-
(Table 9). The prevalence of serious psychological distress was charged patients per 10,000 population among persons aged
generally highest in the southeastern states (Figure 2). 18–64 years. The occurence decreased with age to 64.4 among
those aged ≥65 years (Table 19). Mood disorders were the most
Mentally Unhealthy Days common primary mental illness discharge diagnosis, and the
The question on number of mentally unhealthy days is occurence decreased with age, with a range of 46.0 per 10,000
included in the BRFSS core questionnaire; therefore, data are population among patients aged 18–44 years to 19.2 per
available for every year for all states and territories. Nationwide, 10,000 population among those aged ≥65 years. Alcohol and
for 2009, adults aged ≥18 years reported an average of 3.5 drug use disorders were the second most common diagnoses
mentally unhealthy days during the past 30 days (Table 10). and also decreased with age. In contrast to rates for primary
Among states, in 2009, the median number of mentally diagnoses, discharges rates among patients with mental illness
unhealthy days was 3.4, and the 25th and 75th quartiles were listed as any of the diagnoses increased with age, ranging from
3.1 and 3.7 days, respectively (Table 11). The mean number 231.4 discharged patients per 10,000 population among those
of mentally unhealthy days was highest in the southeastern aged 18–44 years to 650.8 per 10,000 population among those
states (Figure 3). aged >65 years (Table 20). As with primary diagnoses of mental
illness, mood disorders were the most common diagnosis, fol-
Lifetime Diagnosis of Mental Illness lowed by alcohol and drug use disorders.
The BRFSS optional anxiety and depression module includes
NNHS
questions on whether respondents have received a diagnosis of
depression or anxiety disorder in their lifetime. Although the The prevalence of nursing home residents with a primary
number of participating states varied between the 2 years in diagnosis of mental illness in 2004 increased with age, ranging
which the module was administered, rates of reported lifetime from 18.7% among those aged 65–74 years to 23.5% among
diagnosis of depression were similar in 2006 (15.7%) and those aged ≥85 years (Table 21). Dementia and Alzheimer
2008 (16.1%) (Tables 12 and 13). The prevalence of lifetime disease were the most common primary diagnoses among
diagnosis of anxiety disorders was slightly lower, with 11.3% in nursing home residents with a primary diagnosis of mental
2006 and 12.3% in 2008 (Tables 14 and 15). In 2007, NHIS illness, and the prevalence of each increased with age. Among
included a question for all respondents on lifetime diagnosis of nursing home residents with any diagnosis of mental illness
bipolar disorder and schizophrenia; 1.7% of participants had (among any of 16 current diagnoses), mood disorders and
received a diagnosis of bipolar disorder, and 0.6% had received dementia were the most common diagnoses among residents
a diagnosis of schizophrenia (Table 16). aged 65–74 years and 75–84 years (Table 22). Among residents
aged ≥85 years, dementia (41.0%) was the most common

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Supplement

mental illness, followed by mood disorders (35.3%). In 2004, similar, indicating that 18% of adults had an anxiety disorder
approximately two thirds of nursing home residents had a (9%, specific phobia; 7%, social phobia; 4%, posttraumatic
diagnosis of a mental illness, and approximately one third of stress disorder; and 3%, panic disorder); 56% of the disorders
these had a mood disorder. identified were categorized as serious or moderate (5). Several
standardized and validated scales can be used in telephone and
in-person interviews to identify and classify anxiety disorders
Discussion (57,58). Better documentation of the impact of anxiety dis-
CDC national surveillance surveys such as NHANES and orders might help guide national public health policy. At the
NHIS are important for developing national policies and track- state and local levels, documenting the prevalence and impact
ing progress toward national health goals such as those described of anxiety disorders might help ascertain the need for additional
in Healthy People 2010 and Healthy People 2020. Data from these public health services for these disorders.
surveys are useful for national planning and research. Although CDC surveys and information systems have
Two state-based CDC surveys, BRFSS and PRAMS, can provided important information on the prevalence of mental
provide data at the state or substate levels that can be used for illness, none of them was designed solely to monitor mental
both national and state-level planning. For example, variations illness. They are general surveillance tools that have added
in BRFSS estimates for certain mental illnesses might help components on mental illness gradually over time as recogni-
determine the focus of certain mental health services. tion of the importance of mental illness in public health has
The prevalence of current depression varies substantially by increased. For example, NHANES and NHIS are national
state (from 4.3% in North Dakota to 13.7% in Mississippi CDC surveys designed to monitor the entire range of public
and West Virginia), as does the prevalence of serious psycho- health diseases and conditions and can include only a limited
logical distress (from 1.9% in Utah to 9.4% in Tennessee). number of questions concerning mental illness. Likewise, the
These variations might reflect regional differences, includ- state-based CDC BRFSS is designed to provide state and local
ing demographic characteristics, socioeconomic conditions, estimates on a wide range of health behaviors. BRFSS mental
availability of and access to health-care services, and patterns illness questions are primarily contained in two small mental
of reimbursement for mental health services, that would be illness modules that are optional for states and are not included
useful in planning (52,53). Southeastern states generally have on the core BRFSS questionnaire administered by all states.
the highest prevalence of depression, serious psychological States may choose to administer the optional modules, but not
distress, and mean number of mentally unhealthy days. This all states do so because of financial constraints, competing state
finding likely reflects, in part, sociodemographics, access to surveillance priorities, and limitations in the length of time
and use of health care, and the association between mental respondents are willing to spend completing a telephone survey.
illness and certain chronic diseases such as obesity, diabetes, The willingness of the states to administer optional modules is
and cardiovascular disease (13,14). For some states, BRFSS, affected by the rapid rise in the proportion of households that
PRAMS, and other state-based surveys have provided mental no longer contain a landline telephone (59). Survey calls to
illness data that state and local authorities have used to identify cell phone numbers are limited to BRFSS core questions and
the need for services at the local or regional level. do not include the optional survey modules, partly because
CDC surveys focus on depression, and they lack sufficient cell phone respondents are not willing to spend as much time
data on anxiety disorders. Anxiety disorders are as common in completing BRFSS questions as respondents using landline
the population as depression and, like depression and severe telephones. Recognizing that the number of households with
psychological distress, can result in high levels of impairment. landline telephones will continue to decrease, CDC is exploring
Moreover, the pathophysiologic characteristics of anxiety additional methods to obtain a valid sample for mental illness
disorders are similar to those of depression and often are questions in BRFSS.
associated with the same chronic medical conditions (54–56). Increasingly, physicians and others who treat mental illness,
The National Epidemiologic Survey on Alcohol and Related as well as public health experts, are recognizing the substan-
Conditions (NESARC), conducted by the National Institute tial overlap between mental illness and diseases traditionally
on Alcohol Abuse and Alcoholism, estimated that during considered to be matters of public health concern. The ability
2001–2002, 14% of U.S. adults had an anxiety disorder (7%, of certain mental illnesses to exacerbate morbidity from sev-
specific phobia; 3%, social phobia; 2%, generalized anxiety eral chronic diseases is well-established. Recent studies have
disorder; and 1%, panic disorder) (23). Estimates from the explored the causal pathways from mental illness to certain
2003 National Comorbidity Survey Replication (NCS-R) were chronic diseases (60,61), highlighting the need for more accu-
rate and timely information on the epidemiology of mental

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Supplement

illness in the United States. Future mental illness surveillance 2. World Health Organization. Promoting mental health: concepts, emerg-
surveys should measure both depression and anxiety disorders ing evidence, practice (summary report). Geneva, Switzerland: World
Health Organization; 2004. Available at http://www.who.int/mental_
and include more detailed questions concerning their impact health/evidence/en/promoting_mhh.pdf. Accessed July 1, 2011.
on quality of life, associated chronic medical conditions, and 3. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE.
issues such as family violence, alcohol and substance abuse, Lifetime prevalence and age-of-onset distributions of DSM-IV disorders
in the National Comorbidity Survey Replication. Arch Gen Psych
and access to and use of health care. For example, CDC is 2005;62:593–602.
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Catherine Simile, PhD, Patricia Barnes, MA, Vladislav Beresovsky, 13. Chapman DP, Perry GS, Strine TW. The vital link between chronic
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FIGURE 1. Prevalence of current depression* among adults aged ≥18 FIGURE 3. Mean number of mentally unhealthy days* during past
years, by state quartile† — Behavioral Risk Factor Surveillance 30 days among adults aged ≥18 years, by state quartile — Behavioral
System, United States, 2006§ Risk Factor Surveillance System, United States, 2009

DC DC
PR GU
VI PR
VI

≥9% ≥3.7
8% to <9% 3.4 to <3.7
7% to <8% 3.0 to <3.4
<7% <3.0
No data No data

* Patient Health Questionnaire-8 severity score of ≥10. * Survey question: “Now thinking about your mental health, which includes
† Quartiles based on point estimates (see Table 4).
stress, depression, and problems with emotions, for how many days during
§ For Arizona, Colorado, Idaho, Illinois, Massachusetts, New York, and Ohio, data
the last 30 days was your mental health not good?”
are from 2008.

FIGURE 2. Prevalence of serious psychological distress* among adults

aged ≥18 years, by state quartile † — Behavioral Risk Factor
Surveillance System, United States, 2007§

DC
PR

≥5%
4% to <5%
3% to <4%
<3%
No data

* Kessler-6 score of ≥13.

† For Tennessee and Utah, data are from 2009.
§ Quartiles based on point estimates (see Table 9).

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TABLE 1. CDC surveys and surveillance systems that collect data on mental illness among adults
Method of data
Name, website, and CDC sponsor Description collection Survey topics Mental health topics and questions Population

Behavioral Risk Factor Surveillance BRFSS is a state-based Telephone Heath-risk Anxiety and depression module (PHQ-8, National sample of one
System (BRFSS) system of health surveys interviews behaviors lifetime diagnosis of anxiety and person (aged ≥18 years)
http://www.cdc.gov/brfss that collects information Preventive health depression) from each household
on health-risk behaviors, practices Mental illness and stigma module (K-6, Approximately 450,000
Public Health Surveillance Program preventive health
Office Health-care access stigma, mental health treatment, and completed interviews,
practices, and health-care mental illness–related disability) as of 2010
access primarily related to Health-related
chronic disease and injury. quality of life Health-related quality of life (number of
For many states, BRFSS is days in past 30 days respondent felt that
Mental illness mental health was not good, felt
the only available source of
screening depressed, felt anxious, felt not getting
timely, accurate data on
health-related behaviors. Disability enough sleep, and felt full of energy)
Violence Life satisfaction
Social support
Smoking, alcohol use, physical activity,
and body mass index
Health-care use and access
Sexual and intimate partner violence

National Health Interview Survey NHIS is a national survey on In-person Health status and Activity limitations from physical, Approximately 40,000
(NHIS) the health of the civilian household limitations mental, or emotional problems households per year,
http://www.cdc.gov/nchs/nhis.htm noninstitutionalized U.S. interviews Health-care use External causes and circumstances of as of 2010
population. The main injury Oversample of blacks,
National Center for Health Statistics objective of NHIS is to Family resources
Mental health-care use Hispanics, Asians, and
monitor the health of the Health insurance adults aged ≥65 years
U.S. population through Mental health conditions and symptoms
Health-care access
the collection and analysis (in 2007 survey), including ADHD;
of data on a broad range of Vaccination schizophrenia; bipolar disorder;
health topics. Injury depression, anxiety, and emotional
problems; dementia and senility; mental
Health behaviors
retardation; learning disabilities; and
Functioning general distress symptoms
Disability Health-risk behaviors (including tobacco
use and alcohol use)
K-6 measure of serious psychological
distress

National Health and Nutrition NHANES is designed to In-person Numerous diseases, Sleep disorders Approximately 5,000
Examination Survey (NHANES) assess the health and household medical Alcohol and drug use persons per year, as
http://www.cdc.gov/nchs/nhanes.htm nutritional status of adults interviews conditions, and of 2008
and children in the United Physical health indicators Social and emotional support Oversample of blacks,
National Center for Health Statistics States. The survey Use of mental health-care professionals
examinations Nutrition and Mexican-Americans,
combines interviews and nutritional
Laboratory tests Activity limitations from poor physical or adolescents, and adults
physical examinations. disorders aged ≥60 years
mental health
Nutritional
assessments Environmental risk PHQ-9 depression screening
factors
DNA repository
Health-care use
Mental, behavioral,
and emotional
problems of
children
Weight and physical
fitness
Risk factors
See table footnotes on page 16.

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TABLE 1. (Continued) CDC surveys and surveillance systems that collect data on mental illness among adults
Method of data
Name, website, and CDC sponsor Description collection Survey topics Mental health topics and questions Population

Pregnancy Risk Assessment Monitoring PRAMS is a surveillance Mailed surveys Postpartum Whether health-care provider discussed Approximately 50,000
System (PRAMS) project of CDC and state with follow-up depressive with respondent healthy and risky women with live-born
http://www.cdc.gov/prams health departments. telephone symptoms pregnancy behaviors (including infants per year, as of 2008
PRAMS collects interviews for Attitudes and drinking alcohol and smoking during
National Center for Chronic Disease state-specific, population- nonresponders pregnancy)
Prevention and Health Promotion, feelings about
based data on maternal most recent Maternal tobacco and alcohol use before,
Division of Reproductive Health attitudes and experiences pregnancy during, and after pregnancy
before, during, and shortly
after pregnancy. Prenatal care Difficult or traumatic events before or
Maternal alcohol during pregnancy
and tobacco use Pregnancy intention, both of mother and
HIV testing of partner
Health insurance Whether respondent needed and
coverage received counseling for substance use
or personal problems during or after
Physical abuse pregnancy
before and during
pregnancy Interpersonal violence before and during
pregnancy
Pregnancy-related
morbidity Injury control and prevention
Infant health care Social support and stress
Contraceptive use Infant sleeping behaviors
Breastfeeding Infant and maternal exposure to smoke
practices Feelings, diagnosis, and treatment of
Health-care postpartum depression, hopelessness,
provider advice and anxiety

National Ambulatory Medical Care NAMCS is a national survey Patient record Demographic Current diagnosed mental health Office-based physicians and
Survey (NAMCS) that collects data on the forms completed characteristics of conditions then visits within the
http://www.cdc.gov/nchs/ahcd.htm provision and use of by physicians and patients Current depression practices. In 2007, data
ambulatory medical care staff members or Expected payment were provided on 32,778
National Center for Health Statistics services in the United survey field Cause of injury (including intentional) visits.
sources
States. Findings are based representatives Health education services ordered or
on a sample of visits to Patients’ principal provided at visit (including injury
nonfederal, employed, complaints, prevention, stress management, and
office-based physicians symptoms, or tobacco use and exposure)
who are primarily engaged other reasons for
visit Nonmedication treatment provided at
in direct patient care.
visit (including psychotherapy and
Physician diagnoses, mental health counseling)
diagnostic and
screening services Type of health-care providers patient
visited or was referred to during visit
Medications (including providers of mental health
Types of health-care services)
providers seen Medications
during visit
Disposition
Causes of injury (if
applicable)

See table footnotes on page 16.

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TABLE 1. (Continued) CDC surveys and surveillance systems that collect data on mental illness among adults
Method of data
Name, website, and CDC sponsor Description collection Survey topics Mental health topics and questions Population
National Hospital Ambulatory Medical NHAMCS is designed to Patient record Demographic Emergency department: Nationally representative
Care Survey (NHAMCS) collect data on the use and forms completed characteristics of Patients’ principal complaints, sample of 500 nonfederal
http://www.cdc.gov/nchs/ahcd.htm provision of ambulatory by hospital patients symptoms, or other reasons for visit short-stay (<30 days)
care services in hospital physicians and Expected payment Causes of injury (including intentional) hospitals
National Center for Health Statistics emergency and outpatient staff members sources
departments. Findings are Health-care provider diagnoses
based on a national sample Patients’ principal
complaints, Medications
of visits to the emergency
departments and symptoms, or Mental health providers seen during visit
outpatient departments of other reasons for
Transfer to psychiatric hospital
noninstitutional general visit
Admission to mental health or
and short-stay hospitals. Physician diagnoses,
detoxification unit
diagnostic and
screening services Outpatient department:
Procedures Current diagnosed mental health
(emergency conditions
department only) Current depression
Medications Cause of injury (including intentional)
Disposition Health education services ordered or
Types of provided at visit (including injury
health- care prevention, stress management, and
providers seen tobacco use and exposure)
during visit Nonmedication treatment provided at
Causes of injury (if visit (including psychotherapy and
applicable) mental health counseling)
Type of health-care providers patient
visited or was referred to during visit
(including providers of mental health
services)
Medications

National Hospital Discharge Survey NHDS is a national Medical record Demographic Discharge diagnoses (up to seven) Nationally representative
(NHDS) probability survey of abstraction characteristics of Surgical and diagnostic procedures sample of nonfederal
http://www.cdc.gov/nchs/nhds.htm characteristics of inpatients patients (up to four) short-stay hospitals and
discharged from Expected sources of systematic samples of
National Center for Health Statistics nonfederal short-stay discharges within hospitals
payment
hospitals in the United
States. Type and source of
admission
Disposition
Discharge
diagnoses (up to
seven)
Surgical and
diagnostic
procedures (up to
four)

National Nursing Home Survey (NNHS) NNHS is a continuing series Interviews with Demographic Behavioral problems Sample of nursing homes
http://www.cdc.gov/nchs/nnhs.htm of national sample surveys staff member characteristics of Depressed mood (that had at least three beds
of nursing homes and their best acquainted patients and were either certified by
National Center for Health Statistics residents and staff with resident Medications Medicare or Medicaid or
Admitting diagnosis
members. medical records Admitting diagnosis had a state license to
Current diagnoses operate as a nursing home)
(up to 16) Current diagnoses (up to 16)
and then sample of
Health status Current assignment to specialty unit residents within nursing
(i.e., dementia or behavioral health) homes
Activities of daily
living Decision-making ability
Vision and hearing
Continence
Pain assessment
Behavior
Mood
Medications
Falls
Services received
Sources of payment
Abbreviations: ADHD = attention deficit hyperactivity disorder; HIV = human immunodeficiency virus; K-6 = Kessler-6; PHQ-8 = Patient Health Questionnaire-8; PHQ-9 = Patient Health
Questionnaire-9.

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TABLE 2. Prevalence of depression* among adults aged ≥18 years,

by sociodemographic characteristics — National Health and
Nutrition Examination Survey, United States, 2005–2008
Characteristic No. % (95% CI)
Total 10,279 6.8 (5.8–7.8)
Sex
Male 6,240 4.9 (3.9–5.9)
Female 6,397 8.4 (7.4–9.4)
Age group (yrs)
18–39 4,093 6.2 (5.2–7.2)
40–59 2,992 8.4 (6.8–10.0)
≥60 3,194 5.2 (4.0–6.4)
Race/Ethnicity
Mexican-American 1,983 7.2 (5.6–8.8)
Black, non-Hispanic 2,273 9.7 (7.9–11.5)
White, non-Hispanic 4,882 6.2 (5.0–7.4)
Abbreviation: CI = confidence interval.
* Patient Health Questionnaire-9 score of ≥10.

TABLE 3. Prevalence of current depression* among adults aged ≥18 years, by sociodemographic characteristics and year — Behavioral Risk
Factor Surveillance System, multiple states, 2006 and 2008
2006† 2008§
Characteristic No. % (95% CI) No. % (95% CI)
Total 198,678 8.7 (8.4–9.0) 85,004 8.2 (7.8–8.6)
Sex
Male 76,288 6.8 (6.4–7.3) 32,243 6.6 (6.1–7.2)
Female 122,390 10.5 (10.1–10.9) 52,761 9.8 (9.2–10.3)
Age group (yrs)
18–24 9,186 10.9 (9.7–12.2) 2,963 10.2 (8.5–12.2)
25–34 24,493 8.7 (8.0–9.4) 8,327 8.3 (7.3–9.4)
35–44 34,910 8.8 (8.2–9.4) 12,967 8.3 (7.5–9.3)
45–54 42,321 9.9 (9.3–10.5) 18,071 10.2 (9.4–11.1)
≥55 86,396 6.9 (6.5–7.3) 42,071 6.1 (5.7–6.6)
Race/Ethnicity
White, non-Hispanic 153,642 8.0 (7.7–8.3) 68,695 7.5 (7.1–7.9)
Black, non-Hispanic 15,819 11.0 (10.1–12.1) 4,837 12.7 (11.1–14.6)
Other, non-Hispanic¶ 11,955 10.4 (9.3–11.7) 6,258 9.4 (7.9–11.2)
Hispanic 15,602 9.9 (8.9–11.0) 4,458 9.5 (7.9–11.3)
Abbreviation: CI = confidence interval.
* Patient Health Questionnaire-8 depression severity score of ≥10.
† Data from 38 states, District of Columbia, Puerto Rico, and U.S. Virgin Islands.
§ Data from 16 states.
¶ Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

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TABLE 4. Prevalence of current depression* among adults aged ≥18 years, by state/area and year — Behavioral Risk Factor Surveillance System,
United States, 2006 and 2008
2006 2008
State/Area No. % (95% CI) No. % (95% CI)
Alabama 2,758 12.5 (10.4–15.0) — — —
Alaska 1,806 6.7 (5.4–8.2) — — —
Arizona —† — — 5,314 9.7 (8.0–11.7)
Arkansas 4,809 12.2 (11.0–13.4) — — —
California 5,177 8.8 (7.8–9.9) — — —
Colorado — — — 5,093 7.0 (6.0–8.1)
Connecticut 4,109 5.9 (5.0–6.9) — — —
Delaware 3,780 8.2 (6.9 – 9.6) — — —
District of Columbia 3,485 7.9 (6.6–9.4) — — —
Florida 9,298 8.9 (7.9–9.9) — — —
Georgia 6,485 8.2 (7.3–9.2) — — —
Hawaii 5,840 7.2 (6.3–8.1) 5,901 7.4 (6.5–8.5)
Idaho — — — 4,570 7.6 (6.6–8.7)
Illinois — — — 4,879 8.4 (7.4–9.6)
Indiana 5,746 9.6 (8.7–10.7) — — —
Iowa 4,692 5.8 (5.0–6.7) — — —
Kansas 3,797 6.9 (5.9–8.1) 3,783 8.6 (7.4–9.9)
Louisiana 5,774 9.5 (8.5–10.5) 5,388 9.3 (8.3–10.4)
Maine 3,605 7.4 (6.4–8.6) 3,724 7.8 (6.8–9.0)
Maryland 4,261 7.5 (6.3–8.8)
Massachusetts — — — 5,835 7.1 (6.2–8.2)
Michigan 5,077 10.5 (9.4–11.8) — — —
Minnesota 4,119 6.2 (5.4–7.2) — — —
Mississippi 5,225 13.0 (11.8–14.2) 6,387 13.7 (12.5–15.0)
Missouri 4,771 9.4 (8.3–10.7) — — —
Montana 5,262 6.7 (5.8–7.6) — — —
Nebraska 3,516 5.6 (4.6–6.9) 4,840 8.5 (6.9–10.3)
Nevada 3,222 9.0 (7.5–10.7) — — —
New Hampshire 5,230 6.8 (6.0–7.8) — — —
New Mexico 5,745 9.3 (8.3–10.5) — — —
New York — — — 3,444 7.3 (6.3–8.4)
North Dakota 4,164 5.3 (4.4–6.2) 4,482 4.3 (3.6–5.1)
Ohio — — — 5,797 9.2 (8.2–10.4)
Oklahoma 6,117 11.5 (10.5–12.6) — — —
Oregon 4,294 7.6 (6.6–8.7) — — —
Rhode Island 4,002 8.6 (7.4–9.9) — — —
South Carolina 7,853 8.8 (8.0–9.7) — — —
Tennessee 3,860 10.3 (9.0–11.8) — — —
Texas 5,856 8.5 (7.3–9.9) — — —
Utah 4,621 8.7 (7.5–10.0) — — —
Vermont 6,297 7.1 (6.3–8.0) 6,185 7.8 (6.9–8.7)
Virginia 4,636 7.3 (6.0–8.9) — — —
Washington 10,397 6.4 (5.8–7.1) 9,382 7.4 (6.7–8.2)
West Virginia 3,439 13.7 (12.3–15.2) — — —
Wisconsin 4,228 6.7 (5.7–7.8) — — —
Wyoming 4,495 7.3 (6.4–8.3) — — —
Puerto Rico 4,181 11.2 (10.1–12.3) — — —
U.S. Virgin Islands 2,649 7.1 (6.0–8.5) — — —
Abbreviation: CI = confidence interval.
* Patient Health Questionnaire-8 depression severity score of ≥10.
† Not measured.

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TABLE 5. Prevalence of postpartum depressive symptoms, by sociodemographic characteristics and symptoms — Pregnancy Risk Assessment
Monitoring System, United States, multiple sites, 2004–2008*
Self-reported symptoms†
Down, depressed, or hopeless Little interest or pleasure in doing things Either or both symptoms§
Characteristic No. % (95% CI) No. % (95% CI) No. % (95% CI)
Total 138,113 9.5 (9.2– 9.7) 137,979 9.8 (9.5–10.0) 137,461 14.5 (14.2–14.8)
Age group (yrs)
≤19 13,266 14.3 (13.2–15.4) 13,251 15.5 (14.3–16.7) 13,209 23.3 (21.9–24.7)
20–29 70,749 10.5 (10.1–10.9) 70,699 10.6 (10.2–11.1) 70,433 15.8 (15.3–16.3)
30–39 49,724 6.7 (6.4– 7.1) 49,648 7.0 (6.6– 7.4) 49,465 10.3 (9.9–10.8)
≥40 4,365 7.5 (6.3– 8.9) 4,372 8.2 (6.9– 9.8) 4,345 12.1 (10.5–13.9)
Race/Ethnicity
Hispanic 20,847 9.9 (9.2–10.6) 20,729 11.8 (11.0–12.6) 20,632 16.8 (15.9–17.7)
White, non-Hispanic 73,272 8.8 (8.5– 9.1) 73,362 7.5 (7.2– 7.9) 73,106 11.9 (11.6–12.3)
Black, non-Hispanic 20,307 12.1 (11.3–13.0) 20,219 15.9 (14.9–16.8) 20,184 21.5 (20.5–22.6)
Other 22,803 9.3 (8.5–10.2) 22,783 14.5 (13.5–15.6) 22,659 19.7 (18.5–20.9)
Abbreviation: CI = confidence interval.
* New York state excludes New York City, which conducts a separate survey. 2004: Alaska, Colorado, Georgia, Hawaii, Maine, Maryland, Minnesota, Nebraska, New
Mexico, New York, North Carolina, Oregon, Rhode Island, South Carolina, Utah, Vermont, and Washington; 2005: Alaska, Colorado, Georgia, Hawaii, Maine, Maryland,
Minnesota, Nebraska, New Mexico, New York, North Carolina, Ohio, Oregon, Rhode Island, South Carolina, Utah, Vermont, and Washington; 2006: Alaska, Colorado,
Georgia, Hawaii, Maine, Maryland, Minnesota, Nebraska, New York, Ohio, Oregon, Rhode Island, South Carolina, Utah, Vermont, and Washington; 2007: Alaska,
Colorado, Delaware, Georgia, Hawaii, Maine, Maryland, Massachusetts, Minnesota, Missouri, Nebraska, New York, North Carolina, Oregon, Pennsylvania, Rhode Island,
South Carolina, South Dakota Tribal, Utah, Vermont, Washington, Wisconsin, and Wyoming; 2008: Alaska, Colorado, Delaware, Georgia, Hawaii, Maine, Maryland,
Massachusetts, Minnesota, Nebraska, New York, North Carolina, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Utah, Vermont, Washington, Wisconsin, and
Wyoming.
† Survey questions: “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and “Since your new baby was born, how often have you
had little interest or little pleasure in doing things?” Possible responses are “never,”“rarely,”“sometimes,”“often,” and “always.” Women who answered “often” or “always”
were categorized as having symptoms of postpartum depression.
§ Women who answered “often” or “always” to either question or both questions.

TABLE 6. Prevalence of postpartum depressive symptoms, by state and symptoms — Pregnancy Risk Assessment Monitoring System,
22 states, 2008
Self-reported symptoms*
Little interest or pleasure
Down, depressed, or hopeless in doing things Either or both symptoms†
State % (95% CI) % (95% CI) % (95% CI)
Alaska 8.0 (6.3–10.1) 9.1 (7.3–11.2) 13.2 (11.0–15.7)
Colorado 7.9 (6.5–9.6) 9.5 (7.9–11.4) 13.5 (11.6–15.6)
Delaware 8.8 (7.3–10.5) 9.0 (7.5–10.8) 14.4 (12.6–16.6)
Georgia 9.5 (7.0–12.8) 9.0 (6.6–12.2) 12.8 (9.9–16.5)
Hawaii 7.9 (6.7–9.4) 10.2 (8.8–11.7) 14.7 (13.1–16.5)
Maine 10.3 (8.4–12.6) 8.4 (6.7–10.5) 12.6 (10.5–15.1)
Maryland 8.9 (7.0–11.3) 8.6 (6.7–10.9) 13.5 (11.1–16.3)
Massachusetts 7.9 (6.3–9.9) 8.8 (7.3–10.6) 12.9 (10.9–15.1)
Minnesota 6.7 (5.4–8.3) 6.4 (5.1–7.9) 9.8 (8.3–11.6)
Nebraska 7.4 (5.9–9.1) 6.8 (5.5–8.4) 10.8 (9.1–12.8)
New York 7.5 (5.8–9.7) 9.4 (7.4–11.8) 12.7 (10.4–15.4)
North Carolina 10.0 (8.3–12.0) 9.2 (7.6–11.1) 14.2 (12.2–16.4)
Ohio 11.2 (9.2–13.6) 10.9 (9.0–13.3) 16.4 (14.0–19.1)
Oregon 9.0 (7.0–11.5) 7.4 (5.7–9.6) 12.3 (10.0–15.0)
Pennsylvania 7.3 (5.8–9.3) 8.8 (7.1–10.9) 12.0 (10.0–14.3)
Rhode Island 9.1 (7.4–11.2) 10.1 (8.3–12.2) 13.9 (11.8–16.3)
Tennessee 15.0 (11.9–18.7) 12.3 (9.5–15.7) 21.3 (17.7–25.4)
Utah 8.5 (7.2–10.0) 8.3 (7.1–9.8) 12.6 (11.0–14.3)
Vermont 8.7 (7.2–10.6) 6.9 (5.5–8.6) 11.7 (9.8–13.8)
Washington 8.9 (7.1–11.0) 9.6 (7.8–11.7) 13.8 (11.6–16.2)
Wisconsin 7.8 (6.2–9.9) 9.4 (7.5–11.6) 13.8 (11.6–16.3)
Wyoming 8.1 (6.3–10.4) 8.2 (6.3–10.6) 12.0 (9.7–14.7)
Total 9.1 (8.5–9.7) 9.2 (8.7–9.8) 13.7 (13.1–14.4)
Abbreviation: CI = confidence interval.
* Survey questions: “Since your new baby was born, how often have you felt down, depressed, or hopeless?” and “Since your new baby was born, how often have you
had little interest or little pleasure in doing things?” Possible responses are “never,”“rarely,”“sometimes,”“often,” and “always.” Women who answered “often” or “always”
were categorized as having symptoms of postpartum depression.
† Women who answered “often” or “always” to either question or both questions

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TABLE 7. Prevalence of serious psychological distress* among adults

aged ≥18 years, by sociodemographic characteristics — National
Health Interview Survey, United States, 2009
Characteristic No. % (95% CI)
Total 27,858 3.2 (2.9–3.5)
Sex
Male 12,322 2.8 (2.4–3.2)
Female 15,536 3.7 (3.3–4.1)
Age group (yrs)
<45 12,846 3.3 (2.9–3.7)
45–64 9,503 3.7 (3.2–4.2)
≥65 5,509 2.1 (1.6–2.6)
Race/Ethnicity
Hispanic 5,196 3.4 (2.9–4.0)
Black, non-Hispanic 4,374 3.8 (3.0–4.7)
White, non-Hispanic 16,187 3.2 (2.8–3.6)
Abbreviation: CI = confidence interval.
*Kessler-6 score of ≥13.

TABLE 8. Prevalence of serious psychological distress* among adults aged ≥18 years, by sociodemographic characteristics
— Behavioral Risk Factor Surveillance System, United States, 2007 and 2009
2007† 2009§
Characteristic No. % (95% CI) No. % (95% CI)
Total 203,096 4.0 (3.8–4.1) 87,992 3.9 (3.6–4.3)
Sex
Male 75,450 3.5 (3.3–3.9) 33,434 3.5 (3.0–4.0)
Female 127,646 4.3 (4.1–4.6) 54,558 4.4 (4.0–4.8)
Age group (yrs)
18–24 7,509 3.6 (3.0–4.3) 2,592 3.1 (2.1–4.5)
25–34 21,168 4.0 (3.6–4.6) 7,329 4.0 (3.2–4.9)
35–44 32,612 4.2 (3.8–4.8) 11,930 3.8 (3.2–4.5)
45–54 42,859 4.6 (4.3–5.0) 17,925 4.9 (4.3–5.6)
≥55 97,652 3.4 (3.1–3.7) 47,668 3.7 (3.3–4.2)
Race/Ethnicity
White, non-Hispanic 158,774 3.4 (3.2–3.5) 68,335 3.5 (3.2–3.9)
Black, non-Hispanic 14,364 6.1 (5.1–7.2) 8,410 5.4 (4.5–6.4)
Other, non-Hispanic¶ 12,700 4.0 (3.3–4.7) 6,507 3.1 (2.3–4.1)
Hispanic 15,552 5.5 (4.8–6.3) 3,886 5.3 (4.2–6.7)
*Kessler-6 score of ≥13.
† Data from 35 states, District of Columbia, and Puerto Rico.
§ Data from 16 states.
¶Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

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TABLE 9. Prevalence of serious psychological distress* among adults aged ≥18 years, by state/area — Behavioral
Risk Factor Surveillance System, United States, 2007 and 2009
2007 2009
State/Area No. % (95% CI) No. % (95% CI)
Alaska 2,329 2.4 (1.5–3.9) —† — —
Arkansas 5,242 5.1 (4.4–6.0) — — —
California 5,169 3.5 (2.9–4.3) 4,784 3.7 (3.0–4.4)
Colorado 5,460 3.2 (2.6–3.9) — — —
District of Columbia 3,545 2.6 (2.0–3.4) — — —
Georgia 6,872 5.0 (4.2–5.9) 5,243 3.1 (2.5–3.9)
Hawaii 6,288 2.4 (1.9–3.0) 6,204 2.4 (1.9–2.9)
Illinois 5,043 3.0 (2.5–3.7) — — —
Indiana 5,473 3.5 (2.9–4.1) — — —
Iowa 4,891 2.3 (1.8–2.8) — — —
Kansas 4,034 2.6 (2.0–3.3) 8,617 2.5 (2.1–3.0)
Kentucky 6,049 6.5 (5.6–7.4) — — —
Louisiana 5,865 5.3 (4.6–6.1) — — —
Maine 3,884 3.8 (3.1–4.7) — — —
Massachusetts 4,394 3.1 (2.4–3.9) 4,738 3.3 (2.6–4.2)
Michigan 4,194 3.8 (3.1–4.7) 2,779 3.5 (2.6–4.6)
Minnesota 4,716 2.7 (2.1–3.4)
Mississippi 7,173 6.6 (5.8–7.5) 10,113 7.1 (6.3–7.9)
Missouri 4,842 5.0 (4.2–6.0) 4,555 4.5 (3.6–5.7)
Montana 5,628 3.5 (2.9–4.2)
Nebraska 5,103 2.5 (1.9–3.3) 4,933 2.6 (1.9–3.7)
Nevada 3,858 4.0 (3.2–5.1) 3,536 4.0 (3.0–5.1)
New Hampshire 5,613 3.2 (2.7–3.8) — — —
New Mexico 5,972 4.1 (3.4–4.8) — — —
Ohio 5,065 4.6 (3.8–5.5) — — —
Oklahoma 6,793 5.3 (4.6–6.1) — — —
Oregon 1,875 2.9 (2.2–3.8) — — —
Rhode Island 3,976 4.7 (3.9–5.6) — — —
South Carolina 9,583 5.0 (4.3–5.8) 8,843 4.4 (3.8–5.2)
Tennessee — — — 2,216 9.4 (7.7–11.6)
Texas 7,673 5.2 (4.3–6.2)
Utah — — — 2,446 1.9 (1.4–2.6)
Vermont 6,592 3.3 (2.7–4.2) 6,278 3.1 (2.5–3.7)
Virginia 5,689 3.3 (2.7–4.0) — — —
Washington 13,317 2.9 (2.5–3.4) 7,062 2.9 (2.4–3.5)
Wisconsin 4,538 2.7 (2.1–3.4) — — —
Wyoming 5,738 3.2 (2.6–3.9) 5,645 2.6 (1.9–3.4)
Puerto Rico 3,776 6.0 (5.2–7.0) — — —
Abbreviation: CI = confidence interval.
* Kessler-6 score of ≥13.
† Not measured.

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TABLE 10. Mean number of mentally unhealthy days* during past TABLE 11. Mean number of mentally unhealthy days* during past
30 days among adults aged ≥18 years, by sociodemographic 30 days among adults aged ≥18 years, by state/area — Behavioral
characteristics — Behavioral Risk Factor Surveillance System, United Risk Factor Surveillance System, United States, 2009
States, 2009†
Mean no. of
Mean no. of mentally
mentally No. of unhealthy
No. of unhealthy State/Area respondents† days (95% CI)
Characteristic respondents days (95% CI) Alabama 6,616 4.2 (3.8–4.5)
Total 424,218 3.5 (3.4–3.6) Alaska 2,363 2.5 (2.1–3.0)
Sex Arizona 5,403 3.4 (3.0–3.9)
Male 161,046 2.9 (2.8–3.1) Arkansas 3,904 3.6 (3.2–4.0)
Female 263,172 4.0 (3.9–4.1) California 17,316 3.7 (3.5–3.9)
Colorado 11,768 3.1 (2.9–3.4)
Age group (yrs)
Connecticut 6,414 3.1 (2.8–3.4)
18–24 13,032 3.9 (3.6–4.2)
Delaware 4,315 3.1 (2.8–3.5)
25–34 36,755 3.8 (3.6–4.0)
District of Columbia 3,844 2.7 (2.4–3.0)
35–44 59,253 3.7 (3.6–3.9)
Florida 11,753 3.5 (3.2–3.8)
45–54 85,446 3.9 (3.8–4.1)
Georgia 5,761 2.8 (2.5–3.1)
≥55 226,168 2.8 (2.7–2.9)
Hawaii 6,642 2.6 (2.3–2.9)
Race/Ethnicity Idaho 5,315 3.2 (2.9–3.5)
White, non-Hispanic 333,119 3.3 (3.2–3.4) Illinois 5,819 3.5 (3.2–3.8)
Black, non-Hispanic 33,741 4.1 (3.9–4.4) Indiana 9,094 3.8 (3.5–4.1)
Other, non-Hispanic§ 23,549 3.6 (3.3–3.8) Iowa 5,941 2.6 (2.4–2.9)
Hispanic 29,361 3.8 (3.6–4.1) Kansas 18,702 2.9 (2.7–3.1)
Abbreviation: CI = confidence interval. Kentucky 9,536 4.6 (4.2–5.0)
* Survey question: “Now thinking about your mental health, which includes Louisiana 8,765 3.5 (3.2–3.8)
stress, depression, and problems with emotions, for how many days during Maine 7,942 3.4 (3.2–3.7)
the past 30 days was your mental health not good?” Maryland 8,440 3.3 (3.0–3.6)
† Data from 50 states, Guam, Puerto Rico, and U.S. Virgin Islands. Only includes Massachusetts 16,397 3.2 (2.9–3.4)
respondents interviewed in 2009. Michigan 9,103 3.7 (3.4–4.0)
§ Asian, Native Hawaiian/ Pacific Islander, American Indian/Alaska Native, other Minnesota 5,583 2.8 (2.5–3.1)
race, and multiple races. Mississippi 10,997 4.1 (3.8–4.4)
Missouri 5,000 3.9 (3.5–4.3)
Montana 7,506 3.3 (3.0–3.6)
Nebraska 15,733 2.6 (2.4–2.9)
Nevada 3,791 4.0 (3.5–4.6)
New Hampshire 5,931 3.1 (2.8–3.4)
New Jersey 12,025 3.3 (3.0–3.6)
New Mexico 8,715 3.5 (3.2–3.8)
New York 6,786 3.5 (3.1–3.8)
North Carolina 13,068 3.8 (3.5–4.1)
North Dakota 4,698 2.4 (2.1–2.7)
Ohio 9,650 3.8 (3.5–4.1)
Oklahoma 7,724 4.3 (3.9–4.6)
Oregon 4,238 3.2 (2.8–3.6)
Pennsylvania 9,003 3.6 (3.3–3.9)
Rhode Island 6,223 3.4 (3.1–3.8)
South Carolina 9,568 3.5 (3.2–3.8)
South Dakota 6,739 2.4 (2.1–2.7)
Tennessee 5,510 3.8 (3.4–4.2)
Texas 11,381 3.6 (3.3–3.9)
Utah 9,997 3.3 (3.0–3.5)
Vermont 6,563 3.3 (3.1–3.6)
Virginia 5,078 3.4 (2.9–3.8)
Washington 20,018 3.3 (3.1–3.5)
West Virginia 4,761 4.1 (3.8–4.5)
Wisconsin 4,517 2.9 (2.5–3.2)
Wyoming 5,965 3.2 (2.8–3.5)
Guam 1,247 2.1 (1.6–2.5)
Puerto Rico 4,136 3.2 (2.8–3.5)
U.S. Virgin Islands 2,414 2.9 (2.4–3.3)
Abbreviation: CI = confidence interval.
* Survey question: “Now thinking about your mental health, which includes
stress, depression, and problems with emotions, for how many days during
the past 30 days was your mental health not good?”
† Only includes respondents interviewed in 2009.

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TABLE 12. Percentage of adults aged ≥18 years who ever received a diagnosis of depression in their lifetime, by
sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008
2006* 2008†
Characteristic No. % (95% CI) No. % (95% CI)
Total 215,576 15.7 (15.4–16.1) 91,377 16.1 (15.6–16.6)
Sex
Male 82,284 11.1 (10.6–11.5) 34,481 11.2 (10.6–11.9)
Female 133,292 20.2 (19.7–20.6) 56,896 20.7 (20.0–21.3)
Age group (yrs)
18–24 9,652 14.5 (13.3–15.8) 3,081 14.8 (12.9–17.0)
25–34 25,525 14.4 (13.7–15.2) 8,584 14.4 (13.2–15.7)
35–44 36,586 16.7 (16.0–17.5) 13,444 16.7 (15.6–17.9)
45–54 44,877 19.3 (18.6–20.0) 18,937 19.9 (18.9–20.9)
≥55 97,304 14.4 (14.0–14.8) 46,637 14.9 (14.3–15.5)
Race/Ethnicity
White, non-Hispanic 165,506 17.2 (16.8–17.6) 73,604 17.3 (16.8–17.8)
Black, non-Hispanic 17,650 11.2 (10.4–12.0) 5,280 12.3 (10.7–14.0)
Other, non-Hispanic§ 13,245 15.1 (13.7–16.6) 6,783 12.2 (10.5–14.1)
Hispanic 17,044 12.6 (11.6–13.7) 4,807 12.8 (11.1–14.7)
Abbreviation: CI = confidence interval.
* Data from 38 states, District of Columbia, Puerto Rico, and U.S. Virgin Islands
† Data from 16 states.
§ Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

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TABLE 13. Percentage of adults aged ≥18 years who ever received a diagnosis of depression in their lifetime,
by state/area — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008
2006 2008
State/Area No. % (95% CI) No. % (95% CI)
Alabama 3,111 17.4 (15.8–19.2) —* — —
Alaska 1,998 17.4 (15.4–19.7) — — —
Arizona — — — 5,768 18.1 (16.1–20.4)
Arkansas 5,288 21.3 (19.9–22.7) — — —
California 5,284 13.5 (12.4–14.7) — — —
Colorado 5,463 17.7 (16.4–19.0)
Connecticut 4,446 14.3 (13.0–15.8) — — —
Delaware 3,941 17.0 (15.2–18.9) — — —
District of Columbia 3,754 15.0 (13.5–16.6) — — —
Florida 10,232 13.1 (12.2–14.2) — — —
Georgia 6,992 14.5 (13.4–15.6) — — —
Hawaii 6,229 8.8 (8.0–9.8) 6,218 9.8 (8.9–10.8)
Idaho — — — 4,893 18.9 (17.4–20.4)
Illinois — — — 5,047 13.5 (12.4–14.7)
Indiana 6,208 19.8 (18.6–21.1) — — —
Iowa 5,164 14.7 (13.5–15.9) — — —
Kansas 4,109 14.1 (12.8–15.6) 4,125 13.5 (12.2–14.8)
Louisiana 6,725 13.2 (12.3–14.2) 5,893 12.4 (11.4–13.4)
Maine 3,864 19.9 (18.5–21.5) 3,981 20.9 (19.3–22.6)
Maryland 4,577 15.4 (13.9–17.1)
Massachusetts — — — 6,326 15.3 (14.0–16.7)
Michigan 5,484 15.9 (14.7–17.0) — — —
Minnesota 4,232 14.4 (13.2–15.8) — — —
Mississippi 5,828 16.9 (15.7–18.2) 6,990 16.8 (15.7–18.1)
Missouri 5,045 18.4 (16.8–20.1) — — —
Montana 5,733 17.1 (15.9–18.4) — — —
Nebraska 3,851 15.5 (13.8–17.3) 5,221 16.9 (15.0–19.1)
Nevada 3,442 15.5 (13.9–17.3) — — —
New Hampshire 5,592 17.2 (16.0–18.6) — — —
New Mexico 6,146 17.1 (16.0–18.3) — — —
New York — — — 3,692 15.5 (14.2–16.9)
North Carolina — — —
North Dakota 4,566 16.8 (15.4–18.4) 4,865 15.0 (13.6–16.4)
Ohio 6,230 19.5 (18.1–20.9)
Oklahoma 6,786 19.9 (18.7–21.1) — — —
Oregon 4,670 21.3 (19.9–22.7) — — —
Rhode Island 4,267 16.8 (15.3–18.4) — — —
South Carolina 8,703 17.3 (16.3–18.4) — — —
Tennessee 4,172 16.4 (14.8–18.0) — — —
Texas 6,395 15.4 (13.9–17.0) — — —
Utah 4,983 19.6 (18.1–21.2) — — —
Vermont 6,794 20.2 (19.1–21.4) 6,586 21.4 (20.2–22.7)
Virginia 5,133 15.1 (13.7–16.7) — — —
Washington 11,301 20.1 (19.1–21.1) 10,079 17.2 (16.2–18.1)
West Virginia 3,725 20.2 (18.7–21.7) — — —
Wisconsin 4,375 16.4 (15.0–17.8) — — —
Wyoming 4,818 18.2 (17.0–19.5) — — —
Puerto Rico 4,588 18.1 (16.9–19.5) — — —
U.S. Virgin Islands 3,025 6.8 (5.8–7.9) — — —
Abbreviation: CI = confidence interval.
* Not measured.

24 MMWR / September 2, 2011 / Vol. 60

 Appendix 1013

Supplement

TABLE 14. Percentage of adults aged ≥18 years who ever received a diagnosis of anxiety in their lifetime, by
sociodemographic characteristics — Behavioral Risk Factor Surveillance System, United States, 2006 and 2008
2006* 2008†
Characteristic No. % (95% CI) No. % (95% CI)
Total 215,522 11.3 (11.0–11.6) 91,339 12.3 (11.8–12.7)
Sex
Male 82,288 8.2 (7.8–8.7) 34,447 9.1 (8.5–9.7)
Female 133,234 14.3 (13.9–14.6) 56,892 15.2 (14.6–15.9)
Age group (yrs)
18–24 9,660 11.3 (10.2–12.5) 3,079 13.0 (11.2–15.1)
25–34 25,530 11.6 (10.9–12.3) 8,574 11.9 (10.8–13.1)
35–44 36,589 12.0 (11.4–12.7) 13,443 13.6 (12.5–14.7)
45–54 44,868 12.9 (12.3–13.5) 18,945 14.1 (13.2–15.0)
≥55 97,246 9.8 (9.5–10.2) 46,606 10.3 (9.8–10.8)
Race/Ethnicity
White, non-Hispanic 165,498 12.2 (11.9–12.5) 73,577 12.9 (12.5–13.4)
Black, non-Hispanic 17,634 8.6 (7.8–9.4) 5,270 9.3 (7.9–10.8)
Other, non-Hispanic§ 13,231 12.0 (10.6–13.7) 6,781 11.8 (9.9–13.9)
Hispanic 17,041 9.0 (8.2–9.8) 4,806 9.7 (8.2–11.3)
Abbreviation: CI = confidence interval.
* Data from 38 states, District of Columbia, Puerto Rico, and U.S. Virgin Islands.
† Data from 16 states.
§ Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, other race, and multiple races.

MMWR / September 2, 2011 / Vol. 60 25

1014 Appendix
Supplement

TABLE 15. Percentage of adults aged ≥18 years who ever received a diagnosis of anxiety in their lifetime, by state/area —
Behavioral Risk Factor Surveillance System, United States, 2006 and 2008
2006 2008
State/Area No. % (95% CI) No. % (95% CI)
Alabama 3,107 14.0 (12.5–15.7) —* — —
Alaska 2,000 12.0 (10.2–14.1) — — —
Arizona 14.0 (12.8–15.2) 5,777 13.0 (11.2–15.1)
Arkansas 5,285 — — —
California 5,283 9.6 (8.6–10.7) — — —
Colorado 5,462 12.3 (11.1–13.5)
Connecticut 4,451 10.0 (8.9–11.3) — — —
Delaware 3,935 12.1 (10.5–13.9) — — —
District of Columbia 3,758 9.5 (8.3–10.9) — — —
Florida 10,241 11.2 (10.3–12.2) — — —
Georgia 6,997 11.1 (10.1–12.1) — — —
Hawaii 6,222 8.0 (7.2–8.9) 6,212 8.3 (7.4–9.2)
Idaho — — — 4,896 11.6 (10.4–12.9)
Illinois — — — 5,044 10.8 (9.7–12.0)
Indiana 6,209 13.8 (12.7–15.0) — — —
Iowa 5,173 9.1 (8.2–10.1) — — —
Kansas 4,110 9.9 (8.8–11.2) 4,128 10.4 (9.2–11.7)
Louisiana 6,719 10.9 (10.0–11.8) 5,896 11.5 (10.5–12.6)
Maine 3,863 16.1 (14.5–17.7) 3,986 16.7 (15.2–18.4)
Maryland 4,582 10.9 (9.6–12.4)
Massachusetts — — — 6,289 13.9 (12.6–15.2)
Michigan 5,487 11.1 (10.1–12.1) — — —
Minnesota 4,232 10.1 (9.1–11.3) — — —
Mississippi 5,808 13.7 (12.6–14.8) 6,984 13.1 (12.1–14.3)
Missouri 5,044 12.5 (11.0–14.3) — — —
Montana 5,735 10.9 (9.8–12.0) — — —
Nebraska 3,850 9.8 (8.4–11.4) 5,223 10.6 (8.9–12.5)
Nevada 3,434 11.6 (10.2–13.2) — — —
New Hampshire 5,604 12.8 (11.7–14.0) — — —
New Jersey — — — — — —
New Mexico 6,155 12.0 (11.0–13.1) — — —
New York — — — 3,692 12.2 (11.0–13.5)
North Dakota 4,564 10.2 (9.0–11.6) 4,868 10.7 (9.4–12.1)
Ohio — — — 6,226 13.8 (12.6–15.2)
Oklahoma 6,775 14.8 (13.8–15.9) — — —
Oregon 4,667 13.2 (12.1–14.5) — — —
Rhode Island 4,266 13.2 (12.0–14.6) — — —
South Carolina 8,694 12.9 (12.0–13.8) — — —
Tennessee 4,171 12.2 (10.7–13.8) — — —
Texas 6,386 10.3 (9.1–11.8) — — —
Utah 4,982 12.6 (11.4–14.0) — — —
Vermont 6,782 14.2 (13.2–15.2) 6,579 14.6 (13.6–15.7)
Virginia 5,135 10.7 (9.5–12.1) — — —
Washington 11,285 12.9 (12.0–13.8) 10,077 11.8 (11.0–12.7)
West Virginia 3,717 17.2 (15.8–18.7) — — —
Wisconsin 4,377 10.2 (9.1–11.5) — — —
Wyoming 4,815 10.6 (9.6–11.7) — — —
Puerto Rico 4,594 14.8 (13.6–16.0) — — —
U.S. Virgin Islands 3,028 5.4 (4.6–6.4) — — —
Abbreviation: CI = confidence interval.
* Not measured.

26 MMWR / September 2, 2011 / Vol. 60

 Appendix 1015
Supplement

TABLE 16. Percentage of adults aged ≥18 years who ever received a diagnosis of bipolar
disorder or schizophrenia,* by sociodemographic characteristics — National Health Interview
Survey, United States, 2007
Bipolar disorder Schizophrenia
Frequency % (SE) % (SE)
Total 23,354 1.7 (0.1) 0.6 (0.1)
Sex
Male 10,356 1.4 (0.1) 0.8 (0.2)
Female 12,998 1.9 (0.2) 0.4 (0.1)
Age group (yrs)
18–39 8,852 2.2 (0.2) 0.6 (0.2)
40–54 6,529 1.9 (0.2) 0.7 (0.1)
≥55 7,973 0.8 (0.1) 0.5 (0.1)
Race/Ethnicity
Hispanic 4,191 0.9 (0.2) 0.5 (0.1)
White, non-Hispanic 14,030 1.9 (0.1) 0.6 (0.1)
Black, non-Hispanic 3,697 1.3 (0.2) 0.8 (0.2)
Abbreviation: SE = standard error.
*Bipolar disorder and schizophrenia are not mutually exclusive.

TABLE 17. Annual average number and rate of ambulatory care visits* for mental health disorders among adults aged ≥18 years, by diagnosis
and medical setting — National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS),
United States, 2007–2008
Medical setting
Physician office OPD ED
No. visits (SE) (NAMCS) (NHAMCS) (NHAMCS)
(in (in Rate of
Primary diagnosis group† ICD-9-CM codes thousands) thousands) visits§ (SE) % (SE) % (SE) % (SE)
All diagnoses 961,646 (28,861) 42,982 (1,290) 82.3 (0.9) 8.0 (0.7) 9.7 (0.4)
Mental health disorders 290–319 47,835 (2,534) 2,138 (113) 80.7 (1.6) 11.8 (1.5) 7.5 (0.5)
Schizophrenic disorders 295 2,730 (507) 122 (23) 79.4 (4.5) 13.4 (3.3) 7.2 (1.6)
Major depressive disorder 296.2–296.3 7,530 (793) 337 (35) 85.0 (2.7) 13.6 (2.6) 1.4 (0.3)
Other psychoses 290–294, 296.0–296.1, 8,451 (584) 378 (26) 80.8 (2.0) 11.0 (1. 8) 8.3 (0.8)
296.4–299
Anxiety states 300.0 6,679 (544) 299 (24) 84.7 (1.5) 7.0 (1.1) 8.3 (0.9)
Neurotic depression 300.4 3,231 (323) 144 (14) 89.6 (1.7) 8.4 (1.6) 2.0 (0.5)
Alcohol dependence syndrome 303 653 (116) 29 (5) —¶ (7.4) 38.7 (7.2) 23.5 (4.8)
Drug dependence and 304–305 3,164 (459) 141 (21) 40.3 (6.5) 29.8 (7.4) 29.9 (4.5)
nondependent use of drugs
Acute reaction to stress and 308–309 2,778 (308) 124 (14) 81.8 (3.2) 14.5 (3.1) 3.7 (0.7)
adjustment reaction
Depressive disorder, not 311 7,299 (622) 326 (28) 85.8 (1.7) 7.9 (1.3) 6.4 (0.8)
elsewhere classified
Attention deficit disorder 314.0 1,736 (242) 78 (11) 94.6 (1.4) 5.4 (1.4) — (0.0)
Other mental disorders 300.1–300.3, 300.5–300.9, 3,585 (494) 160 (22) 83.1 (2.7) 8.5 (1.7) 8.4 (1.5)
301–302, 306–307, 310,
312–313, 314.1–319
Abbreviations: ED = emergency department; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; OPD = outpatient department;
SE = standard error.
* Visits to physician offices and hospital outpatient and emergency departments.
† Primary diagnosis groups are based on a reclassification of codes.
§ Rate per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized adult population as of July 1, 2007, and July 1, 2008. Additional
information on calculation of rates available at http://www.cdc.gov/nchs/ahcd.htm.
¶ Number does not meet standards of reliability or precision.

MMWR / September 2, 2011 / Vol. 60 27

1016 Appendix

Supplement

TABLE 18. Annual average number and rate of ambulatory care visits* for mental health disorders† among adults aged ≥18 years, by age group,
sex, and medical setting — National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey
(NHAMCS), United States, 2007–2008
No. (in thousands) and % of visits Rate§ of visits
Physician office All three Physician office OPD ED
All three settings (NAMCS) OPD (NHAMCS) ED (NHAMCS) settings (NAMCS) (NHAMCS) (NHAMCS)
Characteristic No. (SE) % No. (SE) % No. (SE) % No. (SE) % Rate (SE) Rate (SE) Rate (SE) Rate (SE)
Total 47,835 (—) 100 38,621 (—) 80.7 5,630 (—) 11.8 3,584 (—) 7.5 2,138 (—) 1,726 (—) 252 (—) 160 (—)
Age group (yrs)
18–44 22,443 (1,203) 100 17,303 (1,104) 77.1 3,070 (443) 13.7 2,070 (118) 9.2 2,036 (109) 1,570 (100) 279 (40) 188 (11)
45–64 19,451 (1,291) 100 16,205 (1,268) 83.3 2,086 (260) 10.7 1,160 (74) 6.0 2,533 (168) 2,110 (165) 272 (34) 151 (10)
≥65 5,941 (493) 100 5,113 (489) 86.1 474 (76) 8.0 354 (40) 6.0 1,617 (134) 1,392 (133) 129 (21) 96 (11)
Sex
Male 18,463 (1,206) 100 14,422 (1,170) 78.1 2,194 (308) 11.9 1,847 (105) 10.0 1,710 (112) 1,336 (108) 203 (29) 171 (10)
Female 29,372 (1,584) 100 24,199 (1,511) 82.4 3,436 (425) 11.7 1,737 (105) 5.9 2,537 (137) 2,090 (131) 297 (37) 150 (9)

Abbreviations: ED = emergency department; ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; OPD = outpatient department; SE = standard error.
* Visits to physician offices and hospital outpatient and emergency departments.
† Visits with a primary diagnosis of a mental health disorder (ICD-9-CM codes 290–319).
§ Rate per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized population as of July 1, 2007, and July 1, 2008.

TABLE 19. Hospital* discharge rates† among adults aged ≥18 years with mental illness as primary discharge diagnosis, by age group, diagnosis,
and sex — National Hospital Discharge Survey, United States, 2007
Age group (yrs)
18–44 45–64 ≥65
Men Women Total Men Women Total Men Women Total
Primary discharge
diagnosis Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE)
Adult mental illness§ 105.7 (14.4) 90.1 (14.7) 97.9 (14.2) 104.9 (12.0) 88.9 (11.4) 96.7 (11.1) 63.7 (9.2) 64.9 (7.0) 64.4 (7.2)
Alcohol and drug use 32.4 (5.0) 17.5 (3.1) 25.0 (4.0) 44.6 (5.5) 15.4 (2.1) 29.7 (3.6) 12.9 (1.8) 7.6 (1.4) 9.8 (1.2)
disorders¶
Schizophrenia** 18.2 (2.4) 10.4 (1.7) 14.3 (1.9) 17.0 (2.4) 17.1 (3.1) 17.1 (2.3) 5.4 (1.4) 6.6 (1.2) 6.1 (1.0)
Mood disorders†† 41.5 (6.8) 50.6 (9.7) 46.0 (8.0) 32.8 (4.7) 44.4 (7.2) 38.7 (5.8) 14.7 (2.4) 22.5 (3.4) 19.2 (2.6)
Anxiety, stress, and 3.8 (0.7) 4.5 (0.6) 4.1 (0.5) 2.6 (0.5) 4.7 (0.9) 3.7 (0.5) 1.2 (0.3) 5.3 (1.0) 3.6 (0.6)
adjustment disorders§§

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error.
* Nonfederal, short-stay (<30 days) hospitals.
† Per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized adult population as of July 1, 2007.
§ ICD-9-CM codes 290–312.
¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1).
** ICD-9-CM code 295.
†† ICD-9-CM codes 296, 300.4, and 311.
§§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309.

TABLE 20. Hospital* discharge rates† among adults aged ≥18 years with mental illness among any discharge diagnoses, by age group, diag-
nosis, and sex — National Hospital Discharge Survey, United States, 2007
Age group (yrs)

Discharge 18–44 45–64 ≥65

diagnosis (among Men Women Total Men Women Total Men Women Total
any listed
diagnoses) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE) Rate (SE)
Adult mental 220.3 (16.7) 242.7 (18.3) 231.4 (17.0) 394.1 (22.5) 349.2 (20.2) 371.1 (20.4) 580.1 (42.3) 702.3 (38.0) 650.8 (37.6)
illness§
Alcohol and drug 107.2 (9.8) 74.7 (7.7) 91.1 (8.6) 166.9 (11.7) 70.9 (5.7) 117.7 (8.2) 90.4 (5.4) 40.7 (3.4) 61.6 (3.5)
use disorders¶
Schizophrenia** 24.3 (2.6) 16.1 (1.9) 20.2 (2.1) 32.9 (3.2) 30.1 (3.4) 31.5 (2.8) 19.7 (2.7) 22.2 (2.4) 21.1 (2.1)
Mood disorders†† 78.3 (9.8) 125.5 (13.1) 101.7 (11.1) 110.1 (9.8) 163.1 (11.4) 137.3 (10.0) 114.0 (9.5) 219.2 (14.6) 174.9 (11.4)
Anxiety, stress, 23.2 (2.7) 42.1 (4.1) 32.5 (3.1) 32.6 (2.5) 52.9 (4.1) 43.0 (3.1) 48.5 (3.8) 84.5 (5.5) 69.3 (4.1)
and adjustment
disorders§§

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error.
* Nonfederal, short-stay (<30 days) hospitals.
† Per 10,000 persons, based on U.S. Census Bureau estimates of the civilian noninstitutionalized adult population as of July 1, 2007.
§ ICD-9-CM codes 290–312.
¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1).
** ICD-9-CM code 295.
†† ICD-9-CM codes 296, 300.4, and 311.
§§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309.

28 MMWR / September 2, 2011 / Vol. 60

 Appendix 1017
Supplement

TABLE 21. Percentage of nursing home residents aged ≥65 years with primary diagnosis of mental illness, by age group, diagnosis, and sex
— National Nursing Home Survey, United States, 2004
Age group (yrs)
65–74 75–84 ≥85
Men Women Total Men Women Total Men Women Total
Primary diagnosis % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE)
Alzheimer disease* 4.3 (1.0) 8.2 (1.1) 6.5 (0.8) 11.8 (1.2) 13.7 (0.8) 13.2 (0.7) 9.5 (1.1) 12.6 (0.6) 12.0 (0.6)
All adult mental 16.9 (1.8) 20.0 (1.7) 18.7 (1.3) 18.8 (1.4) 20.4 (0.9) 20.0 (0.8) 21.3 (1.5) 23.9 (0.8) 23.5 (0.7)
illness†
Dementia§ 7.5 (1.2) 7.0 (1.0) 7.2 (0.8) 13.2 (1.1) 13.9 (0.8) 13.7 (0.7) 15.6 (1.3) 19.2 (0.8) 18.6 (0.7)
Alcohol and drug 0.8 (0.4) 0.3 (0.2) 0.5 (0.2) 0.6 (0.3) 0.1 (0.1) 0.2 (0.1) —¶¶ —¶¶ — — — —
use disorders¶
Schizophrenia** 3.4 (0.8) 5.9 (1.0) 4.8 (0.7) 1.5 (0.4) 2.2 (0.3) 2.0 (0.3) — — 0.5 (0.1) 0.5 (0.1)
Mood disorders†† 1.6 (0.6) 3.2 (0.7) 2.5 (0.4) 1.4 (0.4) 2.2 (0.3) 1.9 (0.2) 2.1 (0.5) 1.8 (0.2) 1.9 (0.2)
Anxiety, stress, 0.3 (0.2) 1.3 (0.4) 0.9 (0.3) 0.1 (0.1) 0.5 (0.1) 0.4 (0.1) 0.5 (0.3) 0.3 (0.1) 0.3 (0.1)
and adjustment
disorders§§

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error.
* ICD-9-CM code 331.0.
† ICD-9-CM codes 290–312.
§ ICD-9-CM codes 290 and 294.
¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1).
** ICD-9-CM code 295.
†† ICD-9-CM codes 296, 300.4, and 311.
§§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309.
¶¶ Estimate is unreliable. Relative standard error >30%.

TABLE 22. Percentage of nursing home residents aged ≥65 years with any diagnosis of mental illness among all diagnoses, by age group,
diagnosis, and sex — National Nursing Home Survey, United States, 2004
Age group (yrs)
65–74 75–84 ≥85
Mental health Men Women Total Men Women Total Men Women Total
diagnosis (among
all diagnoses) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE) % (SE)
Alzheimer disease* 6.8 (1.1) 12.3 (1.3) 10.0 (0.9) 17.0 (1.3) 19.2 (0.9) 18.5 (0.8) 15.7 (1.3) 18.9 (0.7) 18.4 (0.7)
All adult mental 60.4 (2.4) 62.5 (2.0) 61.6 (1.6) 62.7 (1.6) 67.4 (1.1) 66.0 (1.0) 63.2 (1.8) 68.7 (0.9) 67.7 (0.8)
illness†
Dementia§ 25.1 (2.0) 24.5 (1.7) 24.8 (1.3) 35.9 (1.6) 34.5 (1.1) 34.9 (0.9) 38.3 (1.7) 41.6 (0.9) 41.0 (0.9)
Alcohol and drug 5.6 (1.1) 1.9 (0.5) 3.5 (0.6) 2.2 (0.5) 0.7 (0.2) 1.2 (0.2) —¶¶ — — — 0.5 (0.1)
use disorders¶
Schizophrenia** 7.3 (1.2) 12.0 (1.4) 10.0 (1.0) 4.2 (0.7) 4.6 (0.5) 4.5 (0.4) — — 1.2 (0.2) 1.1 (0.2)
Mood disorders†† 33.3 (2.3) 34.6 (1.9) 34.0 (1.5) 30.0 (1.5) 39.4 (1.1) 36.6 (1.0) 31.0 (1.6) 36.2 (0.9) 35.3 (0.8)
Anxiety, stress, 10.0 (1.3) 12.9 (1.3) 11.7 (0.9) 7.2 (0.8) 14.4 (0.8) 12.2 (0.6) 8.1 (1.0) 12.5 (0.6) 11.7 (0.5)
and adjustment
disorders§§

Abbreviations: ICD-9-CM = International Classification of Diseases, Ninth Revision, Clinical Modification; SE = standard error.
* ICD-9-CM code 331.0.
† ICD-9-CM codes 290–312.
§ ICD-9-CM codes 290 and 294.
¶ ICD-9-CM codes 291, 292, 303, 304, and 305 (excluding 305.1).
** ICD-9-CM code 295. Supplement
†† ICD-9-CM codes 296, 300.4, and 311.
§§ ICD-9-CM codes 300.0, 300.2, 300.3, 308, and 309.
¶¶ Estimate is unreliable. Relative standard error >30%.

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 Appendix 1019

National Center for Health Statistics

Data Brief No. 76
October 2011

Antidepressant Use in Persons Aged 12 and Over:

United States, 2005–2008
1020 Appendix

NCHS Data Brief ■ No. 76 ■ October 2011

Antidepressant Use in Persons Aged 12 and Over:

United States, 2005–2008
Laura A. Pratt, Ph.D.; Debra J. Brody, M.P.H.; and Qiuping Gu, M.D., Ph.D.

Antidepressants were the third most common prescription drug taken by

Key findings Americans of all ages in 2005–2008 and the most frequently used by
Data from the National persons aged 18–44 years (1). From 1988–1994 through 2005–2008, the
Health and Nutrition rate of antidepressant use in the United States among all ages increased
Examination Surveys, nearly 400% (1).
2005–2008
This data brief discusses all antidepressants taken, regardless of the reason
• Eleven percent of Americans for use. While the majority of antidepressants are taken to treat depression,
aged 12 years and over take antidepressants also can be taken to treat anxiety disorders, for example.
antidepressant medication. The report describes antidepressant use among Americans aged 12 and over,
• Females are more likely to including prevalence of use by age, sex, race and ethnicity, income, depression
take antidepressants than are severity, and length of use.
males, and non-Hispanic white
persons are more likely to take Keywords: prescription medication • depression • National Health and
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 Appendix 1021

NCHS Data Brief ■ No. 76 ■ October 2011

• Overall, females are 2½ times as likely to take antidepressant medication as males.

However, there is no difference by sex in rates of antidepressant use among persons aged
12–17 (Figure 1).

• Twenty-three percent of women aged 40–59 take antidepressants, more than in any other
age-sex group.

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medication than persons of other races and ethnicities.
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• Fourteen percent of non-Hispanic white persons take antidepressant medications compared

with 4% of non-Hispanic black and 3% of Mexican-American persons (Figure 2).

• There is no difference by income in the prevalence of antidepressant usage.

■ 2 ■
1022 Appendix

NCHS Data Brief ■ No. 76 ■ October 2011

Females are more likely than males to take antidepressant medication at

every level of depression severity.
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• Overall, 40% of females and 20% of males with severe depressive symptoms take
antidepressant medication (Figure 3).

• More than one-third of females with moderate depressive symptoms, and less than one-fifth
of males with moderate depressive symptoms, take antidepressant medication.

• Use of antidepressant medication rises as severity of depressive symptoms increases among

both males and females.

■ 3 ■
 Appendix 1023

NCHS Data Brief ■ No. 76 ■ October 2011

About 14% of Americans taking antidepressant medication have done so

for 10 years or longer.
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• More than 60% of Americans taking antidepressant medication have been taking it longer
than 2 years (Figure 4).

• In general, there was no significant difference between males and females in length of use of
antidepressants.

Less than one-third of persons taking a single antidepressant have seen a

mental health professional in the past year.
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■ 4 ■
1024 Appendix

NCHS Data Brief ■ No. 76 ■ October 2011

• Among persons taking antidepressants, approximately 14% take more than one
antidepressant; the percentage was similar for males and females (data not shown).

• Less than one-half of persons taking multiple antidepressants have seen a mental health
professional in the past year (Figure 5).

• Among those taking multiple antidepressants, males are more likely than females to have
seen a mental health professional in the past year.

• The likelihood of having seen a mental health professional increases as the number of
antidepressants taken increases.

Summary
In 2005–2008, 11% of Americans aged 12 and over took antidepressant medication. There were
significant differences in antidepressant medication usage rates between groups. Females were
2½ times as likely as males to take antidepressants. Antidepressant use was higher in persons
aged 40 and over than in those aged 12–39. Non-Hispanic white persons were more likely to
take antidepressants than other race and ethnicity groups. Other studies have shown similar age,
gender, and race and ethnicity patterns (2,3). There was no variation in antidepressant use by
income group. Among persons taking antidepressants overall, there was no significant difference
in length of use between males and females. Among persons taking antidepressants, males were
more likely than females to have seen a mental health professional in the past year.

About 8% of persons aged 12 and over with no current depressive symptoms took antidepressant
medication. This group may include persons taking antidepressants for reasons other than
depression and persons taking antidepressants for depression who are being treated successfully
and do not currently have depressive symptoms.

Slightly over one-third of persons aged 12 and over with current severe depressive symptoms
were taking antidepressants. According to American Psychiatric Association guidelines,
medications are the preferred treatment for moderate to severe depressive symptomatology (4).
The public health importance of increasing treatment rates for depression is reflected in Healthy
People 2020, which includes national objectives to increase treatment for depression in adults and
treatment for mental health problems in children (5).

■ 5 ■
 Appendix 1025

NCHS Data Brief ■ No. 76 ■ October 2011

Definitions
Prescription drug use: National Health and Nutrition Examination Survey (NHANES) participants
were asked if they had taken a prescription drug in the past month. Those who answered “yes”
were asked to show the interviewer the medication containers of all prescription drugs. For each
drug reported, the interviewer recorded the product’s complete name from the container.

Antidepressant medication: Prescription drugs were classified based on the three-level nested
therapeutic classification scheme of Cerner Multum’s Lexicon (6). Antidepressants were
identified using the second level of drug categorical codes, specifically code 249.

Income group: Defined by dividing family income by a poverty threshold based on the size of the
family (http://www.census.gov/hhes/www/poverty/methods/definitions.html#ratio of income to
poverty). Income groups included less than 100% of the poverty level, 100% to less than 200% of
the poverty level, and 200% or more of the poverty level.

Severity of depressive symptoms: Measured in NHANES using the Patient Health Questionnaire
(PHQ–9), a nine-item screener that asks questions about the frequency of symptoms of depression
over the past 2 weeks (7). PHQ–9 is based on the diagnostic criteria for a major depressive
episode in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (8). Major
depression includes mood symptoms such as feelings of sadness or irritability, loss of interest in
usual activities, inability to experience pleasure, feelings of guilt or worthlessness, and thoughts
of death or suicide; cognitive symptoms such as inability to concentrate and difficulty making
decisions; and physical symptoms such as fatigue, lack of energy, feeling restless or slowed
down, and changes in sleep, appetite, and activity levels.

In PHQ–9, the response categories “not at all,” “several days,” “more than half the days,” and
“nearly every day” are given a score ranging from 0 (not at all) to 3 (nearly every day). A total
score is calculated ranging from 0 to 27. The following four categories of depressive symptom
severity are based on the total score from the PHQ–9 screening instrument (7):

• None or minimal 0–4

• Mild 5–9

• Moderate 10–14

• Severe 15 or more

Length of use of antidepressants: Evaluated by asking participants how long they had been
taking the medication. Among persons taking more than one antidepressant, the one they had
taken the longest was used for Figure 4.

Contact with a mental health professional: Defined by the question: “During the past 12 months,
have you seen or talked to a mental health professional such as a psychologist, psychiatrist,
psychiatric nurse, or clinical social worker about your health?”

The data do not indicate whether persons who contacted a mental health professional actually
began treatment for depression. The question also does not ask about mental health treatment
received from primary care providers.

■ 6 ■
1026 Appendix

NCHS Data Brief ■ No. 76 ■ October 2011

Data source and methods

NHANES is a continuous survey conducted to assess the health and nutrition of Americans.
The survey is designed to be nationally representative of the U.S. civilian noninstitutionalized
population. Survey participants complete a household interview and visit a mobile examination
center (MEC) for a physical examination and private interview. The annual interview and
examination sample includes approximately 5,000 persons of all ages. In 2005–2006, non-
Hispanic black persons, Mexican-American persons, adults aged 60 and over, and low-income
persons were oversampled to improve the statistical reliability of the estimates for these groups.
In 2007–2008, the same groups were oversampled with one exception: Rather than oversampling
only the Mexican-American population, all Hispanic persons were oversampled.

This report is based on the analysis of data from interviews in the household and in the MEC. The
questions on prescription drug use were asked in the household interview, and the questions on
depression were asked in the MEC. Questions were administered in English and Spanish.

Of the 13,897 persons aged 12 and over who participated in the NHANES medical examination,
analyses for this data brief included 12,637 persons with information on medication usage and
depression severity. Estimates by income group were based on 11,827 persons who also reported
their family income.

NHANES sample examination weights, which account for the differential probabilities of
selection, nonresponse, and noncoverage, were used for all analyses. Standard errors of the
percentages were estimated using Taylor series linearization, a method that incorporates the
sample design and weights.

Overall differences between groups were evaluated using the chi square statistic. In cases where
the chi square test was significant, differences between subgroups were evaluated using the
univariate t statistic. A test for trends was done to evaluate changes in the estimates by depression
severity in Figure 3 and by number of antidepressants taken in Figure 5. All significance tests
were two-sided using p < 0.05 as the level of significance, with no adjustment for multiple
comparisons. All comparisons reported are statistically significant unless otherwise indicated.
Data analyses were performed using SAS version 9.2 (SAS Institute, Cary, N.C.) and SUDAAN
version 9.0 (RTI International, Research Triangle Park, N.C.).

About the authors

Laura A. Pratt is with the Centers for Disease Control and Prevention’s National Center for
Health Statistics, Office of Analysis and Epidemiology. Debra J. Brody and Qiuping Gu are with
the Centers for Disease Control and Prevention’s National Center for Health Statistics, Division
of Health and Nutrition Examination Surveys.

■ 7 ■
 Appendix 1027

NCHS Data Brief ■ No. 76 ■ October 2011

References Suggested citation

Pratt LA, Brody DJ, Gu Q. Antidepressant
1. National Center for Health Statistics. Health, United States, 2010: With use in persons aged 12 and over:
special feature on death and dying. Table 95. Hyattsville, MD. 2011. United States, 2005–2008. NCHS data brief,
no 76. Hyattsville, MD: National Center for
2. Olfson M, Marcus SC. National patterns in antidepressant medication Health Statistics. 2011.
treatment. Arch Gen Psychiatry 66(8):848–56. 2009.
Copyright information
3. Paulose-Ram R, Safran MA, Jonas BS, Gu Q, Orwig D. Trends in All material appearing in this report is in
psychotropic medication use among U.S. adults. Pharmacoepidemiol Drug the public domain and may be reproduced
Saf 16(5):560–70. 2007. or copied without permission; citation as to
source, however, is appreciated.
4. American Psychiatric Association. Practice guideline for treatment
of patients with major depressive disorder, third edition. Washington, National Center for Health
Statistics
DC. 2010. Available from: http://www.psychiatryonline.com/pracGuide/
Edward J. Sondik, Ph.D., Director
pracGuideTopic_7.aspx.
Jennifer H. Madans, Ph.D., Associate
Director for Science
5. U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion. Healthy People 2020 summary of Office of Analysis and Epidemiology
objectives: Mental health and mental disorders. Available from: http://www. Diane M. Makuc, Dr.P.H., Acting Director
healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicid=28.
Division of Health and Nutrition
Examination Surveys
6. Multum Lexicon database. In: National Health and Nutrition
Clifford L. Johnson, M.S.P.H., Director
Examination Survey—1988–2008 data documentation, codebook, and
frequencies. 2010. Available from: http://www.cdc.gov/nchs/nhanes/
nhanes2007-2008/RXQ_DRUG.htm.
For e-mail updates on NCHS publication
7. Kroenke K, Spitzer RL, Williams JB. The PHQ–9: Validity of a brief releases, subscribe online at:
http://www.cdc.gov/nchs/govdelivery.htm.
depression severity measure. J Gen Intern Med 16(9):606–13. 2001.
For questions or general information about
8. American Psychiatric Association. Diagnostic and statistical manual of NCHS: Tel: 1–800–232–4636
E-mail: [email protected]
mental disorders, fourth edition. Washington, DC. 2000. Internet: http://www.cdc.gov/nchs

ISSN 1941–4927 (Print ed.)

ISSN 1941–4935 (Online ed.)
CS227006
DHHS Publication No. (PHS) 2012–1209
 Appendix 1029

Centers for Disease Control and Prevention

Morbidity and Mortality Weekly Report
May 28, 2010

Attitudes Toward Mental Illness –

35 States, District of Columbia, and Puerto Rico, 2007
1030 Appendix

Morbidity and Mortality Weekly Report (MMWR)

Attitudes Toward Mental Illness --- 35 States, District of Columbia, and

Puerto Rico, 2007
Weekly
May 28, 2010 / 59(20);619-625

Negative attitudes about mental illness often underlie stigma, which can cause affected persons to deny symptoms; delay
treatment; be excluded from employment, housing, or relationships; and interfere with recovery (1). Understanding
attitudes toward mental illness at the state level could help target initiatives to reduce stigma, but state-level data are
scant. To study such attitudes, CDC analyzed data from the District of Columbia (DC), Puerto Rico, and the 35 states
participating in the 2007 Behavioral Risk Factor Surveillance System (BRFSS) (the most recent data available), which
included two questions on attitudes toward mental illness. Most adults (88.6%) agreed with a statement that treatment
can help persons with mental illness lead normal lives, but fewer (57.3%) agreed with a statement that people are generally
caring and sympathetic to persons with mental illness. Responses to these questions differed by age, sex, race/ethnicity,
and education level. Although most adults with mental health symptoms (77.6%) agreed that treatment can help persons
with mental illness lead normal lives, fewer persons with symptoms (24.6%) believed that people are caring and
sympathetic to persons with mental illness. This report provides the first state-specific estimates of these attitudes and
provides a baseline for monitoring trends. Initiatives that can educate the public about how to support persons with
mental illness and local programs and media support to decrease negative stereotypes of mental illness can reduce
barriers for those seeking or receiving treatment for mental illness (2,3).
To measure attitudes about mental illness through BRFSS and other surveys, the Substance Abuse and Mental Health
Services Administration (SAMHSA) and CDC collaborated in 2005 to develop brief questions suitable for surveillance (4).
BRFSS is an ongoing, state-based, random-digit--dialed telephone survey of the noninstitutionalized civilian population
aged !18 years.* With SAMHSA and CDC support, 35 states, DC, and Puerto Rico questioned survey respondents to the
2007 BRFSS about mental illness. Questions included the Kessler-6 scale of serious psychological distress (5), frequent
mental distress, one question about current treatment for an emotional problem, and two attitudinal questions.
The Kessler 6-scale asks respondents how often in the past 30 days they felt six symptoms of mental illness (i.e., feeling
nervous, depressed, hopeless, restless, like a failure, like everything was an effort). Each item is scored on a 5-point scale
indicating frequency, ranging from 0 (none of the time) to 4 (all of the time), and summed (score range: 0--24).
Respondents scoring 13 or more on this scale were classified as having serious psychological distress (5). Frequent mental
distress was measured with the question, "For how many days in the past 30 days was your mental health (due to stress,
depression, or problems with emotions) not good?" Respondents reporting 14 or more poor mental health days were
identified as having frequent mental distress. To determine current treatment for an emotional problem, survey
participants were asked, "Are you now taking medicine or receiving treatment from a doctor or other health professional
for any type of mental health condition or emotional problem?"
Attitudes were assessed by asking respondents to indicate their level of agreement with two statements. The first
statement assessed attitude on the effectiveness of treatment: "Treatment can help people with mental illness lead normal
lives." The second statement assessed the respondent's perception of others' attitudes toward persons with mental illness:
"People are generally caring and sympathetic to people with mental illness."† Before inclusion in BRFSS, cognitive testing
in a sample of the general population confirmed that adults understood these questions as intended. For example,
respondents suggested that "normal lives" meant "being able to do everyday things, like going to the grocery store, paying
bills, things that you have to do to live." The question about attitudes toward treatment also demonstrated acceptable
construct validity with expectations regarding mental illness recovery.
Data were weighted to estimate population parameters. CDC used statistical software to calculate unadjusted and adjusted
proportions (adjusted for sex, age group, racial/ethnic group, education, and household income) of agreement by state and
by serious psychological distress, frequent mental distress, and mental health treatment, and to account for the complex
BRFSS survey design. After adjustment, CDC examined differences in proportions across agreement categories for both
questions by serious psychological distress, frequent mental distress, and mental health treatment status. The analyses
excluded persons who responded "did not know" or "refused" to answer the questions.§ The sample size included 202,065
adults. Among the 35 states, DC, and Puerto Rico, the median Council of American Survey Research Organization
(CASRO) response rate was 51% and the CASRO cooperation rate was 71.4%.¶
 Appendix 1031

Most adults agreed, either strongly (62.8%) or slightly (25.8%), that treatment could help persons with mental illness lead
normal lives, but responses varied by states (Table 1). The highest percentages of strongly agreeing with this statement
were in Connecticut, DC, Louisiana, Oregon, Vermont, Virginia, and Washington; the lowest was in Puerto Rico (Figure).
Proportions for neither agree nor disagree ranged from 0.6% (Iowa) to 9.2% (Puerto Rico). Younger adults, men, persons
other than white non-Hispanics, and persons at lower education levels were less likely to agree strongly with this statement
(Table 2).
In contrast with the statement about treatment, a lower proportion of adults agreed, either strongly (22.3%) or slightly
(35.0%), with the statement that people are caring and sympathetic to persons with mental illness (Table 3). The highest
percentages of strongly agreeing with this statement occurred in Hawaii, Louisiana, Mississippi, Oklahoma, Nevada, and
New Mexico. The lowest was in Puerto Rico. Adults aged 25--54 years, women, white non-Hispanics and black non-
Hispanics, and college graduates were less likely to agree with this statement (Table 2).
Approximately 4.0% of adults were classified with serious psychological distress, 10.0% were classified with frequent
mental distress, and 10.8% reported receiving treatment for an emotional problem. Although most adults with mental
health symptoms (77.6%) agreed strongly or slightly that treatment can help persons with mental illness lead normal lives,
about 17.8% disagreed (Table 2). Fewer respondents with mental health symptoms (24.6%) agreed strongly or slightly that
people are generally caring and sympathetic to persons with mental illness than those without such distress or treatment
(Table 2).

Reported by
R Manderscheid, PhD, National Assoc of County Behavioral Health and Developmental Disability Directors. P Delvec-
chio, MSW, C Marshall, Center for Mental Health Svcs, Substance Abuse and Mental Health Svcs Admin. RG Palpant,
MS, J Bigham, TH Bornemann, EdD, Carter Center Mental Health Program. R Kobau, MPH, MAPP, M Zack, MD, G
Langmaid, W Thompson, PhD, D Lubar, MSW, Div of Adult and Community Health, National Center for Chronic Disease
Prevention and Health Promotion, CDC.

Editorial Note
This is the first state-specific study of attitudes toward mental illness treatment and empathy toward persons with mental
illness. The study sought to assess attitudes related to the course of mental illness (i.e., treatment prognosis and possibility
of recovery; and perception of supportive behaviors) that might directly influence seeking treatment or recovery and might
reflect stigmatizing attitudes amenable to public health intervention. In the 37 jurisdictions surveyed, most adults believed
in the effectiveness of mental illness treatment, but fewer agreed that people are caring and sympathetic toward persons
with mental illness. These results have public health implications because adverse attitudes about mental illness can lead
to stigmatization of persons with mental illness. In addition, the results have implications for mental health treatment
because adults who do not believe in the effectiveness of mental illness treatment might be less likely to seek treatment
when needed. Also, persons with mental health symptoms who believe that others are not caring and sympathetic toward
persons with mental illness might be less likely to disclose mental health problems to friends, family members, colleagues,
or other persons who could help.
Some of the adverse attitudes indicated in this report might be caused by stigma experienced by some respondents (e.g.,
those with mental health problems who received less support at work or at home or who experienced exclusion from activi-
ties) (6). Respondents who perceived adverse attitudes about empathy in other persons also might have had less contact
with persons with mental illness, or also might harbor misconceptions about the risks associated with mental illness symp-
toms (7).
Although the study did not include all 50 states and U.S. territories, state-to-state differences were noted, but no clear
regional patterns emerged on the attitudes studied. Differences might have resulted from culture and the social environ-
ment (e.g., norms, customs, language, lifestyle, and degree of acculturation), differences in how mental health is portrayed
in various media, and differences in awareness of and access to mental health treatment. Geographic variability in attitudes
toward mental illness and its causes should be a topic of further study.
Attitudes toward persons with mental illness appear to be improving in the United States. One study determined that
in 2006, compared with previous decades since the 1950s, more U.S. adults believed that mental health problems could
improve with treatment (8). The large proportion of adults with positive attitudes toward mental illness treatment in the
United States (and in the 37 jurisdictions studied for this report) might result from antistigma campaigns, and greater at-
tention, awareness, and understanding of mental health (9).
One result from the analysis presented in this report was the varying attitudes by education level. For example, adults with
greater education were more likely to agree strongly that mental health treatment can help persons with mental illness lead
normal lives but were less likely to agree strongly that people can be caring and sympathetic to persons with mental illness.
In one study, among some professionals, more knowledge and contact with persons with mental illness was associated with
more stigmatizing attitudes (10). Another possibility is that these adults might have experienced less
1032 Appendix

supportive behaviors associated with mental illness (i.e., feel stigmatized) and thus were more likely to report negative at-
titudes compared with other groups.
The findings in this report are subject to at least four limitations. First, BRFSS surveys include only noninstitutionalized
adults with telephones. Persons in institutions and in households without telephones are excluded, and this population
might include a higher proportion of persons with mental health symptoms. Second, because states commonly use only
English- or Spanish-language surveys, persons who speak other primary languages are excluded, which could affect race-
and ethnicity-specific results. Third, because these data are not nationally representative, no conclusions can be drawn
about the entire U.S. population. Finally, the question on caring and sympathy requires further validation in terms of un-
derstanding its association with other mental health attitudinal measures (4).
Persons with mental illness generally are able to live successful, full lives, particularly if they receive proper treatment and
support. To reduce the effects of stigma, public health and mental health agencies can implement local activities to reduce
negative attitudes about mental illness (3). Because the media can frame public opinion, they can be important partners
in this and in promoting accounts of mental illness recovery (2). Public educational resources, such as those available on
SAMHSA’s “What a difference a friend makes” Internet site,** also can reduce negative attitudes toward mental illness by
providing information about mental illness and its treatment, and help persons learn how to reassure, be friends with, and
accept persons who seek or receive treatment for mental illness.

Acknowledgments
This report is based, in part, on data contributed by BRFSS state coordinators and state mental health services data
infrastructure coordinators.

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ity and change. Public report on the MacArthur Mental Health Module, 1996 General Social Survey. Bloomington,
IN: Indiana Consortium of Mental Health Services Research, Indiana University, and the Joseph P. Mailman School
of Public Health, Columbia University; 2000. Available at http://www.indiana.edu/~icmhsr/docs/Americans’%20
Views%20of%20Mental%20Health.pdf .
9. US Department of Health and Human Services. Mental health: a report of the Surgeon General. Rockville, MD: US
Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for
Mental Health Services, National Institutes of Health, National Institute of Mental Health, 1999.
10. Jorm AF, Korten AE, Jacomb PA, Christensen H, Henderson S. Attitudes towards people with a mental disorder: a
survey of the Australian public and health professionals. Aust N Z J Psychiatry 1999;33:77--83.

* Additional information available at http://www.cdc.gov/brfss.

†
These questions were modified from the 2002 National Scottish Survey of Public Attitudes to Mental Health, Well Being
and Mental Health Problems, included in more recent versions of the survey available at http://www.scotland.gov.uk/pub-
lications/2009/09/15120147/10 .
§
For each question, approximately 2% of respondents answered “did not know” and approximately 0.3% of respondents
refused to answer each question.
¶
The response rate is the percentage of persons who completed interviews among all eligible persons, including those who
were not successfully contacted. The cooperation rate is the percentage of persons who completed interviews among all
 Appendix 1033

eligible persons who were

were contacted.
contacted. Rates
Rates are
are available
available at
at
http://ftp.cdc.gov/pub/data/brfss/2007summarydataqualityreport.pdf.
http://ftp.cdc.gov/pub/data/brfss/2007summarydataqualityreport.pdf .
** Available at http://www.whatadifference.samhsa.gov.
http://www.whatadifference.samhsa.gov .

What is already known

known on
on this
this subject?
subject?
Negative
Negative attitudes
attitudes about
about mental
mental illness
illness pose
pose barriers
barriers for
for persons
personsneeding
needingmental
mentalhealth
healthtreatment
treatmentor
orrecovering
recoveringfrom
from
mental
mental illness.
illness.
What
What isis added
added byby this
this report?
report?
This report provides the first state-specific estimates of attitudes toward persons with mental illness and treatment of
This report
mental provides
illness. the first
Most adults state-specific
agreed estimates
(89%) with of attitudes
the effectiveness oftoward
mental persons with mental
illness treatment butillness and treatment
fewer agreed of
(57%) that
mental
other illness.
people areMost adults
caring and agreed (89%)toward
sympathetic with the effectiveness
those of mental
with mental illness. illness treatment but fewer agreed (57%) that
other people are caring and sympathetic toward those with mental illness.
What are the implications for public health practice?
What are the implications for public health practice?
Initiatives that can educate the public about how to support persons with mental illness and local programs and media
Initiatives
support to that can educate
decrease negativethe public about
stereotypes how toillness
of mental supportcanpersons
reduce with mental
barriers illnessseeking
for those and local programstreatment
or receiving and media
support
for mentalto illness.
decrease negative stereotypes of mental illness can reduce barriers for those seeking or receiving treatment
for mental illness.

TABLE
TABLE 1.
1. Level
Level of
of agreement*
agreement* with
with the
the statement
statement that
that treatment
treatmentcan
canhelp
helppersons
personswith
withmental
mentalillness
illness
lead
lead normal
normal lives,
lives,† by
†
by state
state and
and territory
territory ---
--- Behavioral
BehavioralRisk
RiskFactor
FactorSurveillance
SurveillanceSystem,
System,2007
2007
Unweighted
Unweighted Disagree
Disagree Disagree
Disagree Neither
Neitheragree
agreenor
nor Agree
Agree Agree
Agree
sample
sample size
size strongly
strongly slightly
slightly disagree
disagree slightly
slightly strongly
strongly
State N % (95% CI§) §% (95% CI) % (95% CI) % (95%
(95% (95%
(95%
State N % (95% CI ) % (95% CI) % (95% CI) % CI) %
%
CI) CI)
CI)
Alaska 2,365 1.2 (0.7--2.1) 3.7 (2.4--5.5) 1.4 (0.5--3.2) 25.9(23.0--2
(23.0--2 63.3 (60.0--
(60.0--
Alaska 2,365 1.2 (0.7--2.1) 3.7 (2.4--5.5) 1.4 (0.5--3.2) 25.9 9.1) 63.3 66.5)
9.1) 66.5)
Arkansas 5,299 1.9 (1.3--2.7) 3.5 (2.8--4.4) 0.7 (0.4--1.0) 23.9(22.2-- (65.4--
(22.2-- (65.4--
Arkansas 5,299 1.9 (1.3--2.7) 3.5 (2.8--4.4) 0.7 (0.4--1.0) 23.9 25.6) 67.2 69.0)
25.6) 69.0)
California 5,052 1.8 (1.3--2.5) 4.3 (3.5--5.2) 1.5 (1.1--2.0) 29.6(27.7--
31.5) 61.6(59.7--
(27.7-- (59.7--
California
Colorado 5,052
5,423 1.8(1.0--1.9)
1.4 (1.3--2.5)3.84.3 (3.5--5.2)
(3.0--4.8) 1.5 (1.1--2.0)
0.7 (0.4--1.1) 29.6(24.3--
25.9 61.6 63.6)
31.5) 63.6)
Connecticut 6,586 1.1 (0.7--1.6) 2.4 (1.9--3.1) 1.9 (1.4--2.6) 21.6(20.1-- (63.5--
(24.3-- (63.5--
Colorado 5,423 1.4 (1.0--1.9) 3.8 (3.0--4.8) 0.7 (0.4--1.1) 25.9 27.6) 65.3 67.0)
27.6)
65.3 67.0)
(69.7--
(20.1-- (69.7--
Connecticut 6,586 1.1 (0.7--1.6) 2.4 (1.9--3.1) 1.9 (1.4--2.6) 21.6 23.1) 71.3 72.9)
23.1)
71.3 72.9)
(71.9--
District
District of
of 3,419 1.5 (1.0--2.1) 2.9 (2.2--3.7) 1.3 (0.7--2.1) 18.3(16.5--
(16.5-- (71.9--
Columbia 3,419 1.5 (1.0--2.1) 2.9 (2.2--3.7) 1.3 (0.7--2.1) 18.3 20.2) 74.0 76.0)
Columbia 20.2)
74.0
76.0)
(63.5--
Georgia 6,838 1.8 (1.3--2.5) 3.8 (3.1--4.6) 3.0 (2.4--3.8) 23.7(22.1--
(22.1-- 67.1)
(63.5--
Georgia 6,838 1.8 (1.3--2.5) 3.8 (3.1--4.6) 3.0 (2.4--3.8) 23.7 65.3
25.4)
25.4) 67.1)
Hawaii 6,262 2.4 (1.9--3.0) 4.8 (4.0--5.8) 1.7 (1.3--2.2) 26.9(25.2--
65.3 (58.1--
(25.2-- 61.7)
(58.1--
Hawaii 6,262 2.4 (1.9--3.0) 4.8 (4.0--5.8) 1.7 (1.3--2.2) 26.9 59.9
28.6) 61.7)
Illinois 5,030 1.5 (1.0--2.0) 4.0 (3.2--5.0) 0.9 (0.6--1.3) 27.2 28.6)
(25.4--
(63.1--
59.9
(25.4-- 66.9)
(63.1--
Illinois 5,030 1.5 (1.0--2.0) 4.0 (3.2--5.0) 0.9 (0.6--1.3) 27.2 65.0
Indiana 5,467 1.4 (0.9--2.0) 3.5 (2.8--4.4) 1.3 (0.9--1.7) 26.6(24.8--
29.0) 66.9)
29.0) (62.6--
65.0 66.4)
Iowa 4,921 1.3 (24.8-- (62.6--
Indiana 5,467 1.4 (0.9--1.9)
(0.9--2.0)3.33.5
(2.6--4.2) 0.6 (0.3--1.0)
(2.8--4.4) 1.3 (0.9--1.7) 26.0
26.6(24.3-- 64.5
28.4) 66.4)
(64.7--
28.4) 68.3)
(24.3--
64.5
(64.7--
Iowa 4,921 1.3 (0.9--1.9) 3.3 (2.6--4.2) 0.6 (0.3--1.0) 26.0 66.5
27.8) 68.3)
1034 Appendix

Kansas 4,081 1.1 (0.7--1.4) 2.6 (1.9--3.3) 2.3 (1.6--2.9) 25.5 (23.8-- 66.2 (64.3--
27.3) 68.1)

(23.4-- (60.1--
Kentucky 6,185 1.7 (1.0--2.8) 1.5 (1.1--2.0) 5.7 (4.7--6.9) 25.2 62.1
27.0) 64.1)

(15.3-- (70.3--
Louisiana 6,098 2.1 (1.6--2.8) 3.6 (2.8--4.6) 1.9 (1.4--2.6) 16.6 72.0
18.1) 73.7)

(21.9-- (68.5--
Maine 3,734 1.5 (0.8--2.4) 3.3 (2.5--4.2) 1.0 (0.7--1.6) 23.7 70.5
25.6) 72.5)

(21.3-- (64.5--
Massachusetts 4,162 2.1 (1.3--3.1) 3.6 (2.7--4.6) 1.8 (1.3--2.5) 23.4 66.9
25.7) 69.3)

(23.4-- (63.8--
Michigan 4,235 1.6 (1.0--2.6) 3.5 (2.7--4.5) 0.9 (0.5--1.4) 25.2 65.9
27.1) 67.8)

(27.3-- (65.2--
Minnesota 4,485 ---¶ --- --- --- 3.6 (2.9--4.3) 29.2 67.2
31.2) 69.2)

(20.2-- (65.3--
Mississippi 7,381 2.2 (1.5--3.1) 4.4 (3.6--5.4) 1.3 (1.0--1.7) 21.6 67.0
23.1) 68.7)

(23.1-- (66.3--
Missouri 4,738 1.5 (1.0--2.1) 3.2 (2.4--4.2) 1.7 (1.1--2.3) 25.1 68.6
27.3) 70.7)

(24.2-- (60.8--
Montana 5,415 1.6 (1.1--2.3) 3.5 (2.8--4.4) 3.3 (2.6--4.1) 25.9 62.7
27.6) 64.5)

(22.3-- (64.0--
Nebraska 4,890 1.1 (0.6--1.9) 3.2 (2.3--4.5) 1.7 (1.0--2.8) 24.9 66.9
27.7) 69.7)

(26.8-- (57.7--
Nevada 3,868 2.0 (1.3--2.8) 3.7 (2.9--4.8) 2.0 (1.3--3.0) 29.2 60.2
31.7) 62.7)

New (22.7-- (66.0--

5,453 0.9 (0.6--1.3) 3.1 (2.5--3.9) 2.1 (1.6--2.6) 24.3 67.7
Hampshire 25.9) 69.3)

(22.8-- (61.5--
New Mexico 5,961 1.8 (1.2--2.6) 3.8 (3.1--4.6) 2.4 (1.9--3.0) 24.4 63.3
26.2) 65.2)

(21.3-- (66.9--
Ohio 5,014 1.2 (0.7--1.7) 3.6 (2.9--4.5) 1.4 (1.0--2.0) 23.0 68.8
24.7) 70.6)

(22.7-- (64.9--
Oklahoma 6,885 1.2 (0.8--1.6) 3.1 (2.5--3.8) 0.8 (0.5--1.2) 24.1 66.5
25.6) 68.0)

(19.0-- (68.8--
Oregon 1,898 0.9 (0.4--1.6) 2.2 (1.4--3.5) 1.4 (0.7--2.5) 21.4 71.7
24.1) 74.4)

(54.3-- (23.9--
Puerto Rico 3,832 1.6 (1.1--2.2) 4.4 (3.6--5.3) 9.2 (8.0--10.6) 56.4 25.7
58.4) 27.6)

(26.2-- (59.7--
Rhode Island 3,915 1.3 (0.8--2.0) 3.5 (2.7--4.5) 2.9 (2.1--3.8) 28.3 61.9
30.5) 64.2)

(25.4-- (60.1--
South Carolina 9,889 1.4 (1.1--1.8) 4.4 (3.7--5.1) 1.1 (0.8--1.5) 26.8 61.6
28.2) 63.1)

(23.2-- (56.1--
Texas 7,386 2.2 (1.8--2.8) 4.9 (4.1--5.8) 4.4 (3.7--5.2) 24.9 26.6) 57.9 59.7)

(21.4-- (68.6--
Vermont 6,589 1.0 (0.7--1.5) 2.1 (1.6--2.6) 1.4 (1.0--1.9) 22.8 70.2
 Appendix 1035

24.3) 71.7)
(19.0-- (68.5--
Virginia 5,305 2.1 (1.0--4.2) 2.8 (2.1--3.6) 1.8 (1.3--2.4) 20.8 70.8
22.7) 72.9)

(19.8-- (68.8--
Washington 13,325 1.5 (1.1--1.9) 3.0 (2.4--3.6) 1.9 (1.5--2.3) 20.8 70.0
21.9) 71.2)

(27.7-- (59.4--
Wisconsin 4,332 1.5 (1.0--2.1) 4.3 (3.2--5.5) 0.7 (0.4--1.1) 29.8 61.6
31.9) 63.8)

(25.0- (63.7-
Wyoming 5,780 0.9 (0.5-1.4) 3.1 (2.4-3.9) 1.5 (1.0-2.0) 26.7 65.5
28.5) 67.3)

(3.6-- (25.3-- (62.3--

Total 202,065 1.8 (1.6--2.0) 3.9 2.1 (1.9--2.3) 25.8 62.8
4.1) 26.3) 63.4)
* Adjusted for sex, age group, racial/ethnic group, education and household income level. Estimates are weighted; sample size is unweighted.
† Attitudes were assessed by asking respondents to indicate their level of agreement with the statement, "Treatment can help people with mental illness lead normal
lives."
§ Confidence intervals.

¶ Data suppressed because of unstable estimates; before adjustment, about 4% of Minnesota adults disagreed with this statement.

FIGURE. Level of agreement* with the statement that people are caring and sympathetic to persons with
mental illness,† by state and territory --- Behavioral Risk Factor Surveillance System, 2007
1036 Appendix

FIGURE. Level of agreement* with the statement that people are caring and sympathetic to persons with
mental illness,† by state and territory --- Behavioral Risk Factor Surveillance System, 2007

* Adjusted for sex, age group, racial/ethnic group, education and household income level. Estimates are weighted; sample
size is omitted. Neither agree nor disagree responses are not shown.
†
Attitudes were assessed by asking respondents to indicate their level of agreement with the statement, “People are
generally caring and sympathetic to people with mental illness.”
Alternate Text: The figure above shows the level of agreement with the statement that people are caring and sympa-
thetic to persons with mental illness, by state and territory from the Behavioral Risk Factor Surveillance System in 2007.
Six states (Hawaii, Louisiana, Mississippi, Oklahoma, Nevada, and New Mexico) had the highest percentages, and Puer-
to Rico, the lowest percentage of agreeing strongly that people are caring and sympathetic to those with mental illness.
 Appendix 1037

TABLE 2. Level of agreement with statements about mental illness* by demographic characteristics,
TABLE
serious2. Level of agreement
psychological with
distress, statements
and about mental
having received illness*Behavioral
treatment--- by demographic
Risk Factor Surveillance
characteristics,serious psychological distress, and having received treatment--- Behavioral Risk Factor
System, 2007
Surveillance System, 2007

Unweighted Disagree Disagrees Neither Agree Agree

sample size strongly lightly agree slightly stongly
nor
disagree

(95% (95% (95% (95% (95%

Statements/Characteristics N %† % % % %
CI§) CI) CI) CI) CI)

Treatment can help persons with mental illness lead normal lives

(1.6-- (3.6-- (1.9- (25.3- (62.3-

Total† 202,065 1.8 3.9 2.1 25.8 62.8
2.0) 4.1) -2.3) -26.3) -63.4)

Age group (yrs)

(1.7-- (5.7-- (1.6-- (36.2- (48.2-
18--24 7,286 2.3 6.8 2.1 38.4 50.5
3.1) 8.0) 2.7) -40.6) -52.7)
(1.5-- (3.5-- (1.6-- (29.7-- (59.8--
25--34 20,504 1.9 4.0 1.9 31.0 61.2
2.5) 4.6) 2.3) 32.3) 62.5)
(1.2-- (2.7-- (1.6-- (23.2- (69.2--
35--54 72,878 1.4 2.9 1.9 23.9 69.9
1.7) 3.2) 2.1) -24.6) 70.6)
(1.2-- (3.2-- (2.3-- (23.0- (68.4-
!55 93,290 1.4 3.5 2.5 23.6 69.0
1.6) 3.8) 2.7) -24.2) -69.6)
Sex
(1.7-- (4.0-- (2.1-- (29.9- (59.9--
Male 72,350 1.9 4.3 2.3 30.7 60.7
2.2) 4.7) 2.6) -31.5) 61.6)
(1.1-- (2.9-- (1.7-- (22.5-- (70.0-
Female 122,671 1.3 3.2 1.9 23.0 70.6
1.5) 3.5) 2.1) 23.6) -71.2)

Race/Ethnicity

(1.0-- (2.8-- (1.6-- (24.2- (68.9-

White, non-Hispanic 152,980 1.1 3.0 1.8 24.7 69.4
1.3) 3.3) 2.0) -25.2) -69.9)
(2.3-- (5.6-- (1.9-- (25.1-- (59.6--
Black, non-Hispanic 13,772 2.8 6.6 2.4 26.9 61.4
3.3) 7.7) 3.0) 28.7) 63.3)
(2.4-- (4.3-- (2.9-- (32.9- (52.0--
Hispanic 14,689 3.0 5.1 3.4 34.7 53.8
3.7) 6.0) 4.0) -36.5) 55.7)

(1.4-- (3.6-- (1.4-- (27.7-- (59.3--

Other 12,062 2.1 4.4 1.9 29.9 61.7
3.0) 5.4) 2.6) 32.2) 64.0)

Educational level
(2.8-- (5.0-- (2.9-- (30.2- (53.4--
<High school 18,186 3.4 5.8 3.5 31.9 55.3
4.1) 6.7) 4.2) -33.7) 57.1)
(1.6-- (4.5-- (2.1-- (29.3- (59.7--
High school graduate 56,660 1.9 5.0 2.4 30.2 60.6
2.2) 5.4) 2.7) -31.1) 61.6)
(1.1-- (3.4-- (1.8-- (26.6- (64.2--
Some college 51,772 1.4 3.8 2.0 27.6 65.2
1.7) 4.2) 2.3) -28.5) 66.2)
1038 Appendix

College graduate 68,130 1.0 (0.7-- 2.1 (1.8-- 1.5 (1.3-- 21.7 (21.0-- 73.8 (73.0--
1.3) 2.4) 1.7) 22.4) 74.5)

Mental health symptoms†

Frequent mental distress 20,176 3.1 (2.5-- 5.3 (4.6-- 2.1 (1.7-- 24.8 (23.4- 61.5 (59.9--
3.6) 5.9) 2.6) -26.1) 63.0)

Serious psychological distress 8,010 5.7 (4.8-- 9.6 (8.3-- 2.3 (1.6-- 24.6 (22.4- 54.6 (52.0--
6.7) 10.9) 3.1) -26.8) 57.2)

Receiving medicine/treatment- 26,279 1.8 (1.4-- 3.9 (3.4-- 1.4 (1.2-- 20.3 (19.2-- 70.2 (69.0-
from a health professional foran 2.1) 4.5) 1.7) 21.4) -71.3)
emotional problem

None of the above 157,176 1.6 (1.4-- 3.8 (3.5-- 2.2 (2.0-- 26.8 (26.3- 62.4 (61.9--
1.8) 4.1) 2.4) -27.4) 63.0)

All of the above 3,293 6.8 (5.4-- 11.0 (8.8-- 2.3 (1.4-- 25.6 (22.6- 52.0 (48.5--
8.2) 13.2) 3.2) -28.6) 55.5)

People are generally caring and sympathetic to persons with mental illness

Total† 202,065 10.6 (10.3- 24.7 (24.3- 3.2 (3.0- 35.0 (34.5- 22.3 (21.9-
-10.9) -25.2) -3.4) -35.5) -22.8)

Age group (yrs)

18--24 7,339 7.7 (6.8-- 23.0 (21.2-- 2.9 (2.3-- 43.5 (41.3-- 22.8 (20.9-
8.8) 24.9) 3.6) 45.7) -24.8)

25--34 20,579 10.3 (9.6-- 28.3 (27.2-- 3.0 (2.6-- 37.9 (36.6- 20.4 (19.3--
11.2) 29.5) 3.5) -39.2) 21.7)

35--54 72,928 12.0 (11.6-- 27.1 (26.5-- 3.3 (3.0-- 37.0 (36.2- 20.5 (19.9--
12.5) 27.8) 3.6) -37.7) 21.2)

!55 92,814 11.1 (10.7-- 23.5 (22.9-- 3.7 (3.5-- 34.5 (33.9- 27.2 (26.6--
11.5) 24.0) 4.0) -35.2) 27.8)

Sex

Male 72,578 8.9 (8.4-- 22.9 (22.2-- 3.5 (3.2-- 40.6 (39.8- 24.1 (23.4--
9.3) 23.6) 3.8) -41.4) 24.9)

Female 122,140 12.9 (12.5-- 28.5 (27.9-- 3.2 (3.0-- 33.9 (33.3-- 21.5 (20.9-
13.3) 29.0) 3.4) 34.5) -22.0)

Race/Ethnicity

White, non-Hispanic 152,612 11.2 (10.8- 28.0 (27.5-- 3.2 (3.0-- 38.4 (37.9-- 19.3 (18.9--
-11.5) 28.5) 3.4) 38.9) 19.7)

Black, non-Hispanic 13,772 15.1 (13.9-- 23.0 (21.5-- 3.0 (2.5-- 31.7 (29.9- 27.2 (25.6--
16.4) 24.6) 3.7) -33.6) 28.8)
 Appendix 1039

Hispanic 14,672 7.8 (6.9-- 20.3 (18.9-- 4.5 (4.0-- 35.7 (33.9- 31.7 (29.9--
8.7) 21.8) 5.1) -37.6) 33.5)

Other 12,154 10.7 (9.6-- 19.2 (17.5-- 2.9 (2.2-- 35.0 (32.7-- 32.2 (30.0-
12.0) 20.9) 3.7) 37.4) -34.5)

Educational level

<High school 18,096 9.3 (8.4-- 16.3 (15.0-- 3.4 (2.9-- 32.4 (30.7- 38.6 (36.8-
10.3) 17.5) 3.9) -34.2) -40.5)

High school graduate 56,843 10.5 (10.0- 22.3 (21.6-- 3.3 (3.0-- 36.2 (35.2-- 27.7 (26.9--
-11.0) 23.1) 3.7) 37.1) 28.6)

Some college 51,687 12.1 (11.5-- 27.3 (26.4-- 3.5 (3.1-- 36.8 (35.9-- 20.4 (19.6--
12.7) 28.2) 3.8) 37.8) 21.2)

College graduate 67,814 11.0 (10.5-- 30.4 (29.7-- 3.3 (3.0-- 39.8 (39.0- 15.6 (15.0--
11.5) 31.2) 3.6) -40.5) 16.2)

Mental health symptoms†

Frequent mental distress 20,176 22.2 (21.1-- 26.6 (25.2-- 2.9 (2.3-- 28.1 (26.6- 17.3 (16.0--
23.4) 28.0) 3.4) -29.6) 18.6)

Serious psychological distress 8,010 31.4 (29.2- 26.4 (23.7-- 2.3 (1.6-- 22.9 (20.6- 14.4 (12.3--
-33.6) 29.0) 3.0) -25.3) 16.4)

Receiving medicine/treatment 26,279 19.3 (18.3-- 27.2 (26.0- 3.2 (2.7-- 29.3 (28.1-- 17.6 (16.7--
from a health professional for 20.3) -28.3) 3.6) 30.6) 18.6)
an emotional problem

None of the above 157,176 9.2 (8.9-- 24.3 (23.8-- 3.2 (3.0-- 36.4 (35.8- 23.4 (22.9--
9.5) 24.8) 3.5) -36.9) 23.9)

All of the above 3,293 51.1 (47.4- 20.7 (17.3-- 2.0 (0.6-- 15.6 (12.7-- 9.0 (6.7--
-54.8) 24.2) 3.4) 18.5) 11.4)

* Attitudes were assessed by asking respondents to indicate their level of agreement with the statements "Treatment can help people with mental illness lead normal
lives" and "People are generally caring and sympathetic to people with mental illness."
† Adjusted for sex, age group, racial/ethnic group, education and household income level. Row totals do not equal 100% because "don't know" and refusals were
omitted. Estimates are weighted; sample size is unweighted.
§ Confidence intervals.

TABLE 3. Level of agreement* with the statement that people are caring and sympathetic to persons with
mental illness,† by state and territory --- Behavioral Risk Factor Surveillance System, 2007

Unweighted Disagree Disagree Neither agree nor Agree

Agree slightly
sample size strongly slightly disagree strongly

(95% (95% (95%

State N % % % (95% CI) % (95% CI) %
CI§) CI) CI)

(22.7-- (17.7--
Alaska 2,365 9.4 (7.7--11.3) 25.4 28.4) 2.3 (1.2--4.5) 37.8 (34.7--40.9) 20.3 23.2)

(11.6-- (25.8-- (20.2-

1040 Appendix

Arkansas 5,299 12.7 13.9) 27.4 29.1) 1.4 (1.0--1.9) 33.8 (32.0--35.6) 21.6 -23.2)
(20.0-- (23.4-
California 5,052 8.0 (7.0--9.0) 21.6 2.1 (1.6--2.6) 42.0 (40.1--43.9) 25.1
23.2) -26.9)

(26.7-- (20.2-
Colorado 5,422 8.6 (7.7--9.6) 28.3 1.3 (1.0--1.6) 36.3 (34.6--38.0) 21.8
29.9) -23.4)

(9.8-- (27.1-- (17.5--

Connecticut 6,623 10.9 28.7 4.0 (3.3--4.7) 32.8 (31.2--34.5) 18.8
12.0) 30.3) 20.1)

District of (12.8-- (26.3-- (17.7--

3,419 14.3 28.2 3.0 (2.3--3.7) 30.6 (28.5--32.7) 19.5
Columbia 15.9) 30.2) 21.4)

(10.7-- (23.7-- (20.1-

Georgia 6,838 11.8 25.3 4.8 (4.1--5.7) 34.1 (32.3--35.9) 21.6
13.0) 26.9) -23.1)

(19.5-- (28.0-
Hawaii 6,270 10.5 (9.4--11.7) 20.9 2.4 (1.9--3.0) 33.5 (31.8--35.2) 29.7
22.4) -31.4)

(25.2-- (20.7-
Illinois 5,030 10.1 (9.0--11.3) 26.8 1.1 (0.8--1.6) 38.4 (36.5--40.2) 22.3
28.5) -23.9)

(23.7-- (20.6-
Indiana 5,467 10.1 (9.1--11.2) 25.3 2.0 (1.5--2.6) 37.7 (35.8--39.6) 22.2
26.9) -23.9)

(23.7-- (18.9-
Iowa 4,921 10.5 (9.5--11.6) 25.2 1.5 (1.1--2.0) 40.0 (38.2--41.9) 20.3
26.8) -21.9)

(26.9-- (15.7--
Kansas 4,081 10.4 (9.3--11.6) 28.6 4.5 (3.7--5.3) 36.7 (34.7--38.6) 17.2
30.4) 18.8)

(14.6-- (17.0-- (21.6--

Kentucky 6,185 16.1 18.5 11.1 (9.8--12.7) 27.0 (25.2--28.8) 23.3
17.7) 20.2) 25.1)

(12.6-- (17.5-- (31.1--

Louisiana 6,099 13.8 18.9 3.7 (3.1--4.4) 25.7 (24.2--27.4) 32.7
15.1) 20.4) 34.4)

(8.1-- (25.7-- (19.4-

Maine 3,851 9.2 27.5 2.1 (1.6--2.7) 37.9 (35.9--40.0) 21.1
10.4) 29.5) -22.8)

(10.1-- (25.0-- (18.7--

Massachusetts 4,162 11.6 27.1 3.4 (2.6--4.4) 34.7 (32.3--37.1) 20.6
13.3) 29.3) 22.8)

(24.2-- (21.3--
Michigan 4,235 10.0 (8.9--11.2) 26.0 1.5 (0.9--2.4) 37.3 (35.3--39.3) 22.9
27.8) 24.6)

(23.6-- (16.7--
Minnesota 4,729 8.1 (7.1--9.1) 25.3 5.0 (4.2--6.0) 41.9 (39.9--43.9) 18.3
27.0) 20.0)

(16.4-- (21.5-- (26.4-

Mississippi 7,381 17.7 22.8 2.6 (2.1--3.1) 25.7 (24.2--27.2) 28.0
19.1) 24.2) -29.6)

(11.7-- (27.2-- (16.2--

Missouri 4,850 13.2 29.2 1.5 (1.1--2.1) 36.3 (34.1--38.5) 17.8
14.7) 31.4) 19.5)

(8.5-- (23.9-- (16.5--

Montana 5,415 9.5 25.5 4.7 (4.0--5.5) 37.8 (35.9--39.7) 17.9
10.5) 27.2) 19.5)

(23.2-- (17.7--
Nebraska 4,890 8.4 (7.0--10.1) 25.7 2.0 (1.3--3.0) 40.7 (37.8--43.7) 19.9
28.4) 22.3)

(10.1-- (26.4-- (23.2-

Nevada 3,868 11.4 12.9) 28.7 31.0) 2.3 (1.7--3.0) 28.8 (26.6--31.1) 25.5 -27.9)
 Appendix 1041

New 5,453 10.3 (9.3--11.4) 27.5 (26.0-- 3.7 (3.1--4.4) 38.6 (36.9--40.4) 17.7 (16.5--
Hampshire 29.1) 19.1)
(24.5-- (24.0-
New Mexico 5,961 10.5 (9.5--11.7) 26.1 2.3 (1.8--3.0) 31.7 (29.9--33.5) 25.7
27.7) -27.4)

(26.5-- (16.5--
Ohio 5,014 10.9 (9.7--12.1) 28.2 3.3 (2.6--4.1) 37.5 (35.6--39.4) 17.9
30.0) 19.5)

(10.5-- (22.3-- (26.1--

Oklahoma 6,885 11.5 23.6 1.1 (0.8--1.6) 32.7 (31.2--34.3) 27.5
12.5) 24.9) 29.0)

(13.5-- (29.2-- (13.3--

Oregon 1,898 15.5 32.0 2.1 (1.3--3.2) 32.2 (29.5--35.0) 15.3
17.7) 34.8) 17.6)

(33.4-- (6.2--
Puerto Rico 3,832 6.5 (5.5--7.6) 35.4 17.3 (15.7--18.9) 31.1 (29.2--33.1) 7.2
37.4) 8.3)

(8.3-- (21.5-- (20.0-

Rhode Island 3,923 9.4 23.4 4.5 (3.7--5.5) 39.1 (36.9--41.3) 21.8
10.7) 25.3) -23.8)

(10.0-- (23.1-- (23.0-

South Carolina 9,889 10.9 24.3 1.2 (0.9--1.6) 35.0 (33.6--36.5) 24.2
11.9) 25.7) -25.5)

(18.4-- (24.6-
Texas 7,386 10.6 (9.5--11.7) 19.8 5.2 (4.5--6.1) 32.1 (30.4--33.9) 26.3
21.2) -28.0)

(25.4-- (18.9-
Vermont 6,589 8.0 (7.2--8.8) 26.8 2.1 (1.7--2.6) 40.0 (38.4--41.6) 20.2
28.3) -21.5)

(9.8-- (26.0-- (16.4-

Virginia 5,305 11.0 28.3 4.2 (3.4--5.1) 36.1 (33.8--38.4) 18.3
12.4) 30.6) -20.3)

(16.7-- (25.7-- (18.5--

Washington 13,366 17.6 26.8 3.1 (2.7--3.6) 28.1 (27.0--29.3) 19.5
18.6) 27.9) 20.6)

(8.3-- (27.1-- (18.1--

Wisconsin 4,332 9.6 29.1 0.5 (0.3--0.9) 40.1 (37.9--42.4) 19.8
11.0) 31.2) 21.6)

(28.7-- (16.3--
Wyoming 5,780 10.7 (9.7--11.8) 30.4 1.6 (1.2--2.0) 37.4 (35.7--39.2) 17.6
32.0) 19.0)

(21.9-
(10.3-- (24.3--
Total 202,065 10.6 24.7 3.2 (3.0--3.4) 35.0 (34.5.35.5) 22.3 -
10.9) 25.2)
22.8)
* Adjusted for sex, age group, racial/ethnic group, education and household income level. Estimates are weighted; sample size is unweighted.
† Attitudes were assessed by asking respondents to indicate their level of agreement with the statement, "People are generally caring and sympathetic to people with
mental illness."
§ Confidence intervals.

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 Index
Index note: Article titles and their page numbers are in boldface.

A access to care, 1:209, 1:251, 1:462

AA. See Alcoholics Anonymous (AA) availability, 1:253
AACC (American Association of Christian equitable, 1:297
Counselors), 2:751–752 facilitating, 2:800
ABA (Applied Behavioral Analysis), inequalities, 2:915
1:66 insufficient in prison psychiatry, 2:684
Abdel-Khalek, Ahmed, 1:23 legislation, 1:463
Abi-Rached, Joelle M., 2:701 limited, 1:349
abnormality, 2:589 policy: federal government, 2:653
as adaptive maladaptive, 2:588 rights, 1:252
mental, 2:668 Accounts of Innocence (Davis, J.), 2:892
statistical, 2:588 acculturation, 1:1–4, 2:971. See also cultural
Abraham, Karl, 2:764 prevalence; culture; diagnosis in cross-national
Abramowski, Edward, 2:647 context
abreaction, 2:894 adapting to change, 1:2
absenteeism, 1:97, 1:156, 1:270, defined, 1:1
2:649 future and, 1:3–4
absurd evil, 2:956 learning new language and, 1:1–2
abuse, 2:876. See also alcoholism; drug abuse; mental health and, 1:2–3
drug abuse: cause and effect; substance abuse; ACF (Administration for Children and Families),
Substance Abuse and Mental Health Services 1:191
Administration (SAMHSA) achievement gap, 2:951
barbiturates, 1:77 ACL (Administration for Community Living),
compulsory treatment and, 1:146 1:191
inhalant abuse, 2:975 ACNP (American College of
minor tranquilizers, 1:546 Neuropychopharmacology), 2:722
NCMDA, 1:225 ACT (assertive community treatment teams),
NIAAA, 2:881 1:147, 2:789, 2:971
NIDA, 1:226, 2:881 Act De Praerogative Regis, 1:xxxv

1043
1044 Index

“Active Therapy in the Lunatic Facility,” 1:xxxviii talk therapy and, 1:7
Actor Prepares, The (Stanislavsky), 2:874 United States prevalence, 2:922–923
Actor’s Studio, 2:874 YRBS, 2:920
acute somatoform illnesses, 2:971 Adorno, Theodor, 1:164, 1:489
AD (atypical depression), 1:548 adults
ADA. See Americans with Disabilities Act (ADA) adult day care centers, 2:972
Adam Walsh Act (AWA), 1:137 psychiatric treatment, pathways to,
Addams, Jane, 1:123 2:696–697
addiction, 2:869. See also alcoholism; drug United Kingdom epidemiology, 2:915–917
abuse; substance abuse United States prevalence, 2:921–922
benzodiazepines, 1:78 advanced practice nursing, 2:595–596
CAMH, 2:623 advocacy. See also patient activism; patient
cybersex, 1:366 rights; rights
diazepam, 1:211 children’s support and advocacy services,
sex, 1:366 1:140
ADHD. See attention-deficit hyperactivity National Association for Rights Protection
disorder (ADHD) and Advocacy, 1:152
adjustment disorders, 2:971–972 NGOs, 2:844
Adler, Alfred, 1:318, 2:714, 2:883 Protection and Advocacy for Mentally Ill
Administration for Children and Families (ACF), Individuals Act of 1986, 1:152
1:191 Treatment Advocacy Center, 1:147
Administration for Community Living (ACL), aerosols, 2:975
1:191 Aeschylus, 1:308
adolescence, 1:4–7. See also children; family “Aetiology of Hysteria, The,” 2:706
support; peer identification affective disorders. See mood disorders
ADHD and, 1:5–6 Afghanistan, 1:7–9
adolescent limited (AL), 1:36 baymaree ruhi wa rawanee, 1:7
anorexia nervosa, 1:5 mental health of veterans, 2:931
biotherapies and, 1:7 NGOs and, 1:8
bulimia nervosa, 1:5 rates, risk, treatment, 1:7–8
CARDIA, 2:807 social determinants of health, 1:7
depression, 1:5 WHO on, 1:8
diagnosis and, 1:4 World Bank on, 1:7
epidemiology United Kingdom, 2:917 African Americans
experimentation period, 1:4 Alzheimer’s disease and, 1:25
family therapy, 1:7 chronic pain and, 1:114
incidence rates, 1:5 eating disorders, 1:248
National Longitudinal Study of Adolescent exercise, 1:186
Health, 2:748 hallucinations and, 1:347
ongoing trends, 1:6 insomnia, 2:807
pathways to psychiatric treatment, 2:697 prayer and, 1:114
prevention and treatment, 1:6 sleep disorders among, 2:807–808
research, 1:6 sociological perspectives of mental illness and,
risk factors, 1:4–5 1:521
self-help groups, 1:7 Tourette syndrome and, 2:887
self-injury, 1:5 age, 1:9–11. See also adolescence; adults;
SES and, 1:4 children; geriatrics; nursing homes
sex differences, 1:5–6 ADHD and, 1:9
sexual surgery, 2:800 anxiety and, 1:9–10
suicide, 1:5–6 cognitive abilities and, 1:xlv
 Index 1045

across cultures, 1:184–185 coining, 1:xxxvi

depression and, 1:9–10 constructions of alcohol-related disorders,
life stages and types of mental illness, 1:9–11 1:17–18
methodological issues, 1:11 as disease, 1:xli
OCD and, 2:606 IPV and, 1:20
psychosis and, 1:9 MAST, 1:51
PTSD and, 1:10 NIAAA, 2:881
trauma and, 1:11 research, 1:19–20
ageism, 1:12–14, 2:972 treatment and considerations for future, 1:20
barriers to care, 1:12–14 WHO and, 1:17, 1:21
coining, 1:12 Alexander, Franz, 2:725
future clinical, health care, and research Algeria, 1:22–23
needs, 1:13–14 colonialism, 1:22
health and health care problems, 1:13 diagnoses, epidemiology, treatment, 1:22–23
research, 1:12 FLN, 1:22
resilience, 1:14 jinnoon, 1:22
stigma, 1:12 PTSD in, 1:22
WPA on, 1:13 religiosity, 1:23
Agency for Healthcare Research and Quality alienism, 1:525
(AHRQ), 1:191 Al-Issa, Ihsan, 1:22
Agency for Toxic Substances and Disease alkoholismus chronicus, 1:xxxvi
Registry (ATSDR), 1:191 all cause dementia, 1:186
aggression, 1:302 All We Have to Fear (Horwitz, Wakefield),
aggressive advertising of drugs, 1:487–488 1:503
sex and, 1:499 Alles, Gordon, 1:29
agoraphobia, 1:xxxvi, 1:14–17, 2:642, 2:972 All-Russian Congress for Psychoneurology,
definitions and characteristics, 1:14 2:699
DNA and, 1:16 Al-Majusi, Ali ibn Abbas, 2:725, 2:726
DSM on, 1:14 alprazolam, 1:77, 1:78, 2:797
etiology, epidemiology, treatment, 1:16 altered state of consciousness, 1:218
lifetime prevalence, 1:14 altruistic suicide, 1:244–245
panic disorder, 1:14 Alyard, Elizabeth, 1:407
variations in culture, 1:14–15 Alzheimer, Alois, 1:xxxvii, 1:23
Ahl, Frederick, 1:308 Alzheimer’s disease, 1:xxxvii, 1:xliv, 1:23–26.
AHRQ (Agency for Healthcare Research and See also delusions; dementia; memory loss
Quality), 1:191 African Americans and, 1:25
Alaskan Natives, 2:857–858 bereavement, 1:25
alcohol-induced mood disorders, 1:549 care, 1:25
Alcoholics Anonymous (AA) care giving, 1:25–26
founding, 1:xxxix coining, 1:23
self-help group, 2:781, 2:881 costs, 1:26
worldwide spread, 1:18 dementia and, 1:23, 1:184
Alcoholics Anonymous: The Story of How More depression and, 1:24
Than One Hundred Men Have Recovered Egypt, 1:255
From Alcoholism (Wilson, Smith, B.), 1:xxxix epidemiology and diagnosis, 1:24
alcoholism, 1:17–21, 2:972, 2:974 Latinos and, 1:25
AMA and, 1:18 PTSD and, 1:24
causes and diagnoses, 1:18–20 research, 1:24
Centre for Alcohol Studies, 1:17 schizophrenia and, 1:24
cirrhosis and, 1:21 stigma, 1:26
1046 Index

AMA. See American Medical Association (AMA) headquarters, 1:28

American Association for the Advancement of implications for cultural sociology of mental
Science (AAAS), 2:721 illness, 1:29
American Association of Christian Counselors membership, 1:27–28
(AACC), 2:751–752 Mind/Body Health Public Education
American Bar Association, 1:xli Campaign, 1:543
American Board of Medical Specialties, publications, 1:28
2:699 Section on Clinical Psychology, 1:121
American Board of Neurological Surgery, American Sociological Association, Canada,
2:699 1:xliv
American College of Neuropychopharmacology American Sociological Review, 1:xl
(ACNP), 2:722 Americans with Disabilities Act (ADA), 1:xliv
American ethnoscape, 1:1 accommodations, 1:271
American Family Physician, 2:787 amendments, 1:152, 1:328
American Journal of Psychiatry, 1:471, 2:903 antidiscrimination statutes, 1:214
American Law Institute, 1:159, 1:356–357 compulsory treatment and, 1:147
American Medical Association (AMA), 1:xli impact, 1:212
alcoholism and, 1:18 passage, 1:451, 1:461, 1:483
Benzedrine and, 1:30 reauthorization, 2:594
Council on Pharmacy and Chemistry, signing of, 1:270
1:124–125 AMHPs (approved mental health professionals),
Szasz criticism, 2:864 2:689
American Neurological Association, amnesia, 1:211, 1:562
2:698–699 anterograde, 1:132, 1:180
American Notes for General Circulation as cognitive disorder, 1:131–132
(Dickens), 1:54–55 dissociative, 1:219, 2:974
American Pharmaceutical Manufacturer’s minor tranquilizers and, 1:545
Association, 2:718 psychogenic, 1:219
American Philosophical Association, 1:27 retrograde, 1:132, 1:180
American Psychiatric Association, 1:xli, 1:xlv, spirit possession and, 1:219
1:2, 1:26–27. See also Diagnostic and Statistical trauma and, 2:893
Manual (DSM) amok, 1:219, 1:414, 2:641, 2:972
on delusions, 1:182 amphetamines, 1:29–30
on DSM usage, 1:204 ADHD and, 1:29
ethnocentrism by, 2:702 Benzedrine, 1:29–30
founding, 1:26, 2:698 discovery, 1:29–30
gay activists and, 1:35 during World War II, 1:30
headquarters, 1:27 “Anatomy of an Illness as Perceived by the
homosexuality classification, 1:xlii Patient,” 1:xliii
platform, 1:26 Anatomy of Melancholy, The (Burton), 1:507
psychiatrist defined, 1:26 Andreasen, N. C., 1:49
publications, 1:27 anesthesia, 2:727, 2:760, 2:877
Szasz criticism, 2:864 barbiturates, 1:75, 1:76
American Psychoanalytic Association, 1:xlv case records, 1:103
American Psychological Association, 1:xl, development, 2:800
1:27–29, 1:118 diazepam, 1:211
contributions to mental health, 1:28 Anglophones, 1:17
EPPP, 1:28 anhedonia, 2:774, 2:805, 2:972
ethical code, 1:28, 1:284–285 Animal Hoarding, 2:869
founding, 1:27 animal magnetism, 1:262
 Index 1047

ankylosing spondylitis, 1:xliii anxiety, chronic, 1:xxxvii, 1:38–40. See also

anomic suicide, 1:244–245 generalized anxiety disorder (GAD); obsessive
anorexia nervosa, 1:xxxvi, 1:xxxviii, 1:xliii, compulsive disorder
1:248, 2:972. See also bulimia nervosa; eating age and, 1:9–10
disorders anticipation, 2:642
adolescence, 1:5 anxiety disorder, 2:642, 2:972
distorted body image, 2:797 anxiety hysteria, 1:15
melancholia and, 1:508 Brazil, 1:89
prevalence, 1:417–418 characteristics and treatment, 1:39–40
self-starvation different from, 1:xlii diagnostic terms across cultures, 1:38–39
anterograde amnesia, 1:132, 1:180 DSM on, 1:78
anthropology, 1:31–32 Egypt, 1:256
cultural analysis methods, 1:31–32 epidemiology, 1:279–280
cultural analysis of personhood, 1:31 GAD, 1:39
anticipation anxiety, 2:642 locomotor, 1:15
antidepressants, 1:7, 1:16, 1:32–34. See sex differences and, 2:797–798
also monoamine oxidase inhibitor (MAOI) somatization, 1:38
antidepressants; Selective Serotonin Reuptake Spielberger State-Trait Anxiety Inventory, 1:51
Inhibitors (SSRIs); tricyclic antidepressants; state and trait, 1:38
specific antidepressants syndrome, 1:15
coining, 1:33 APA. See American Psychiatric Association;
fluoxetine license, 1:34 American Psychological Association
history, 1:32–33 Apadurai, Arjun, 2:700
Prozac, 1:34 APD (Antisocial Personality Disorder), 1:36–37,
side effects, 1:33, 2:804–805 2:798, 2:972
antiglutamate drugs, 1:xlvi Appadurai, Arjun, 1:32
Antigone (Sophocles), 2:710, 2:711 Applied Behavioral Analysis (ABA), 1:66
antipsychiatry, 1:xli–xlii, 1:34–36, approved mental health professionals (AMHPs),
2:972 2:689
Antipsychiatry Coalition, 1:152 apraxia of speech, 1:455
coining, 1:34 Aquinas, Thomas, 1:309
deinstitutionalization movement and, archetypal images, 2:706, 2:710
1:35–36 archetypal literary theory, 2:710
Scheff and, 2:816 architecture, 1:40–43
Szasz and, 1:499, 2:619, 2:816, 2:863 architectural determinism, 1:40
antipsychotic drugs. See also atypical Cottage Plan, 1:41–42
antipsychotics; first-generation antipsychotics; Kirkbride Plan, 1:40–141
second-generation antipsychotics; Thorazine moral architecture and treatment, 1:54
and first-generation antipsychotics; specific socioarchitecture, 1:42
drugs stigma and, 1:40
side effects, 2:803–804 Archives of General Psychiatry, 1:xlv
therapy, 1:xl Aretaeus of Cappadocia, 1:83
antisocial behavior, 1:36–38 Argentina, 1:43–45
ASPD, 1:36–37 demographics and health care, 1:43
CD, 1:36 mental illness perception and practices,
treatment, 1:37 1:43–44
Antisocial Personality Disorder (APD), 1:36–37, psychotherapy, 1:45
2:798, 2:972 reform, 1:44–45
Anton, Gabriel, 2:699 Aristophanes, 1:308
Antwone Fisher, 1:560 Aristotle, 1:507, 1:542, 2:820
1048 Index

Arnold, Thomas, 1:552 Menninger Clinic, 1:56

art and artists, 1:45–48. See also creativity; moral architecture and treatment, 1:54
fiction; movies and madness; visual arts Morocco, 1:555
defining works of art, 1:46–47 Pennsylvania Hospital, 1:53, 1:514
extreme behaviors, 1:45 psychoanalysis, 1:56
productivity and mental illness, 1:48–49 Salpetriere Asylum, Paris, 1:xxxv, 1:496,
psychopathology, 1:47–48 2:698
Artaud, Antoine, 2:875 Thailand, 2:872–873
As Good As It Gets, 1:562 trade in lunacy, 1:53
ASDs (autism spectrum disorders), 1:64–67, Utica State Lunatic Asylum, 1:xxxvi
1:455–456 Women’s Lunatic Asylum, Blackwell Island,
Asher, Richard, 1:563 1:xxxvii
Ashkenazi Jews, 1:407 Asylums (Goffman), 1:55–56, 1:499, 2:847
Asia American Family Conflicts Scale, 1:51 Atharvada, 1:386
Asperger, Hans, 1:xxxix Atkins v. Virginia, 1:160
Asperger’s syndrome, 1:xxxix, 1:6, 2:972 ATSDR (Agency for Toxic Substances and
autism and, 1:xlv Disease Registry), 1:191
pervasive developmental disorder, 2:634 attachment, 1:273, 1:306, 2:633, 2:678, 2:708
assertive community treatment teams (ACT), doctor-patient, 1:563
1:147, 2:789, 2:971 figures, 1:80
assessment issues in mental health, 1:49–53. infant, 2:821
See also measuring mental health insecure, 1:16
defined, 1:50 mother-child, 1:65
demographics, 1:51 to place, 1:277
depression, 1:196–197 study, 2:708
diagnosis in cross-national context, styles, 2:822
1:208–209 unstable, 1:107
framework, 1:50–51 attaque de nervios, 1:2
historiography, 1:50–51 attention-deficit hyperactivity disorder (ADHD),
instruments, 1:51 1:36, 1:57–59, 1:455, 2:971. See also Ritalin
reliability and validity, 1:51–52 adolescence and, 1:5–6
Association for Children with Learning age and, 1:9
Disabilities, 2:760 amphetamines and, 1:29
Association of Medical Superintendents of blood lead levels and, 1:xlv
American Institutions for the Insane, 1:xxxvi, CDC on, 1:xlv
1:27 in children, 1:203
AstraZeneca, 1:61, 2:786 as dangerousness risk factor, 1:175
asylums, 1:53–57. See also board and care definitions and diagnostic criteria, 1:57–58,
homes; group homes; mental institutions, 1:456
history of in DSM, 1:6
Bellevue Place, Illinois, 1:55 implications of cultural issues, 1:58–59
Bethlem Royal Hospital, 1:53, 1:496 sex differences and, 2:798–799
Bicetre Hospital, Paris, 1:496 social and cultural factors, 1:57
Chestnut Lodge, 1:56 symptoms and characteristics, 1:58
deinstitutionalization movement and, 1:56 “Attitude and Orientation of the Counselor in
Great Depression, 1:55 Client-Centered Therapy, The,” 1:xl
growth and criticism, 1:54–56 attitude toward mental illness
Indonesia, 1:389–390 Japan, 1:432–433
Jydske Asylum, Denmark, 1:190 Nigeria, 2:586
McLean Hospital, 1:56 United States, 2:923
 Index 1049

atypical antipsychotics, 1:59–61, 2:639–640. Bangladesh, 1:69–74

See also Thorazine and first-generation future directions, 1:73
antipsychotics health care system, 1:72
clozapine, 1:59–60 history, 1:69–70
development, 1:59–60 manoshik rog, 1:71
EPS, 1:59, 1:61 mental illness across life span, 1:71
fate of category, 1:61 mental illness prevalence, rates, risk factors,
insomnia and, 1:60 1:70
Risperdol, 1:60 professionals, 1:72
side-effect profile, 1:59 somatoform disorders, 1:70
success and dangers, 1:60–61 stigma, 1:71–72
atypical depression (AD), 1:548 suicide, 1:71
Australia, 1:61–64 training, 1:73
Australian National Mental Health Promotion treatment and costs, 1:72–73
and Prevention Action Plan, 2:730 urban and rural, 1:70–71
emotional distress, 1:63 Banting, Frederick, 2:719
national mental health policy, Barbital, 1:75
1:62–63 barbiturates, 1:xl, 1:74–76, 2:972–973
NGOs, 1:62–63 anesthesia, 1:75, 1:76
prevalence of mental illness, 1:63–64 barbituric acid, 1:74–75
schizophrenia, 1:63 FDA and, 1:76
autism, 1:xxxv, 1:xxxix, 1:64–67, 1:189. for insomnia, 1:76
See also refrigerator mother side effects, 1:75
Asperger’s syndrome and, 1:xlv sleep and awakening therapies, 1:75–76
Autism Society of America, 2:745 from synthesis to application, 1:74–75
DSM classification, 1:64 ubiquity, abuse, regulation, 1:77
incidence and prevalence worldwide, Veronal, 1:74–75
1:64–66 World War I consumption, 1:75
MMR vaccine, 1:64–65 Bardet, Daniel, 1:75
pervasive developmental disorder, 2:633 Barth, Richard, 1:286
treatment options, 1:66 Barthes, Roland, 1:490, 2:710
autism spectrum disorders (ASDs), 1:64–67, Basdische Anulinund Soda Fabrik (BASF), 2:902
1:455–456 Basquiat, Jean-Michel, 1:45, 1:47
autogenic training, 1:xxxix Bastide, Roger, 1:317
Aviator, The, 1:562 Bates, Kristin, 1:201
AWA (Adam Walsh Act), 1:137 Bates, M. S., 1:113
Axelrod, Julius, 2:584 Bateson, Gregory, 1:222–223, 1:447
Axis II diagnoses, 2:662 Battegay, Raymond, 1:34, 2:902
Ayd, Frank, 1:546, 2:722 Baudrillard, Jean, 1:490–491
Ayllon, Teodoro, 1:538 Bauer, F., 1:389
Ayurveda, 1:386–387, 2:747 Bauman, Zygmunt, 1:490
Bayer, Frederich, 1:74
B Bayer Pharmaceuticals, 1:74–75
Bachynski, Kathleen, 2:931 baymaree ruhi wa rawanee, 1:7
Back, Simone, 1:421 BD-NOS (bipolar disorder not otherwise
Baillarger, Jules, 1:83 specified), 1:549
Bailly, Jean Sylvain, 1:532 Beard, George Miller, 1:xxxvi, 1:262, 1:268,
Baker, T. A., 1:113 2:579, 2:698
Bakos, A., 1:112 Beaumont, George, 2:903
Bandura, Albert, 2:977 Beautiful Mind, A, 1:561
1050 Index

Beck, Aaron T., 1:xlii, 1:xlv, 1:129, 2:879, bereavement, 1:79–81

2:883 Alzheimer’s disease, 1:25
Beck Depression Inventory, 1:51 culture, religion, sociological factors,
Becker, Gary, 2:743–744 1:79–81
Becker, Howard, 1:199–200, 1:201, 1:443–444 defined, 1:79
Beckett, Samuel, 1:56 grief and, 1:81
bedlam, 1:xxxv, 1:496 Berger, Peter, 2:743
Beers, Clifford, 1:xxxvii–xxxviii, 1:55, 1:176 Berkman, John Mayo, 1:xxxviii
confinement, 1:511 Berlin Wall, 1:332
Mental Health America and, 1:508–509 Bernays, Martha, 1:318
mental hygiene movement, 2:625 Bernstein, Carol, 1:243
National Council for Mental Hygiene founder, Bernthsen, Henrich August, 2:902
2:677 Bertillon, Jacques, 1:xxxvii, 1:411
behavior. See also antisocial behavior; cognitive Bertillon Classification of Causes of Death,
behavior therapy; help-seeking behavior 1:xxxvii, 1:411
ABA, 1:66 Best Little Girl in the World, The, 1:559
behavioral health services, 2:837–838 Bethlem Royal Hospital, 1:53, 1:496
behavioral therapy, 1:128–129, 2:883 Bettelheim, Bruno, 2:745, 2:976
compulsive sexual, 1:366 Better Outcomes in Mental Health Care
DBT, 2:785 (BOiMHC), 2:681
deviant, 2:974 “Better Services for the Mentally Ill,” 1:xlii
extreme, 1:45 better than well, 2:787
genetics, 1:325–326 Beyond Blue, 2:851
social control, 2:815–816 “Beyond the Pleasure Principle,” 2:893
unconventional, 1:203 Bezerra, Ana Catarian, 1:367
YRBS, 2:920 Bible, 2:665, 2:749, 2:752, 2:784, 2:901.
Behavioral and Brain Sciences, 2:632 See also Christianity; religion
behaviorism, 2:919 Biblical counseling, 2:752
Being Mentally Ill (Scheff), 1:xlii Bicetre Hospital, Paris, 1:496
Belknap, Ivan, 1:55 Big Bang Theory, 2:868
Bell, Alexander Graham, 2:845 Binet, Alfred, 1:xxxviii
Bell Curve, The (Herrnstein, Murray), binge eating, 1:xlv
1:406–407 biological psychiatry, 1:81–83
Bellevue Place, Illinois, 1:55 developments, 1:81–82
Benazzi, Franco, 1:83 history, 1:81
Benedict, P. K., 1:xli sociology response, 1:81–82
Benjamin, Harry, 2:800 biomedical reductionism, 2:690
Benson, Herbert, 1:xlii–xliii Bion, Wilfred, 2:880
Benzedrine, 1:29–30 biotherapies, 1:7
benzisoxazole, 2:977 bipolar disorder, 1:xl, 1:83–85, 1:549.
benzodiazepine-induced mood disorders, See also manic depression; mood disorders
1:549 arise of, 1:84
benzodiazepines, 1:16, 1:76–79, 1:545 BD-NOS, 1:549
clinical trials, 1:78 Brazil, 1:89
dependence and addiction, 1:78 cultural trends, 1:85
discovery, 1:77–78 hallmark of, 1:280
FDA and, 1:77, 1:78 lithium treatment, 1:470–471, 2:975
regulation, 1:78 pharmaceutical industry and, 1:84–85
risks with, 1:78 research, 1:83–84
testing, 1:77 risk-factors, 1:85
 Index 1051

bipolar disorder not otherwise specified culture and mental health, 1:88–89
(BD-NOS), 1:549 schizophrenia, 1:89
black box, 2:744 Breggin, Peter, 2:687
Black Death, 1:427 Breuer, Josef, 1:318, 1:370, 2:706, 2:727
Black Swan, 2:874 Brickner, Richard, 1:472
Blaschko, Herman, 1:546 Bride of Lammermoor, The (Scott),
Bleckwen, William, 1:75 1:310
Bleuler, Eugene, 1:xxxviii, 1:189, 1:440, 1:441, brief psychotic disorder, 1:182
2:773–774 Brill, Henry, 2:722
blinding, 2:741–742 Briquet, Paul, 1:370, 2:826
blockbusters, 2:635, 2:720 Briquet’s Syndrome, 1:370
blood-brain barrier, 2:973 Bristol-Myers Squibb, 1:61
bloodletting, 1:41, 1:124 Brodie, Bernard, 2:722
Blue Cross and Blue Shield, 1:348 bromides, 1:xl, 1:77
Bly, Nelly, 1:xxxvii, 1:527–528 Brook, Peter, 2:875
board and care homes, 1:85–87. See also Brown, Brene, 2:738
asylums; group homes Bruch, Hilde, 1:xlii
regulation and operation, 1:86–87 Brundin, Lena, 1:xlvi
small-scale, 1:86 Brydall, John, 1:xxxv
Boas, Franz, 1:414, 2:713, 2:919 Buber, Martin, 2:820
body image, 2:973 Buck, Carrie, 1:xxxviii
BOiMHC (Better Outcomes in Mental Health Buck v. Bell, 2:844
Care), 2:681 Buddhism, 1:113, 2:747, 2:900
born gay, 1:500 Four Noble Truths, 2:900
Bourdieu, Pierre, 1:317, 2:713 mindfulness meditation, 2:749,
Bourne, Harold, 1:402 2:900
Boyer, Carol A., 2:696 bulimia nervosa, 1:xliii, 1:5, 1:248, 2:973.
Boys and Girls Club, 2:678 See also anorexia nervosa; eating disorders
Bradford-Hill, Austin, 1:125 Bullon, Antonio, 1:254
Bradley, Charles, 1:30 bullying, 1:xlv, 2:622, 2:731, 2:800, 2:829,
Braid, James, 1:367–368, 1:532–533, 2:922
2:705 Burckhardt, Gottlieb, 1:471–472
brain, 2:632. See also psychiatry and neurology; Bureau of Narcotics and Dangerous Drugs,
psychiatry and neuroscience; traumatic brain 2:760
injury (TBI) Burgess, Ernest, 1:123, 2:575
blood-brain barrier, 2:973 Burma (Myanmar), 1:89–90
brain death, 1:xlii history and mental illness, 1:89–90
brain fog, 1:39 narcotics, 1:90
DBS, 2:701 Burton, Robert, 1:xxxv, 1:507
decade of, 2:701 Bury, Michael, 1:376
imaging, 2:701, 2:973 Bush, George W., 2:701
science, 2:632 business and workplace issues, 1:91–94
TMS, 2:701 business challenges, 1:92
trauma, patient’s view and, 2:892–893 individual challenges, 1:91–92
brainwashing, 2:973 prevalence of disorders, 1:93
Braiterman, Ken, 2:620 workplace environment, 1:92–93
Brawner Rule, 1:356 Butler, Robert, 1:12
Brazil, 1:87–89 butobarbital, 1:75
anxiety, 1:89 Bychowski, Gustav, 2:648
bipolar disorder, 1:89 Byrne, E., 1:xli
1052 Index

C education, 1:101
Cade, John Frederick Joseph, 1:xl, 1:470 teams, 1:102
CAM (complementary and alternative medicine), case records, 1:102–104
1:66, 2:595, 2:746 anesthesia, 1:103
CAM (Confusion Assessment Method), 1:180 definitions, 1:103
Cameron, D. Ewen, 2:699 electronic, 1:104
CAMH (Centre for Addiction and Mental history, 1:103
Health–Canada), 2:623 nutrition in, 1:103
Canada, 1:95–99, 2:623 privacy and confidentiality, 1:103–104
Canadian War on Drugs, 1:xliv Cases of Hysteria, Neurasthenia, Spinal
future directions, 1:98 Irritation or Allied Affections (Beard), 1:xxxvi
mental health strategy, promotion, best Castel, Robert, 1:317
practices, 1:97–98 caste-like minorities, 1:407
mental illness prevalence and risk factors, Castillo, Ruiz, 2:832
1:95–97 CAT (computerized axial tomography),
population, 1:95 2:973
Canham-Chervak Michelle, 2:931 catastrophes, 1:214, 1:216
Cannon, W. B., 2:727 catatonic depression, 1:548
Capitalism and Schizophrenia (Deleuze, catechol-O-methyl-transferase (COMT),
Guattari), 2:710 2:584
Captain Newman, M.D., 1:560 categorical fallacy, 1:416–417
Carak Samhita, 1:386, 2:747 catharsis, 2:894
CARDIA (Coronary Artery Risk Development in Catholicism, 2:747, 2:901
Young Adults), 2:807 Catholic charismatics, 1:417
care, sociology of, 1:99–101 decline, 2:751
community-based care, 1:99–100 depression and, 2:749
institutionalization and deinstitutionalization, CATT (crisis assessment and treatment team),
1:99–100 1:142
care ethics, 1:288 CBT. See cognitive behavior therapy
Care Quality Commission, 2:790 C-CAR (Consortium on Child and Adolescent
caregiving and caregivers Research), 1:xliv
Alzheimer’s disease, 1:25–26 CCBT (computerized cognitive behavioral
dementia, 1:185–186 therapy), 1:129
movies and madness and, 1:558–559 CCMD (Chinese Classification of Mental
vicarious traumatization, 2:675 Disorders), 1:111, 1:169
Carlsson, Arvid, 1:220, 2:584, 2:786 CD (conduct disorder), 1:36, 2:973
Carnegie, Dale, 2:781 CDC. See Centers for Disease Control and
Carpenter, Karen, 1:xliii Prevention (CDC)
Carson, S. H., 1:47 CDD (childhood disintegrative disorder),
Carter, Dianne, 1:xliii 2:633–634
Carter, Jimmy, 1:459 Celexa, 2:977
behavioral health system, 2:840 Center for Epidemiological Studies Depression
Vietnam Veterans Week, 2:956 Scale, 1:51
Cartesian dualism, 1:543 Center for Spirituality, 2:751
Carthew, Morden, 2:872–873 Centers for Disease Control and Prevention
Cartwright, Samuel, 1:35 (CDC), 1:269
cascading hazards, 1:214 on ADHD, 1:xlv
case managers, 1:101–102, 1:140, 2:973 on dementia risk factors, 1:186
case loads and budgets, 1:101 in Department of Health and Human Services,
definitions, 1:102 1:191
 Index 1053

on maximum health, 1:519 Treatment and Education of Autistic

serotonin reuptake inhibitors reporting, and Related Communication of
2:785 Handicapped Children (TEACCH),
surveys, 2:920 1:66
Centers for Medicare and Medicaid Services United States prevalence, 2:922–923
(CMS), 1:191, 1:460, 1:506 Child’s Relations With Others, The
central sleep apnea (CSA), 2:808 (Merleau-Ponty), 1:530
Centre for Addiction and Mental Health–Canada China, 1:109–112
(CAMH), 2:623 CCMD, 1:111
Centre for Alcohol Studies, 1:17 Cultural Revolution, 1:110
cerebral-spinal disease, 1:500 eating disorders, 1:xliv
certified public expenditures (CPEs), 2:839 future challenges and opportunities,
Cervantes, 1:309 1:111–112
chaining, 2:876 TCM, 1:110
Chamberlain, Judi, 2:619, 2:790 Chinese Classification of Mental Disorders
Charcot, Jean-Martin, 1:368, 1:370, 2:698, (CCMD), 1:111, 1:169
2:826, 2:832 chlordiazepoxide, 1:76
hypnosis and, 2:705, 2:894 chlorpromazine, 1:xl, 1:181
hysteric patients, 2:946 CHMP (Committee for Medicinal Products for
somatic origins, 2:876 Human Use), 1:230
Charmaz, Kathy, 2:617 Cho, Seung Hui, 1:147
chemical lobotomy, 2:885 cholera, 1:124
chemical vapors, 2:975 Chorpita, Bruce, 1:286
Chestnut Lodge, 1:56 Chrichton-Miller, Hugh, 2:915
Cheyne, George, 2:727 Christianity, 2:901
Childhood and Society (Erikson), 1:xl American Association of Christian Counselors
childhood disintegrative disorder (CDD), (AACC), 2:751–752
2:633–634 Christian faith-based interventions,
children, 1:xl, 1:104–109. See also adolescence 2:751–752
Administration for Children and Families in history of mental institutions, 1:522–523
(ACF), 1:191 chronic illness. See also chronic pain; chronicity
community-based approaches, psychosocial adaptation and, 2:725
1:107–108 Robert Wood Foundation Program for
Consortium on Child and Adolescent Chronic Mental Illness, 1:100
Research (C-CAR), 1:xliv chronic pain, 1:112–116
epidemiology United Kingdom, 2:917 African Americans and, 1:114
internalizing and externalizing problems, cultural beliefs and pain coping, 1:114
1:106 cultural beliefs and pain intensity, 1:113
Kaufman Assessment Battery for Children, cultural beliefs and pain tolerance, 1:112–113
1:51 cultural beliefs and treatment, 1:115
life course, 1:464 chronicity, 1:116–117
NSCH, 2:920 community support, 1:117
overview of mental illness, 1:104–105 controversy, 1:116
panic disorder in, 2:613 demographics, 1:116
pathways to psychiatric treatment, 2:697 health care services, 1:117
risk factors and resilience, 1:106–107 prognosis and, 1:116
school-based approaches, 1:108–109 quality of life, 1:116
sexual surgery, 2:800 Churchill, Winston, 2:845
“Suffer the Little Children,” 1:538 CIBA, 2:759–760
support and advocacy services, 1:140 Cicero, 1:308
1054 Index

CIDI (Composite International Diagnostic clinical trials, 1:124–127

Interview), 1:166–167 benzodiazepines, 1:78
cigarette smoking, 1:198 guidelines, 1:125–126
cirrhosis, 1:21 history, 1:124–125
cisgender, 2:800 lithium, 1:471
CIT (Crisis Intervention Team), 2:973 in mental illness, 1:126–127
citalopram, 1:181, 2:977 monoamine oxidase inhibitor (MAOI)
civil rights antidepressants, 1:456–457
CRIPA, 1:461 Clockwork Orange, A, 1:560
legislation, 1:460–461 Cloetta, Max, 1:75
Civil Rights of Institutionalized Persons Act Close, Glen, 2:622
(CRIPA), 1:461 clozapine, 1:59–60, 1:127–128, 2:977
Civilization and Its Discontents (Freud), early history, 1:127
2:709 EPS, 1:128
Clarke, Alicia, 2:784 FDA approval, 1:128
Clausen, John A., 2:697 club drugs, 2:973
Clayson, Dennis E., 1:xliv CMHA. See Community Mental Health Act of
Clementi, Tyler, 1:420 1963 (CMHA)
Clift, Montgomery, 2:874 CMHC (community mental healthcare),
climatic melancholia, 1:508 2:652–653
clinical psychologists, training of, 1:117–120 CMHCA (Mental Retardation Facilities
clinical science model, 1:119 and Community Mental Health Centers
Doctor of Psychology (Psy.D.) model, Construction Act), 1:177, 1:350, 2:838
1:118–119 CMHTs (community mental health teams),
first establishment, 1:117–128 2:689–690, 2:788
outside U.S., 1:119 CMS (Centers for Medicare and Medicaid
scientist-practitioner Ph.D. model, 1:118 Services), 1:191, 1:460, 1:506
during World War II, 1:118 Coalition Against Psychiatric Support, 2:790
clinical psychology, 1:120–122 Cobb, Stanley, 2:699
counseling psychology and, 1:120 COBRA (Consolidated Omnibus Budget
defined, 1:120 Reconciliation Act), 1:xliii
EPPP and, 1:122 Cochrane, Jane, 1:528
history, 1:120–121 co-curring disorders, 2:973
psychiatry and, 1:120 codeine, 1:xxxix, 1:181, 2:976
school psychology and, 1:120 coercion, 2:949–950
scientist-practitioners, 1:121–122 cognitive abilities, 1:xlv, 1:131, 2:588, 2:634,
settings for, 1:120 2:952
social work and, 1:120 cognitive behavior therapy, 1:xlv, 1:16,
VA and, 1:121 1:128–131
during World War I, 1:121 applications, 1:129
during World War II, 1:121 behavioral therapy as first wave, 1:128–129
clinical science model, 1:119 cognitive revolution as second wave, 1:129
clinical sociology, 1:122–124 founding, 1:129
Clinical Sociology Association, 1:123 for impulse control disorder, 1:379
diversity and eclecticism, 1:123 step-by-step process, 2:878–879
funding, 1:124 strengths and weaknesses, 1:129–130
global, 1:124 cognitive disorder, 1:131–133
history, 1:122–123 amnesia, 1:131–132
roles in, 1:124 classifications, 1:132
women and, 1:123 cultural comparisons, 1:132–133
 Index 1055

delirium, 1:132 community mental health centers, 1:138–141,

dementia, 1:132 2:788
development of, 1:131 case management, 1:140
research, 1:133 children’s support and advocacy services,
cognitive dissonance, 1:xli 1:140
cognitive reserve, 1:24 Community Mental Health Centers Extension
cognitive revolution, 1:129 Action of 1978, 1:459
“Cognitive Therapy: Nature and Relation to Ford vetoing, 2:839
Behavior Therapy,” 1:xlii intensive youth services, 1:140
Cohen, Hermann, 1:332 Nixon vetoing, 2:839
collective unconscious, 1:436, 2:706 nonprofit and for-profit structures, 1:140
Colombia, 1:133–135 objective and mission, 1:139–140
Doctors Without Borders, 1:134–135 outpatient mental health services, 1:139
mental health services, 1:134 outpatient substance abuse services, 1:139
colonialism school-based mental health services,
Algeria, 1:22 1:139–140
consciousness and, 1:xl support and advocacy services, 1:140
in history of mental institutions, 1:524–525 community mental health teams (CMHTs),
India, 1:387 2:689–690, 2:788
combat fatigue, 2:880 community mental healthcare (CMHC),
combat neurosis, 2:801 2:652–653
Commission on the Social Determinants of community psychiatry, 1:141–145
Health, 1:337 assessments of care, 1:143–144
commitment laws, 1:135–138 central focus, 1:141
civil, 2:668 specialist teams, 1:142–143
clinical assessment, 1:136 community treatment orders (CTO), 1:144
commitment process, 1:137–138 comorbidity, 1:18, 2:973
criteria for civil commitment, 1:136 compassion fatigue, 2:675
OPC and PAD, 1:136–137 Compendium der Psychiatrie (Kraepelin),
parens patriae, 1:135 1:xxxvii
sexually violent predators, 1:137 competence and credibility, 1:xxxv,
Committed, 1:559 1:145–146
Committee for Medicinal Products for Human Competency Assessment Instrument, 1:145
Use (CHMP), 1:230 competency hearings, 1:159–160
common law, 1:397–398 criminal cases, 1:145–146
Commonwealth Fund, 1:511 Miranda rights and, 1:145
community no unified definition, 1:145
ACL, 1:191 complementary and alternative medicine (CAM),
chronicity and, 1:117 1:66, 2:595, 2:746
community mental health, 2:667–668, 2:973 “Complete Book of the Medical Art, The,”
community-based care, 1:528–529 2:726
homelessness and, 1:355 complex inheritance, 1:326–327
PACT, 1:142 Composite International Diagnostic Interview
patient rights in, 2:623–624 (CIDI), 1:166–167
Community Mental Health, 2:619 comprehensive nosology, 1:441–442
Community Mental Health Act of 1963 comprehensive psychiatric emergency programs
(CMHA), 1:100, 1:103, 1:139, 1:192, 1:235, (CPEPSs), 1:263
1:450 Compulsion, 1:560
facilities created, 1:529 compulsive masturbation, 1:366
passage and impact, 1:458–459 compulsive sexual behavior, 1:366
1056 Index

compulsory treatment, 1:146–147. See also construct validity, 1:52

voluntary commitment consumer participation, 2:619–621
abuse and, 1:146 consumer-survivor movement, 1:151–153
Americans with Disabilities Act and, 1:147 challenges, 1:153
controversy over, 1:146 impact, 1:152–153
court-ordered, 1:147 organization, strategy, tactics, 1:152
exceptional circumstances, 1:146 content validity, 1:52
computer tomography (CT), 1:82 Controlled Substances Act, 1:76
computerized axial tomography (CAT), Convention on the Rights of Persons with
2:973 Disabilities (CRPD), 1:359
computerized cognitive behavioral therapy conversion therapy, 1:xlvi, 2:704
(CCBT), 1:129 Cook, Clayton R., 1:xlv
COMT (catechol-O-methyl-transferase), Cooley, Charles, 1:443
2:584 Cooper, David, 1:34, 2:914
Comte, Auguste, 1:122, 1:124 Coppen, Alec, 2:786
concurrent validity, 1:52 Cornerstone Theater Company, 2:875
conditional reflexes, 1:xxxvii Coronary Artery Risk Development in Young
conduct, unwanted, 1:147–149 Adults (CARDIA), 2:807
dysfunction, 1:148 Corrigan, Patrick, 2:731
human agency versus neurobiological links, corticotrophin releasing factor (CRF), 1:82
1:148–149 costs of mental illness, 1:153–158. See also
social manifestations, 1:148 economics; funding
threat to order and predictability, 1:149 absenteeism and presenteeism, 1:156
conduct disorder (CD), 1:36, 2:973 Alzheimer’s disease, 1:26
confabulation, 1:xxxvii Bangladesh, 1:72–73
conflict, 1:422 electroconvulsive therapy, 1:260–261
Asia American Family Conflicts Scale, 1:51 individual level, 1:154–155
defense mechanisms and, 1:422 societal, 1:156–157
psychiatry and neurology in, 2:698–699 WHO and, 1:155–157
social, 1:536–537 workplace, 1:155–156
Confusion Assessment Method (CAM), 1:180 Cottage Plan, 1:41–42
Cong Ho Shon, Phillip, 2:869 Cotzias, George, 1:220
Congo, Democratic Republic of the, Coulter, Jeff, 1:409
1:149–150 counseling psychology, 1:120
mental health policy, 1:150 courage, 2:724, 2:859, 2:925–926
poverty, 1:150 courtesy stigma, 1:213
sexual violence, 1:150 courts, 1:158–162. See also insanity defense; law
Conolly, John, 1:497 and mental illness; laws; legislation; patient
Conrad, Joseph, 2:710 rights; rights; Supreme Court, U.S.
Conrad, Peter, 1:29, 1:199, 1:203, 1:498, competency hearings, 1:159–160
1:503 compulsory treatment and, 1:147
consciousness, 1:xxxix, 2:743 court diversion program, 2:696
altered state of, 1:218 insanity defenses, 1:158–159
collective unconscious, 1:436, 2:706 mental health, 1:160–161
colonialism and, 1:xl obstacles to, 1:161
secrets of unconscious, 2:712 Cousins, Norman, 1:xliii
Consolidated Omnibus Budget Reconciliation covariation, social causation, 2:810–811
Act (COBRA), 1:xliii CPEPSs (comprehensive psychiatric emergency
Consortium on Child and Adolescent Research programs), 1:263
(C-CAR), 1:xliv CPEs (certified public expenditures), 2:839
 Index 1057

CPT (European Committee for the Prevention cult of curability, 1:54

of Torture and Inhumane and Degrading cultural prevalence, 1:168–171. See also
Treatment or Punishment), 2:911 acculturation
Crane, George, 1:546 cultural factors, 1:169–170
creativity, 1:48, 1:162–164. See also art and diagnostic universality, 1:168–169
artists; fiction; movies and madness; visual arts importance of, 1:168
defining, 1:162–163 WHO and, 1:168
intelligence and personality, 1:163 cultural psychiatry, 1:31
measuring, 1:163 Cultural Revolution, 1:110
mental illness and, 1:164 cultural self-theory, 1:302
motivation, 1:163 cultural sociology, 1:29
small c and big C, 1:162–163 culture. See also acculturation; diagnosis in
sociological perspective, 1:162–163 cross-national context; psychosomatic illnesses,
theories, 1:163 cultural comparisons of
Creutzfeldt-Jakob disease, 1:184 aging across, 1:184–185
CRF (corticotrophin releasing factor), 1:82 beliefs and pain coping, 1:114
CR/HT (crisis resolution and home treatment beliefs and pain intensity, 1:113
teams), 1:142–143 beliefs and pain tolerance, 1:112–113
Criminal Minds, 2:870 beliefs and treatment, 1:115
CRIPA (Civil Rights of Institutionalized Persons bereavement and, 1:79–81
Act), 1:461 borderline personality disorder and,
crisis assessment and treatment team (CATT), 2:628–629
1:142 Brazil, 1:88–89
Crisis Intervention Team (CIT), 2:973 cultural diversity, 2:737–738
crisis resolution and home treatment teams cultural group, 1:112
(CR/HT), 1:142–143 cultural icons, 2:712
criterion validity, 1:52 diagnosis and, 1:204–205
critical incidents, 1:284 drug abuse and, 1:225
critical theory, 1:164–166 economics and, 1:253–255
Frankfurt School, 1:164–165 exclusion and, 1:300–302
Fromm and, 1:165 hallucinations and, 1:346–347
Habermas and, 1:166 help-seeking behavior and, 1:352
Marxism and, 1:164–165 hysteria and, 1:371
positivism, 1:165 Italy, 1:427–428
social change and, 1:165 learning disorders and, 1:457
traditional theory and, 1:165 Mexico, 1:533–534
Cross, Terry, 2:901 mood disorders and, 1:550–551
cross-cultural psychiatry, 1:292 norms, 2:743
cross-dressers, 2:799 panic disorder and, 2:612–613
cross-national prevalence estimates, 1:166–168 personality disorders and, 2:630–631
GBD, 1:167 psychoanalysis and, 2:709
WHM, 1:166–167 psychopathology and, 1:205–207
CRPD (Convention on the Rights of Persons PTSD and, 2:674–675
with Disabilities), 1:359 sociopathic disorders and, 2:825–826
CSA (central sleep apnea), 2:808 treatment and, 2:897–898
CSI, 2:945 trends with bipolar disorder, 1:85
Csordas, Thomas J., 1:417 variations of mania, 1:481
CT (computer tomography), 1:82 Culture and Mental Illness in Indonesia, 1:390
CTO (community treatment orders), 1:144 culture-bound syndrome, 1:2, 1:206–207, 1:417
Cullen, William, 1:262 culturecology model, 1:518–519
1058 Index

Cumming, Elaine, 2:731 Declaration of Hawaii, 1:xliii

Cumming, John, 2:731 decompensation, 1:529, 2:667, 2:820, 2:973
curandero, 1:39–40 deep brain stimulation (DBS), 2:701
cybernetics, 1:222–223 Deer Hunter, The, 1:560
cybersex addiction, 1:366 defense mechanisms, 1:422
cyclothymia, 1:47, 2:975. See also dysthymia “Definition and the Dramatization of Evil,”
1:202
D deinstitutionalization, 1:xl, 1:xli–xlii, 1:175–179,
da Vinci, Leonardo, 1:45, 1:428, 2:711 2:973. See also drugs and deinstitutionalization
DaCosta, Jacob Mendes, 2:929 antipsychiatry and, 1:35–36
Dale, Henry, 2:584 asylums and, 1:56
Daleide, Eric L., 1:286 contemporary struggles, 1:178–179
Dali, Salvador, 1:446, 2:946 health insurance and, 1:349–351
DALY (disability-adjusted life years), 1:157, history of medicalization and, 1:499
1:278 in history of mental institutions,
Damásio, António, 1:543 1:528–529
dangerous and severe personality disorder institutionalization and, 1:175–177
(DSPD), 2:683 jails and prisons and, 1:430
dangerousness, 1:173–175, 2:683 pharmaceutical treatments and, 1:42
ADDHD as risk factor, 1:175 reasons for, 1:35
contemporary approaches to violence risk reversing trends, 1:177–178
assessment, 1:174 right to treatment and, 2:757–758
legal versus mental health perspectives, in sociology of care, 1:99–100
1:173–174 state government policy, 2:667–668
violence risk assessment and special delerium tremens (DTs), 2:974
populations, 1:174–175 Deleuze, Gilles, 2:710, 2:711
Dante, 1:309 delirium, 1:132, 1:179–181
Darkness Visible (Styron), 2:860 characteristics, 1:179
D’Arsonval, Arsene, 1:262 constantium, 1:180
Darwin, Charles, 1:294, 1:499, 2:844–845 cordis, 1:180
Darwin, Leonard, 1:294, 2:845 epilepticum, 1:180
Das, Veena, 1:32 febrile, 1:180
dauernakose, 1:75 hyperactive, 1:180
Daughters of Bilitis, 2:703 hypoactive, 1:180
David and Lisa, 1:561 hystericum, 1:180
Davis, Joseph, 2:892 mussitans, 1:180
Davis, Martha, 2:853 of negation, 1:180
Dawkins, Richard, 1:557 of persecution, 1:180
DBS (deep brain stimulation), 2:701 symptoms, 1:179–180
DBT (dialectical behavior therapy), 2:785 tests and treatment, 1:180–181
DCD (developmental coordination disorder), toxic, 1:180
1:455–457 traumatic, 1:180
DD (developmental disabilities), 1:455 tremens, 1:180
DD-NOS (depressive disorder not otherwise types, 1:180
specified), 1:548–549 Delitzch, Franz, 2:751
De Alimentorum (Galen), 1:260 delusions, 1:181–184. See also Alzheimer’s
de Jong, Joop T. V. M., 1:22 disease; dementia; grandiosity; hallucinations
de Lacroix, Francois Bossier de Sauvages, 1:411 age of onset, 1:181
de Tours, Moreau, 1:414 APA on, 1:182
Death with Dignity Act (DWDA), 1:297 cross-cultural universals, 1:182–183
 Index 1059

defined, 1:181 Department of Defense (DoD), 2:661, 2:932

of descent, 1:182 Department of Health, Education and Welfare
erotomanic, 1:182 (HEW), 1:311
gender and, 1:183 Department of Health and Human Services,
grandiose, 1:182 U.S., 1:191–195
jealous, 1:182 impact of Affordable Care Act, 1:193–194
persecutory, 1:182 organizational structure, 1:191
religious, 1:183–184 prominent divisions, 1:192–193
schizophrenia and, 1:182 role in shaping mental health care system,
subjective, 1:182 1:191–192
DelVecchio, Mary-Jo, 1:254 Department of Labor, 2:751
demedicalization, 1:500–501 Department of Veterans Affairs (VA), 1:xliv,
dementia, 1:132, 1:184–187. See also 1:118. See also veterans
Alzheimer’s disease; delirium; delusions; clinical psychology and, 1:121
memory loss health care, 2:932
aging across cultures, 1:184–185 depersonalization disorder, 1:219
all cause, 1:186 depression, 1:xxxix, 1:195–198, 2:973–974.
Alzheimer’s disease and, 1:23, 1:184 See also melancholia
care giving, 1:185–186 adolescence, 1:5
Egypt, 1:255 age and, 1:9–10
minorities and, 1:187 Alzheimer’s disease and, 1:24
rates of, 1:184 assessment and treatment, 1:196–197
risk factors, 1:186–187 atypical, 1:548
vascular, 1:186 Beck Depression Inventory, 1:51
dementia praecox, 1:xxxviii, 1:188–189, 1:267, catatonic, 1:548
1:435. See also schizophrenia Catholicism and, 2:749
DSM and, 1:189 Center for Epidemiological Studies Depression
history, 2:776 Scale, 1:51
introduction, 1:188 cognitive behavior therapy, 1:xlv
prognosis, 1:188 cultural differences, 1:195–196
schizophrenia and, 1:189 defined, 1:195
demographics. See also geography of madness double, 1:548
Argentina, 1:43 electroconvulsive therapy and, 1:258–259
assessment issues in mental health, 1:51 epidemiology, 1:280
chronicity, 1:116 expressions, 1:417
diagnosis and, 1:204 Geriatric Depression Scale, 1:51
euthanasia and, 1:297 Hamilton Depression Rating Scale, 1:126
mania and, 1:480 in Japan, 1:32
measuring mental health, 1:492 manifestation, 1:198
migration and, 1:536 MDE, 1:550
neighborhood quality, 2:574 melancholic, 1:548
police and, 2:649 mental health co-morbidities, 1:280
poor, 1:25 neurobiology of, 1:32
self-injury, 2:784–785 NIMH on childhood depression, 1:322
social support and, 2:822 PMD, 1:548
DeMyer, Marian, 2:745 PPD, 1:548–549
Denmark, 1:189–191 RBD, 1:548–549
history, 1:189–190 role occupancy theory, 2:976
mental health services and epidemiology, sex differences and, 2:795–797
1:190–191 social conditions and, 1:xliv
1060 Index

specifiers, 1:195 hypersexuality, 1:366

symptoms, 1:195 hysteria, 1:370–371
WHO on, 1:384 iatrogenic illness, 1:374–375
women and, 2:962–963 incidence and prevalence and, 1:384–385
depressive disorder not otherwise specified learning disorders, 1:457–458
(DD-NOS), 1:548–549 pathological gambling, 2:615
depressive personality disorder (DPD), 1:548 psychiatric diagnosis process, 1:xliii
Descartes, René, 1:542–543 psychiatric training, 2:691–692
Desideratum: Or Electricity Made Plain and in psychology of trauma, 2:895
Useful (Wesley), 1:262 PTSD, 2:673, 2:890
Detroit Free Press, 1:179 schizoaffective disorder, 2:770–772
Deutsch, Albert, 1:xl, 1:55 schizophrenia, 2:774–775
Deutsch, Felix, 2:728 in spiritual healing, 2:834
Deutsche Psychoanalytische Gesellschaft (DPB), tardive dyskinesia, 2:867–868
1:333 validity, 2:964
Deutsche Psychoanalytische Vereiningung (DPV), diagnosis in cross-national context, 1:207–210
1:333 difficulties, 1:207
developmental coordination disorder (DCD), methodology and assessment, 1:208–209
1:455–457 patterns, 1:208
developmental disabilities (DD), 1:455 stigma, 1:209–210
Developmental Disabilities Act, 1:460 Diagnostic and Statistical Manual (DSM), 1:27.
Devereux, Georges, 1:293, 2:713 See also American Psychiatric Association;
deviance, 1:198–204 DSM-III; DSM-IV; DSM-5; International
current trends, 1:202–203 Classification of Diseases
defined, 1:198–200 2013 edition changes, 1:xlv
deviant behavior, 2:974 ADHD in, 1:6
folkways, 1:199 on agoraphobia, 1:14
labeling, 1:199 Anglo notions of psychiatry, 1:22
mores, 1:199 on anxiety, 1:78
through sociological lenses, 1:199–200 anxiety appendix, 1:38
unconventional behavior, 1:203 APA on usage, 1:204
Deviance and Medicalization (Conrad), 1:199 autism classification, 1:64
Deviance and Social Control (Inderbitzin, Bates, criticism of, 1:50
K., Gainey), 1:201 dementia praecox and, 1:189
Devil and Daniel Johnston, The, 1:561 first edition published, 1:xl, 2:919
dextropropoxyphene hydrochloride, 2:976 Hamilton Depression Rating Scale and,
Dharmasastras, 1:387 1:126
dhat, 1:39 homosexuality in, 1:xlii
diagnosis, 1:204–207 instruments, 1:384
adolescence and, 1:4 labeling immigrants, 1:2
alcoholism, 1:18–20 long-time use, 1:35
Algeria, 1:22–23 mania defined, 1:480
Alzheimer’s disease, 1:24 on manic depression, 1:83
Axis II, 2:662 mental disorders definitions, 1:155
borderline personality disorder, 2:628 mental health problems focus, 1:120
culture and psychopathology, 1:205–207 panic disorder listed, 2:610
defining culture, 1:204–205 personality disorders in, 2:630
demographics and, 1:204 pervasive developmental disorders in, 2:632
EPSDT, 2:653 PTSD in, 1:xliii
gender and, 1:322–323 who can use, 1:204
 Index 1061

dialectical behavior therapy (DBT), 2:785 Disease Concept of Alcoholism, The (Jellinek),
Diary of a Madman, 1:310 1:18
diazepam, 1:76, 1:210–212, 2:978. Diseases Which Lead to a Loss of Reason
See also Valium (Paracelsus), 1:xxxv
addiction, 1:211 disorders. See also attention-deficit hyperactivity
administration, 1:210–211 disorder (ADHD); bipolar disorder;
anesthesia, 1:211 cognitive disorder; dissociative disorders;
therapeutic uses, 1:211–212 eating disorders; impulse control disorder;
dibenzoxazepine, 2:977 learning disorders; mood disorders; obsessive
Dickens, Charles, 1:54–55 compulsive disorder; panic disorder; personality
Dickenson, Emily, 1:45 disorder, borderline; personality disorders;
dimethytrytamine (DMT), 1:225 pervasive developmental disorders; post-
directedness, 1:530 traumatic stress disorder; schizoaffective
disability, 1:xliv, 1:212–214. See also Americans disorder; sleep disorders; sociopathic disorders
with Disabilities Act (ADA) adjustment disorders, 2:971–972
legal aspects, 1:213–214 alcohol-induced mood disorders,
life expectancy trends, 1:466–467 1:549
mental illness as, 1:451 anxiety, 2:642, 2:972
social model, 2:790 APD, 1:36–37, 2:798, 2:972
Social Security determinants, 2:819–820 ASDs, 1:64–67, 1:455–456
stigma, 1:213 BD-NOS, 1:549
Tanzania, 2:865 benzodiazepine-induced mood disorders,
disability-adjusted life years (DALY), 1:157, 1:549
1:278 brief psychotic disorder, 1:182
disasters, 1:214–217 business and workplace issues, 1:93
catastrophes and, 1:216 CCMD, 1:111, 1:169
definitions, 1:215–216 CD, 1:36, 2:973
emergencies, 1:214 CDD, 2:633–634
hazard, 1:214 co-curring, 2:973
mental health and, 1:216–217 DCD, 1:455–457
WHO and, 1:215 depersonalization, 1:219
Discipline and Punish (Foucault), 1:201 DPD, 1:548
“Discovery of Hyperkinesis, The,” 1:203 dual diagnosis, 2:973
discriminant validity, 1:52 dysthymic, 1:280, 1:548
discrimination. See also identity; labeling; stigma GAD, 1:39, 2:797–798
ADA antidiscrimination statutes, 1:214 GID, 2:799
Global Programme Against Stigma and iatrogenic, 2:975
Discrimination, 2:851 IED, 1:380, 1:439, 2:931
stereotyping and, 1:376–377 internet gaming, 1:381
disease. See also Alzheimer’s disease; Centers MDD, 1:548, 2:795–796
for Disease Control and Prevention (CDC); NPD, 1:337–340
Huntington’s disease; illness; International orofacial myofunctional, 1:455–456
Classification of Diseases overactive, 2:633–634
alcoholism as, 1:xli paraphilia-related, 1:366
ATSDR, 1:191 PMDD, 2:787, 2:963
Creutzfeldt-Jakob disease, 1:184 shared psychotic, 1:182
GBD, 1:167 somatoform, 1:70
mental illness as, 1:450–451 speech sound, 1:455
Parkinson’s disease, 1:184 disorientation, 1:xxxvii, 1:16, 1:132, 1:179,
stress response and, 2:851–852 1:211, 2:630
1062 Index

dissociative disorders, 1:218–220, 2:974 double depression, 1:548

altered state of consciousness, 1:218 Down syndrome, 1:212, 2:974
amok, 1:219 downward social drift, 1:484
depersonalization disorder, 1:219 DPD (depressive personality disorder),
dissociative amnesia, 1:219 1:548
dissociative identity disorder, 1:219–220 DPG (Deutsche Psychoanalytische Gesellschaft),
latah, 1:219 1:333
nonpathological dissociative state, 1:218 DPV (Deutsche Psychoanalytische Vereiningung),
pibloktoq, 1:219 1:333
Qi-gong psychotic reaction, 1:219 drapetomania, 1:35, 2:590
religion and, 1:218–219 Dratzenstein, Christian, 1:261
susto/el espanto, 1:219 drug abuse, 1:223–226. See also alcoholism;
distress tolerance, 1:468 substance abuse
disturbances in affect, 2:977 culture and, 1:225
diversion program, 2:974 definitions, 1:224–225
court, 2:696 etiology, epidemiology, treatment,
police policy, 2:662–663 1:225–226
divination, 2:747 inequality and, 1:394
Divine Comedy (Dante), 1:309 NCMDA, 1:225
Divoky, Diane, 2:760 NIDA, 1:226
Dix, Dorothea, 1:xxxvi, 1:40–41, 1:54, 1:511, variations in cultural terminology, 1:225
1:526, 1:538 drug abuse: cause and effect, 1:226–228
humane care and treatment, 2:665, 2:788, interventions, 1:228
2:919 signs or symptoms, 1:227–228
patient rights and, 2:624–625 drug development, 1:229–231
Dixon, Walter, 2:583 approval for marketing, 1:230
dizziness, 2:579, 2:612, 2:726, 2:801, 2:826, criticisms, 1:230–231
2:975 FDA and, 1:229–231
DMT (dimethytrytamine), 1:225 ICH and, 1:229
DNA stages, 1:229–230
agoraphobia and, 1:16 drug regulation, 1:312–313
CAG repeat, 1:362 drug treatments, early, 1:xlv, 1:231–233
genetics and, 1:324–325 convulsive therapy, 1:233
Doctor of Psychology (Psy.D.) model, 1:118–119 fever therapy, 1:232
Doctors Without Borders, 1:134–135 insulin shock therapy, 1:232
DoD (Department of Defense), 2:661, 2:932 sleep therapy, 1:232–233
Dolto, Francoise, 2:712 drugs and deinstitutionalization, 1:233–236.
Domenjoz, Robert, 2:902 See also deinstitutionalization
Don Quixote (Cervantes), 1:309 deinstitutionalization movement,
Don’t Ask, Don’t Tell policy, 2:660, 2:934 1:234
Don’t Say a Word, 1:560 multilayered implications, 1:234–236
dopamine, 1:220–222 Drummond, Edward, 1:xxxvi, 1:159
isolation and measurement, 1:220 drunks, 1:xxxv
modern neuroleptic drugs, 1:221 DSM. See Diagnostic and Statistical Manual
Doroshow, Deborah, 1:402 (DSM)
dosas, 2:747 DSM-III, 1:236–239. See also Diagnostic and
Dostoyevsky, Fyodor, 2:711 Statistical Manual (DSM); International
double bind theory, 1:222–223 Classification of Diseases
Bateson’s research and theory, 1:222–223 categorical approach, 1:239
impact on treatment, 1:223 creation, 1:238–239
 Index 1063

first publication, 1:236 E

previous editions, 1:236–238 Early Detection and Intervention to Prevent
DSM-IV, 1:239–241. See also Diagnostic and Psychosis (EDIPP), 2:596
Statistical Manual (DSM); International Early Diagnosis and Preventative Treatment
Classification of Diseases (EDAPT), 2:596
first published, 1:239 early infantile autism, 1:xxxix
focus on symptoms, 1:240 early prevention screening diagnosis and
DSM-5, 1:241–243, 2:919. See also Diagnostic treatment (EPSDT), 2:653
and Statistical Manual (DSM); International Early Start Denver Model (ESDM), 1:66
Classification of Diseases eating disorders, 1:247–251. See also anorexia
modernizing gesture, 1:241 nervosa; bulimia nervosa
new additions, 1:241–242 African Americans, 1:248
organization, 1:242–243 in China, 1:xliv
reconfiguration, 1:242 cultural risk factors, 1:247–248
release, 1:241 Latinos, 1:248–250
scholarly concerns, 1:286 movies and madness and,
DSPD (dangerous and severe personality 1:559–560
disorder), 2:683 Native Americans, 1:248
DTs (delerium tremens), 2:974 rates of in U.S., 1:248–250
dual diagnosis disorders, 2:973 rates worldwide, 1:250–251
DuBois, James, 1:396 sex differences and, 2:797
Duchovny, David, 1:367 women and, 2:962–963
Duke, Patty, 2:622 Ebbinghause, Hermann, 1:332
Dumit, Joseph, 1:32, 2:701 EBPP (evidence-based practices in psychology),
Dunbar, Helen Flanders, 2:728 2:884
Dunham, Warren H., 1:xxxix, 1:329–330, ECA. See Epidemiologic Catchment Area Study
1:382 (ECA)
Durer, Albrecht, 2:946 Eccles, John, 2:584
Durham, Monte, 1:356 economics, 1:251–255. See also costs of mental
Durham Rule, 1:356 illness; funding
Durham v. U.S., 1:159, 1:450 cultural complexity and medical machine,
Durham-Humphrey Amendment, 1:76 1:253–255
Durkheim, Émile, 1:xxxvii, 1:122, 1:124, financial barriers to equitable care, 1:252
1:201–202, 1:243–245, 1:317 instability of insurance coverage,
on altruistic, egoistic, fatalistic, anomic 1:252–253
suicide, 1:244–245 vulnerability and, 2:951
influence, 1:244, 2:820 Ecstasy, 1:29, 2:973
stigma and, 2:846–847 ECT. See electroconvulsive therapy
Durst, Rimona, 1:440 EDAPT (Early Diagnosis and Preventative
Dusky v. United States, 1:160, 1:449 Treatment), 2:596
DWDA (Death with Dignity Act), 1:297 Eder, David, 2:915
dynamic psychiatry, 1:511 Edgerton, R. B., 1:20
dynamic sizing, 2:899 EDIPP (Early Detection and Intervention to
dysarthria, 1:455 Prevent Psychosis), 2:596
dyscalculia, 1:455 education. See also public education campaigns;
dysgraphia, 1:455, 1:457 training
dyslexia, 1:455, 2:976 APA, 1:27
dysregulated sexuality, 1:366 case managers, 1:101
dysthymia, 1:280, 1:548, 2:975. See also mood Egypt, 1:256–257
disorders IDEA, 1:451
1064 Index

Mind/Body Health Public Education Ellis, Havelock, 2:914

Campaign, 1:543 EMDR (eye-movement desensitization and
TEACCH, 1:66 reprocessing), 2:974
Edward III, 1:xxxv emergencies. See also right to treatment
Edwards, R., 1:113 disasters, 1:214
EEOC (Equal Employment Opportunity Emergency Medical Treatment and Active
Commission), 1:461, 2:594–595 Labor Act, 1:263
efficacy-effectiveness paradox, 1:543 Emergency Medical Treatment and Active Labor
ego, 2:707–708 Act (EMTALA), 2:758–759
Ego and the Id, The (Freud), 2:707 emergency rooms, 1:263–266
ego psychology, 2:708 for mental health needs, 1:264
egoistic suicide, 1:244–245 research, 1:264–266
Egypt, 1:255–258 types, 1:263
Alzheimer’s disease, 1:255 Emerson, Ralph Waldo, 1:54
anxiety, 1:256 emotions and rationality, 1:266–269
dementia, 1:255 Australia emotional distress, 1:63
law, education, care, 1:256–257 emotion regulation, 1:468
new approach, 1:257 emotionalization of society, 1:268–269
OCD, 1:256 growth of mental health professions, 1:268
prevalence and mental illness types, mania and melancholia, 1:266–267
1:255–256 psychological explanations of mental
WHO and, 1:256–257 disorders, 1:267–268
Ehrenberg, Alain, 1:317 employment, 1:269–272. See also workplace
Ehrlich, Paul, 1:475 accommodations to employees with mental
Einstein, Albert, 1:162 illness, 1:270–271
Eisenhower, Dwight, 1:458 impact on colleagues, 1:270
Electra Complex, 2:715 mental illness stigma, 1:269–270
electric baths, 1:262 Empty Fortress, The (Bettelheim), 2:745
electric belt, 1:262 EMTALA (Emergency Medical Treatment and
electroconvulsive therapy, 1:232–233, Active Labor Act), 2:758–759
1:258–260, 2:877, 2:974 End of Stress as We Know It, The (Lasley),
availability and cost, 1:260–261 2:852
depression and, 1:258–259 Engels, Friedrich, 1:393
first use, 1:258 English Malady, The (Cheyne), 2:727
psychiatrists and, 1:260 English Poor Laws, 1:525
research, 1:259–260 Enlightenment, 1:40
electrotherapy, 1:260–263 mechanical restraint during, 1:496
18th and 19th century practice, 1:261–262 romanticism of, 1:552
early, 1:260–261 environment, 1:xl
Faradism a