A Symbolic Interactionist Approach to Mental Health Assertive Outreach
Background and Introduction
Contemporary mental health policy encourages approaches that focus upon supporting autonomy and citizenship, recovery rather than symptom control. Despite this shift in policy focus, service users continue to experience the effects of stigma and labelling such as troubled personal and professional relationships, impaired views of their own self-worth and significantly limited aspirations and capabilities (Thornicroft 2006). In order to fulfil policy aspirations to support ‘recovery’ and thus the optimisation of autonomy and citizenship amongst those receiving mental healthcare, there is a clear need for research that focuses upon why this might be. These questions are at least, if not more, better addressed by the application of theory and methods drawn from the social sciences.
James Roe (h)
© The Author(s) 2017
H. Middleton, M. Jordan (eds.), Mental Health Uncertainty and Inevitability, DOI 10.1007/978-3-319-43970-9_2
As emphasised elsewhere in this edition, it is clear that since the 1970s psychiatry and the social sciences have diverged, both theoretically and methodologically. This divergence reflects and contributes to fundamental differences concerning the nature of mental health difficulties and the tasks of mental health service providers (Pilgrim and Rogers 1999). Whereas psychiatry has placed emphasis on diagnostic criteria, empiricism and positivist epistemologies, social scientists have focused upon the exercise of power, in particular dominance of the medical profession and the influence of pharmaceutical companies. They have preferred qualitative research methods and more constructivist epistemological positions. Furthermore, whereas psychiatry has accentuated the benefits that mental health services can bring, sociology has, since the 1970s, tended to draw attention to their problematic aspects and ways in which they can cause harm (Rogers and Pilgrim 2003). Landmark contributors to sociological perspectives of mental health difficulties and those who provide for them include Erving Goffman, David Rosenhan and Thomas Szasz. Broadly and collectively, they question the validity of medicine’s authority to label an individual ‘mentally ill’. They consider this to be a socially constructed identity developed within an institutionalised setting which is projected onto an individual by parties with control and power which then, in turn, is internalised by the individual themselves.
Using ethnographic data on particular aspects of patient social life in his seminal 1968 work, Asylums, Goffman identified the hospital as operating as an authoritarian system where its residents are compelled to redefine themselves as being ‘mentally ill’. His main concern was with the development of relationships between individuals confined within, what he called, Total Institutions. Goffman (1968) defined a total institution
A place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life. (1968: 11)
Traditional mid-twentieth-century mental hospitals conformed to this definition, along with similar institutions such as prisons, monasteries and military barracks. Within such institutions a large group of individuals are situated in a place of residence and work, their private life is all but eradicated and communal. Activities are highly structured and the institution is overseen by an influential elite. Through ethnographic study of individuals resident in such settings and their behaviour with one another, Goffman came to the conclusion that specific roles are learned for those labelled as ‘mentally ill’. Individuals who are so labelled come to accept the label as their own self-image. Divisions that exist between ‘staff and ‘inmates’, coupled with a highly structured regime and little or no private life, result in the ‘mortification of the self’, whereby an individual has their old ‘self’ stripped of previous roles in the outside world and is forced to be reconstituted by the social arrangements and restrictions within the institution. One implication of this mortification of the self and reidentification, Goffman argues, is that the ‘mentally ill’ individual venture on a ‘moral career’ in which their self-identity is largely determined by those governing the institution. As he writes:
The self in this sense is not a property of the person to whom it is attributed, but
dwells rather in the pattern of social control that is exerted in connection with
the person by himself and those around him. This special kind of institutional
arrangement does not so much support the self as constitute it. (1968: 154)
Therefore, for Goffman, life in a total institution results in an individual having their previous ‘self’ removed and being subject to a reidentification process whereby they learn to inhabit a new role defined by the ‘mentally ill’ label that is attributed to them. Although this work enjoys little contemporary respect in conventional psychiatric circles, it can be seen to have made a significant contribution to policy decisions which resulted in closure of the large mental hospitals typified by those within which it was conducted.
Rosenhan’s (1973) famous study Being Sane in Insane Places was also very influential, though perhaps in unintended ways. Stooges presented themselves at psychiatric facilities claiming to be suffering psychiatric symptoms, in this case hearing voices. In most cases, they were deemed to be suffering from schizophrenia and admitted to hospital. This illustrated the difficulty psychiatrists had in being able to distinguish between individuals with a mental illness and those without. It was received as a significant embarrassment by the psychiatric profession and made a major contribution to the development of descriptive psychiatric diagnostic schemes such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, now in its fifth edition (DMS- 5; American Psychiatric Association 2013), and which continues to dominate professional psychiatric practice to this day.
The Rosenhan experiment demonstrated that once an individual is labelled with a psychiatric illness, their behaviour is subsequently interpreted by psychiatrists in ways that fit expectations affirming a diagnostic label. As he states:
Having once been labelled schizophrenic, there is nothing the pseudo-patient can do to overcome the tag. The tag profoundly colors others’ perceptions of him and his behaviour. (1973: 161)
An individual’s behaviour is not only interpreted to fit the diagnostic label but also any behaviour which does not fit the label is overlooked and ignored. Similarly, unwelcome behaviour, such as anger, frustration or depression, was seen to be a consequence of the individual’s pathology rather than as a result of the effects of the individual’s environment and interactions with staff.
He describes how, once a label is attributed to an individual, that label can have strong influential effects and acquire a life of its own:
Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be schizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge, with the unconfirmed expectation that he will behave as a schizophrenic again. Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy. Eventually the patient himself accepts the diagnosis, with all of its surplus meanings and expectations, and behaves accordingly. (1973: 6)
Thus, besides questioning the validity of ‘expert’ opinion and diagnosis due to psychiatrists’ inability to identify individuals feigning a mental ill?ness, Rosenhan’s study also resonates with Goffman’s work. It draws attention to ways in which the label of being ‘mentally ill’ leads to a change in the individual’s own behaviour and self-perception in response to expectations and assumptions on the part of mental health professionals.
Thomas Szasz (1920—2012) focused more specifically upon criticising the role of the medical profession, in particular psychiatry. He considered this to be a pseudoscience akin to astrology. In his seminal work The Myth of Mental Illness, he argued that mental illnesses are merely fake diseases established by those with power to perpetuate the need to contain individuals they consider as threatening to society. Szasz believed that psychiatry was merely a tool of social and political control over a victim labelled ‘mentally ill’. His view was that ‘mental illness’ is nothing more than a metaphor accepted as fact. He suggested that whilst we find and categorise physical illnesses in an individual when their bodily functioning deviates from anatomical and physiological norms, we identify mental illnesses when an individual’s behaviour deviates from current ethical, political and social norms (Szasz 1970, 1974). Szasz emphasised the tenuousness of links between a bodily and a mental illness, as he argues in his television set (TV) analogy:
(B)odily illness stands in the same relation to mental illness as a defective television receiver stands to a objectionable television programme. To be sure, the word ‘sick’ is often used metaphorically. We call jokes ‘sick’, economies ‘sick’, sometimes even the whole world ‘sick’ — but only when we call minds ‘sick’ do we systematically mistake metaphor for fact; and send for the doctor to ‘cure’ the ‘illness’. It’s as if a television viewer were to send for a TV repairman because he disapproves of the programme he is watching. (1960: 11)
In this way, he was strongly critical of a medical approach to the domain of ‘mental illness’, suggesting that not only is it illogical to use a doctor to fix the mind, but the concept of being mentally ‘sick’ derives from those holding it exercising power to control individuals who deviate from the ‘norm’ and are considered a threat to ‘normal’ society.
A different sociological perspective upon ‘mental illness’ is that epitomised by the work of George Brown and Tirril Harris. This focused upon the social causes of mental health difficulties. In their classic work exploring the onset of depression and social adversity, they provided evidence suggesting that rather than something inherent in the individual determining the onset of depression, life experiences and emotional and cognitive responses to them make a strong contribution (Brown and Harris 1978). They identified a number of social factors amongst young women that lead to the onset of depression when they act together. These were provoking agents, such as bereavement, symptom formation factors, such as past bereavements or previous depressive episodes, and vulnerability factors such as the absence of employment, death of her mother at a young age and a poor relationship with hus- band/boyfriend. Whereas some women, who would be categorised as vulnerable, may well become depressed, the absence or less intense experience of symptom formation factors would result in the women able to overcome grief and despair (Brown and Harris 1978). Though this body of work was hugely influential at the time, since the 1970s, sociological concerns appear to have shifted away from the lives of those suffering from mental health difficulties towards social aspects of the general population’s mental health concerns: psychological distress, and the impact of generic life events upon stress and coping mechanisms (Cook and Wright 1995 : 95). Nevertheless, Brown and Harris’ work stands as an additional example of ways in which the occurrence of a ‘mental illness’ and its consequences are commonly the outcome of complex interactions between the individual and their social context. An important contribution to that is the nature and conduct of services provided to address them.
Although there are now few institutions akin to those described by Goffman, other less overt institutions are identifiable. Community mental health services are one such. The nature and conduct of these new institutions are under-explored from a sociological perspective, and as a result, there are significant deficits in our knowledge of ways in which they address, provide for and affect individuals served by them.
One exception to this, though conducted in a non-mental healthcare setting, is Philip Strong’s (1979) The Ceremonial Order of the Clinic. Influenced by Goffman’s notions of ceremony and identity and by using his frame analysis method,1 Strong (1979) examined the doctor-patient relationship in paediatric clinics in Scotland and the United States. In particular, he explored the underpinning rules that direct these interactions, identifying four different ‘role formats’ or forms that medical consultations can exhibit: bureaucratic, clinical, charity and private. It was the bureaucratic role (the ceremonial order), exemplified by tight medical control and by impersonal treatment due to the volume of trade and limited time, and backed up by collegial expertise as opposed to individual concerns that dominates these interactions. He demonstrated how routinely repetitive encounters between individuals exhibit this dominant form, which is maintained due to the perceived balance of interests and resources available to parties involved. In particular, he concluded that this particular form becomes a way in which things ought to be solved as opposed to one of several possible ways in which to solve things. He argued that the creation of such forms in these interactions isn’t necessarily something new:
The original negotiation may have taken place many years, decades or even centuries ago, and current users may remain unaware of the political and historical reality which they embody. (Strong 1979: 193)
Although focused upon children’s clinics, Strong’s bureaucratic format can be applied more widely within the medical arena where, as he emphasises, individuals are perceived as subordinate. There are clear parallels between this work and the experience of mental health service users. Responsibility for the definition of health problems and their corresponding treatment has fallen into the hands of the health professional (Peplau 1987). This traditional approach towards illnesses, known as the Medical Model, views the human body as a complex mechanism and describes how particular physical symptoms and physical syndromes can be diagnosed and treated. This standpoint assumes that the relationship between a ‘doctor’ and ‘patient’ can be allied to a technical expert and a client who has an abnormal object in need of repair but it is blind 
to the effects of this upon the client’s self-perceptions and experiences of identity (Goffman 1968) . How the distressed, anxiety provoking, confused or threatening are construed and construe themselves mirrors or at least indirectly reflects prevailing discourse concerning such phenomena and the institutional arrangements put in place to provide for them. Interactions between such individuals and the institutional context within which they are accommodated play an important part in determining their social identity, whether personally or publically experienced. A full understanding of the detrimental effects stigmatisation and other adverse consequences of just being someone with a mental health difficulty have upon an individual requires theory and method that consider social micro-processes occurring within interactions between mental health service users and professionals, in particular approaches which inform the construction of social identity. One such approach is the application of symbolic interaction, which was used in this study to frame interactions between members of a particular community mental health team and their clientele.
-  The idea that during social interactions, individuals define situations through particular frames inwhich their experiences are organised (Goffman 1974).