What is Cross-Cultural Psychiatry?

Introduction

Cross-cultural psychiatry (also known as Ethnopsychiatry or transcultural psychiatry or cultural psychiatry) is a branch of psychiatry concerned with the cultural context of mental disorders and the challenges of addressing ethnic diversity in psychiatric services. It emerged as a coherent field from several strands of work, including surveys of the prevalence and form of disorders in different cultures or countries; the study of migrant populations and ethnic diversity within countries; and analysis of psychiatry itself as a cultural product.

The early literature was associated with colonialism and with observations by asylum psychiatrists or anthropologists who tended to assume the universal applicability of Western psychiatric diagnostic categories. A seminal paper by Arthur Kleinman in 1977 followed by a renewed dialogue between anthropology and psychiatry, is seen as having heralded a “new cross-cultural psychiatry”. However, Kleinman later pointed out that culture often became incorporated in only superficial ways, and that for example 90% of DSM-IV categories are culture-bound to North America and Western Europe, and yet the “culture-bound syndrome” label is only applied to “exotic” conditions outside Euro-American society. Reflecting advances in medical anthropology, DSM-5 replaced the term “culture-bound syndrome” with a set of terms covering cultural concepts of distress: cultural syndromes (which may not be bound to a specific culture but circulate across cultures); cultural idioms of distress (local modes of expressing suffering that may not be syndromes); causal explanations (that attribute symptoms or suffering to specific causal factors rooted in local ontologies); and folk diagnostic categories (which may be part of ethnomedical systems and healing practices).

Definition

Cultural psychiatry looks at whether psychiatric classifications of disorders are appropriate to different cultures or ethnic groups. It often argues that psychiatric illnesses represent social constructs as well as genuine medical conditions, and as such have social uses peculiar to the social groups in which they are created and legitimized. It studies psychiatric classifications in different cultures, whether informal (e.g. category terms used in different languages) or formal (for example the World Health Organisation’s ICD, the American Psychiatric Association’s DSM, or the Chinese Society of Psychiatry’s CCMD). The field has increasingly had to address the process of globalisation. It is said every city has a different culture and that the urban environment, and how people adapt or struggle to adapt to it, can play a crucial role in the onset or worsening of mental illness.

However, some scholars developing an anthropology of mental illness consider that attention to culture is not enough if it is decontextualised from historical events, and history in more general sense. An historical and politically informed perspective can counteract some of the risks related to promoting universalised ‘global mental health’ programmes as well as the increasing hegemony of diagnostic categories such as PTSD (Didier Fassin and Richard Rechtman analyse this issue in their book ‘The Empire of Trauma’). Roberto Beneduce, who devoted many years to research and clinical practice in West Africa (Mali, among the Dogon) and in Italy with migrants, strongly emphasizes this shift. Inspired by the thought of Frantz Fanon, Beneduce points to forms of historical consciousness and selfhood as well as history-related suffering as central dimensions of a ‘critical ethnopsychiatry’ or ‘critical transcultural psychiatry’.

Brief History

As a named field within the larger discipline of psychiatry, cultural psychiatry has a relatively short history. In 1955, a program in transcultural psychiatry was established at McGill University in Montreal by Eric Wittkower from psychiatry and Jacob Fried from the department of anthropology. In 1957, at the International Psychiatric Congress in Zurich, Wittkower organised a meeting that was attended by psychiatrists from 20 countries, including many who became major contributors to the field of cultural psychiatry: Tsung-Yi Lin (Taiwan), Thomas Lambo (Nigeria), Morris Carstairs (Britain), Carlos Alberto Seguin (Peru) and Pow-Meng Yap (Hong Kong). The American Psychiatric Association established a Committee on Transcultural Psychiatry in 1964, followed by the Canadian Psychiatric Association in 1967. H.B.M. Murphy of McGill founded the World Psychiatric Association Section on Transcultural Psychiatry in 1970. By the mid-1970s there were active transcultural psychiatry societies in England, France, Italy and Cuba. There are several scientific journals devoted to cross-cultural issues: Transcultural Psychiatry (est. 1956, originally as Transcultural Psychiatric Research Review, and now the official journal of the WPA Section on Transcultural Psychiatry), Psychopathologie Africaine (1965), Culture Medicine & Psychiatry (1977), Curare (1978), and World Cultural Psychiatry Research Review (2006). The Foundation for Psychocultural Research at UCLA has published an important volume on psychocultural aspects of trauma and most recently the landmark volumes entitled Formative Experiences: the Interaction of Caregiving, Culture, and Developmental Psychobiology edited by Carol Worthman, Paul Plotsky, Daniel Schechter and Constance Cummings. and Re-Visioning Psychiatry: Cultural Phenomenology, Critical Neuroscience, and Global Mental Health edited by Laurence J. Kirmayer, Robert Lemelson and Constance Cummings.

It is argued that a cultural perspective can help psychiatrists become aware of the hidden assumptions and limitations of current psychiatric theory and practice and can identify new approaches appropriate for treating the increasingly diverse populations seen in psychiatric services around the world. The recent revision of the nosology of the American Psychiatric Association, DSM-5, includes a Cultural Formulation Interview that aims to help clinicians contextualise diagnostic assessment. A related approach to cultural assessment involves cultural consultation which works with interpreters and cultural brokers to develop a cultural formulation and treatment plan that can assist clinicians.

Organisations

The main professional organisations devoted to the field are the WPA Section on Transcultural Psychiatry, the Society for the Study of Psychiatry and Culture, and the World Association for Cultural Psychiatry. Many other mental health organisations have interest groups or sections devoted to issues of culture and mental health.

There are active research and training programs in cultural psychiatry at several academic centres around the world, notably the Division of Social and Transcultural Psychiatry at McGill University, Harvard University, the University of Toronto, and University College London. Other organisations are devoted to cross-cultural adaptation of research and clinical methods. In 1993 the Transcultural Psychosocial Organisation (TPO) was founded. The TPO has developed a system of intervention aimed at countries with little or no mental health care. They train local people to become mental health workers, often using people who previously have provided mental health guidance of some kind. The TPO provides training material that is adapted to local culture, language and distinct traumatic events that might have occurred in the region where the organisation is operating. Avoiding Western approaches to mental health, the TPO sets up what becomes a local non-governmental organisation (NGO) that is self-sustainable, as well as economically and politically independent of any state. The TPO projects have been successful in both Uganda and Cambodia.

What is Labelling Theory?

Introduction

Labelling theory posits that self-identity and the behaviour of individuals may be determined or influenced by the terms used to describe or classify them.

It is associated with the concepts of self-fulfilling prophecy and stereotyping. Labelling theory holds that deviance is not inherent in an act, but instead focuses on the tendency of majorities to negatively label minorities or those seen as deviant from standard cultural norms. The theory was prominent during the 1960s and 1970s, and some modified versions of the theory have developed and are still currently popular. Stigma is defined as a powerfully negative label that changes a person’s self-concept and social identity.

Labelling theory is closely related to social-construction and symbolic-interaction analysis. Labelling theory was developed by sociologists during the 1960s. Howard Saul Becker’s book Outsiders was extremely influential in the development of this theory and its rise to popularity.

Labelling theory is also connected to other fields besides crime. For instance there is the labelling theory that corresponds to homosexuality. Alfred Kinsey and his colleagues were the main advocates in separating the difference between the role of a “homosexual” and the acts one does. An example is the idea that males performing feminine acts would imply that they are homosexual. Thomas J. Scheff states that labelling also plays a part with the “mentally ill”. The label does not refer to criminal but rather acts that are not socially accepted due to mental disorders.

Theoretical Foundations

Labelling theory attributes its origins to French sociologist Émile Durkheim and his 1897 book, Suicide. Durkheim found that crime is not so much a violation of a penal code as it is an act that outrages society. He was the first to suggest that deviant labelling satisfies that function and satisfies society’s need to control the behaviour.

As a contributor to American Pragmatism and later a member of the Chicago School, George Herbert Mead posited that the self is socially constructed and reconstructed through the interactions which each person has with the community. The labelling theory suggests that people obtain labels from how others view their tendencies or behaviours. Each individual is aware of how they are judged by others because he or she has attempted many different roles and functions in social interactions and has been able to gauge the reactions of those present.

This theoretically builds a subjective conception of the self, but as others intrude into the reality of that individual’s life, this represents “objective” (intersubjective) data which may require a re-evaluation of that conception depending on the authoritativeness of the others’ judgment. Family and friends may judge differently from random strangers. More socially representative individuals such as police officers or judges may be able to make more globally respected judgments. If deviance is a failure to conform to the rules observed by most of the group, the reaction of the group is to label the person as having offended against their social or moral norms of behaviour. This is the power of the group: to designate breaches of their rules as deviant and to treat the person differently depending on the seriousness of the breach. The more differential the treatment, the more the individual’s self-image is affected.

Labelling theory concerns itself mostly not with the normal roles that define our lives, but with those very special roles that society provides for deviant behaviour, called deviant roles, stigmatic roles, or social stigma. A social role is a set of expectations we have about a behaviour. Social roles are necessary for the organization and functioning of any society or group. We expect the postman, for example, to adhere to certain fixed rules about how he does his job. “Deviance” for a sociologist does not mean morally wrong, but rather behaviour that is condemned by society. Deviant behaviour can include both criminal and non-criminal activities.

Investigators found that deviant roles powerfully affect how we perceive those who are assigned those roles. They also affect how the deviant actor perceives himself and his relationship to society. The deviant roles and the labels attached to them function as a form of social stigma. Always inherent in the deviant role is the attribution of some form of “pollution” or difference that marks the labelled person as different from others. Society uses these stigmatic roles to them to control and limit deviant behaviour: “If you proceed in this behavior, you will become a member of that group of people.”

Whether a breach of a given rule will be stigmatised will depend on the significance of the moral or other tenet it represents. For example, adultery may be considered a breach of an informal rule or it may be criminalised depending on the status of marriage, morality, and religion within the community. In most Western countries, adultery is not a crime. Attaching the label “adulterer” may have some unfortunate consequences but they are not generally severe. But in some Islamic countries, zina is a crime and proof of extramarital activity may lead to severe consequences for all concerned.

Stigma is usually the result of laws enacted against the behaviour. Laws protecting slavery or outlawing homosexuality, for instance, will over time form deviant roles connected with those behaviours. Those who are assigned those roles will be seen as less human and reliable. Deviant roles are the sources of negative stereotypes, which tend to support society’s disapproval of the behaviour.

George Herbert Mead

One of the founders of social interactionism, George Herbert Mead, focused on the internal processes of how the mind constructs one’s self-image. In Mind, Self, and Society (1934), he showed how infants come to know persons first and only later come to know things. According to Mead, thought is both a social and pragmatic process, based on the model of two persons discussing how to solve a problem. Mead’s central concept is the self, the part of an individual’s personality composed of self-awareness and self-image. Our self-image is, in fact, constructed of ideas about what we think others are thinking about us. While we make fun of those who visibly talk to themselves, they have only failed to do what the rest of us do in keeping the internal conversation to ourselves. Human behaviour, Mead stated, is the result of meanings created by the social interaction of conversation, both real and imaginary.

Thomas Scheff

Thomas J. Scheff (1966), professor emeritus of Sociology at UCSB, published the book Being Mentally III: A Sociological Theory. According to Scheff, society has perceptions about people with mental illness. He stated that everyone in the society learns the stereotyped imagery of mental disorder through ordinary social interaction. From childhood, people learn to use terms like “crazy,” “loony,” “nuts,” and associated them with disturbed behaviours. The media also contributes to this bias against mentally ill patients by associating them with violent crimes. Scheff believes that mental illness is a label given to a person who has a behaviour which is away from the social norms of the society and is treated as a social deviance in the society. Once a person is given a label of “mentally ill person”, they receive a set of uniform responses from the society, which are generally negative in nature. These responses from the society compel to the person to take the role of a “mentally ill person” as they start internalising the same. When the individual takes on the role of being mentally ill as their central identity, they become a stable mental ill person. Chronic mental illness is thus a social role and the societal reaction is the most determinant of one’s entry into this role of chronically ill. According to Scheff hospitalisation of a mentally ill person further reinforces this social role and forces them to take this role as their self-perception. Once the person is institutionalised for mental disorder, they have been publicly labelled as “crazy” and forced to become a member of a deviant social group. It then becomes difficult for a deviant person to return to their former level of functioning as the status of ‘patient’ causes unfavourable evaluations by self and by others.

Frank Tannenbaum

Frank Tannenbaum is considered the grandfather of labelling theory. His Crime and Community (1938), describing the social interaction involved in crime, is considered a pivotal foundation of modern criminology. While the criminal differs little or not at all from others in the original impulse to first commit a crime, social interaction accounts for continued acts that develop a pattern of interest to sociologists.

Tannenbaum first introduced the idea of “tagging.” While conducting his studies with delinquent youth, he found that a negative tag or label often contributed to further involvement in delinquent activities. This initial tagging may cause the individual to adopt it as part of their identity. The crux of Tannenbaum’s argument is that the greater the attention placed on this label, the more likely the person is to identify themselves as the label.

Kerry Townsend (2001) writes about the revolution in criminology caused by Tannenbaum’s work:

“The roots of Frank Tannenbaum’s theoretical model, known as the ‘dramatization of evil’ or labeling theory, surfaces in the mid- to late-thirties. At this time, the ‘New Deal’ legislation had not defeated the woes of the Great Depression, and, although dwindling, immigration into the United States continued.[7] The social climate was one of disillusionment with the government. The class structure was one of cultural isolationism; cultural relativity had not yet taken hold. ‘The persistence of the class structure, despite the welfare reforms and controls over big business, was unmistakable.'[7]:117 The Positivist School of Criminological thought was still dominant, and in many states, the sterilization movement was underway. The emphasis on biological determinism and internal explanations of crime were the preeminent force in the theories of the early thirties. This dominance by the Positivist School changed in the late thirties with the introduction of conflict and social explanations of crime and criminality.” “One of the central tenets of the theory is to encourage the end of labeling process. In the words of Frank Tannenbaum, ‘the way out is through a refusal to dramatize the evil”, the justice system attempts to do this through diversion programs. The growth of the theory and its current application, both practical and theoretical, provide a solid foundation for continued popularity.”

Edwin Lemert

Sociologist Edwin Lemert (1951) introduced the concept of “secondary deviance.” The primary deviance is the experience connected to the overt behaviour, say drug addiction and its practical demands and consequences. Secondary deviation is the role created to deal with society’s condemnation of the behaviour of a person.

With other sociologists of his time, Lemert saw how all deviant acts are social acts, a result of the cooperation of society. In studying drug addiction, Lemert observed a very powerful and subtle force at work. Besides the physical addiction to the drug and all the economic and social disruptions it caused, there was an intensely intellectual process at work concerning one’s own identity and the justification for the behaviour: “I do these things because I am this way.”

There might be certain subjective and personal motives that might first lead a person to drink or shoplift. But the activity itself tells us little about the person’s self-image or its relationship to the activity. Lemert writes: “His acts are repeated and organised subjectively and transformed into active roles and become the social criteria for assigning status.…When a person begins to employ his deviant behaviour or a role based on it as a means of defence, attack, or adjustment to the overt and covert problems created by the consequent societal reaction to him, his deviation is secondary.”

Howard Becker

While it was Lemert who introduced the key concepts of labelling theory, it was Howard Becker who became their successor. He first began describing the process of how a person adopts a deviant role in a study of dance musicians, with whom he once worked. He later studied the identity formation of marijuana smokers. This study was the basis of his Outsiders published in 1963. This work became the manifesto of the labelling theory movement among sociologists. In his opening, Becker writes:

“…social groups create deviance by making rules whose infraction creates deviance, and by applying those rules to particular people and labeling them as outsiders. From this point of view, deviance is not a quality of the act the person commits, but rather a consequence of the application by other of rules and sanctions to an ‘offender.’ The deviant is one to whom that label has been successfully applied; deviant behavior is behavior that people so label.”

While society uses the stigmatic label to justify its condemnation, the deviant actor uses it to justify his actions. He wrote: “To put a complex argument in a few words: instead of the deviant motives leading to the deviant behavior, it is the other way around, the deviant behavior in time produces the deviant motivation.”

Becker’s immensely popular views were also subjected to a barrage of criticism, most of it blaming him for neglecting the influence of other biological, genetic effects and personal responsibility. In a later 1973 edition of his work, he answered his critics. He wrote that sociologists, while dedicated to studying society, are often careful not to look too closely. Instead, he wrote: “I prefer to think of what we study as collective action. People act, as Mead and Blumer have made clearest, together. They do what they do with an eye on what others have done, are doing now, and may do in the future. One tries to fit his own line of action into the actions of others, just as each of them likewise adjusts his own developing actions to what he sees and expects others to do.”

Francis Cullen reported in 1984 that Becker was probably too generous with his critics. After 20 years, Becker’s views, far from being supplanted, have been corrected and absorbed into an expanded “structuring perspective.”

Albert Memmi

In The Colonizer and the Colonized (1965), Albert Memmi described the deep psychological effects of the social stigma created by the domination of one group by another. He wrote:

The longer the oppression lasts, the more profoundly it affects him (the oppressed). It ends by becoming so familiar to him that he believes it is part of his own constitution, that he accepts it and could not imagine his recovery from it. This acceptance is the crowning point of oppression.

In Dominated Man (1968), Memmi turned his attention to the motivation of stigmatic labelling: it justifies the exploitation or criminalisation of the victim. He wrote:

Why does the accuser feel obliged to accuse in order to justify himself? Because he feels guilty toward his victim. Because he feels that his attitude and his behavior are essentially unjust and fraudulent.… Proof? In almost every case, the punishment has already been inflicted. The victim of racism is already living under the weight of disgrace and oppression.… In order to justify such punishment and misfortune, a process of rationalization is set in motion, by which to explain the ghetto and colonial exploitation.

Central to stigmatic labelling is the attribution of an inherent fault: It is as if one says, “There must be something wrong with these people. Otherwise, why would we treat them so badly?”

Erving Goffman

Perhaps the most important contributor to labelling theory was Erving Goffman, President of the American Sociological Association (ASA), and one of America’s most cited sociologists. His most popular books include The Presentation of Self in Everyday Life, Interaction Ritual, and Frame Analysis.

His most important contribution to labelling theory, however, was Stigma: Notes on the Management of Spoiled Identity published in 1963. Unlike other authors who examined the process of adopting a deviant identity, Goffman explored the ways people managed that identity and controlled information about it.

Goffman’s Key Insights

The modern nation state’s heightened demand for normalcy. Today’s stigmas are the result not so much of ancient or religious prohibitions, but of a new demand for normalcy:

“The notion of the ‘normal human being’ may have its source in the medical approach to humanity, or in the tendency of large-scale bureaucratic organizations such as the nation state, to treat all members in some respects as equal. Whatever its origins, it seems to provide the basic imagery through which laymen currently conceive themselves.”

Living in a divided world, deviants split their worlds into:

  1. Forbidden places where discovery means exposure and danger;
  2. Places where people of that kind are painfully tolerated; and
  3. Places where one’s kind is exposed without need to dissimulate or conceal.

Dealing with others is fraught with great complexity and ambiguity:

“When normals and stigmatized do in fact enter one another’s immediate presence, especially when they attempt to maintain a joint conversational encounter, there occurs one of the primal scenes of sociology; for, in many cases, these moments will be the ones when the causes and effects of stigma will be directly confronted by both sides.” “What are unthinking routines for normals can become management problems for the discreditable.… The person with a secret failing, then, must be alive to the social situation as a scanner of possibilities, and is therefore likely to be alienated from the simpler world in which those around them apparently dwell.”

Society’s demands are filled with contradictions:

On the one hand, a stigmatized person may be told that he is no different from others. On the other hand, he must declare his status as “a resident alien who stands for his group.” It requires that the stigmatized individual cheerfully and unselfconsciously accept himself as essentially the same as normals, while at the same time he voluntarily withholds himself from those situations in which normals would find it difficult to give lip service to their similar acceptance of him. “One has to convey the impression that the burden of the stigma is not too heavy yet keep himself at the required distance. “A phantom acceptance is allowed to provide the base for a phantom normalcy.”

Familiarity need not reduce contempt. In spite of the common belief that openness and exposure will decrease stereotypes and repression, the opposite is true:

“Thus, whether we interact with strangers or intimates, we will still find that the fingertips of society have reached bluntly into the contact, even here putting us in our place.”

David Matza

In On Becoming Deviant (1969), sociologist David Matza gives the most vivid and graphic account of the process of adopting a deviant role. The acts of authorities in outlawing a proscribed behaviour can have two effects, keeping most out of the behaviour, but also offering new opportunities for creating deviant identities. He says the concept of “affinity” does little to explain the dedication to the behaviour. “Instead, it may be regarded as a natural biographical tendency born of personal and social circumstances that suggests but hardly compels a direction or movement.”

What gives force to that movement is the development of a new identity:

“To be cast as a thief, as a prostitute, or more generally, a deviant, is to further compound and hasten the process of becoming that very thing.”

“In shocked discovery, the subject now concretely understands that there are serious people who really go around building their lives around his activities—stopping him, correcting him, devoted to him. They keep records on the course of his life, even develop theories on how he got that way…. Pressed by such a display, the subject may begin to add meaning and gravity to his deviant activities. But he may do so in a way not especially intended by agents of the state.”

“The meaningful issue of identity is whether this activity, or any of my activities can stand for me, or be regarded as proper indications of my being. I have done a theft, been signified a thief. am I a thief? To answer affirmatively, we must be able to conceive a special relationship between being and doing—a unity capable of being indicated. That building of meaning has a notable quality.”

The “Criminal”

As an application of phenomenology, the theory hypothesizes that the labels applied to individuals influence their behaviour, particularly the application of negative or stigmatising labels (such as “criminal” or “felon”) promote deviant behaviour, becoming a self-fulfilling prophecy, i.e. an individual who is labelled has little choice but to conform to the essential meaning of that judgment. Consequently, labelling theory postulates that it is possible to prevent social deviance via a limited social shaming reaction in “labellers” and replacing moral indignation with tolerance. Emphasis is placed on the rehabilitation of offenders through an alteration of their labels. Related prevention policies include client empowerment schemes, mediation and conciliation, victim-offender forgiveness ceremonies (restorative justice), restitution, reparation, and alternatives to prison programmes involving diversion. Labelling theory has been accused of promoting impractical policy implications, and criticised for failing to explain society’s most serious offenses.

Some offenses, including the use of violence, are universally recognised as wrong. Hence, labelling either habitual criminals or those who have caused serious harm as “criminals” is not constructive. Society may use more specific labels such as “murderer” or “rapist” or “child abuser” to demonstrate more clearly after the event the extent of its disapproval, but there is a slightly mechanical determinism in asserting that the application of a label will invariably modify the behaviour of the one labelled. Further, if one of the functions of the penal system is to reduce recidivism, applying a long-term label may cause prejudice against the offender, resulting in the inability to maintain employment and social relationships.

The “Mentally Ill”

The social construction of deviant behaviour plays an important role in the labelling process that occurs in society. This process involves not only the labelling of criminally deviant behaviour, which is behaviour that does not fit socially constructed norms, but also labelling that which reflects stereotyped or stigmatised behaviour of the “mentally ill”. In 1961 Thomas Szasz, in The Myth of Mental Illness, asked, “Who defines whom as troublesome or mentally sick?… [the one] who first seizes the word imposes reality on the other; [the one] who defines thus dominates and lives; and [the one] who is defined is subjugated and may be killed.” Thomas J. Scheff in Being Mentally Ill challenged common perceptions of mental illness by claiming that mental illness is manifested solely as a result of societal influence. He argued that society views certain actions as deviant and, in order to come to terms with and understand these actions, often places the label of mental illness on those who exhibit them. Certain expectations are then placed on these individuals and, over time, they unconsciously change their behaviour to fulfil them. Criteria for different mental illnesses are not consistently fulfilled by those who are diagnosed with them because all of these people suffer from the same disorder, they are simply fulfilled because the “mentally ill” believe they are supposed to act a certain way so, over time, come to do so. Scheff’s theory had many critics, most notably Walter Gove who consistently argued against Scheff with an almost opposite theory; he believed that society has no influence at all on “mental illness”. Instead, any societal perceptions of the “mentally ill” come about as a direct result of these people’s behaviours. Most sociologists’ views of labelling and mental illness have fallen somewhere between the extremes of Gove and Scheff. On the other hand, it is almost impossible to deny, given both common sense and research findings, that society’s negative perceptions of “crazy” people has had some effect on them. It seems that, realistically, labelling can accentuate and prolong the issues termed “mental illness”, but it is rarely the full cause.

Many other studies have been conducted in this general vein. To provide a few examples, several studies have indicated that most people associate being labelled mentally ill as being just as, or even more, stigmatising than being seen as a drug addict, ex-convict, or prostitute (for example: Brand & Claiborn 1976). Additionally, Page’s 1977 study found that self declared “ex-mental patients” are much less likely to be offered apartment leases or hired for jobs. Clearly, these studies and the dozens of others like them serve to demonstrate that labelling can have a very real and very large effect on the mentally ill. However, labelling has not been proven to be the sole cause of any symptoms of mental illness.

Peggy Thoits (1999) discusses the process of labelling someone with a mental illness in her article, “Sociological Approaches to Mental Illness”. Working off Thomas Scheff’s (1966) theory, Thoits claims that people who are labelled as mentally ill are stereotypically portrayed as unpredictable, dangerous, and unable to care for themselves. She also claims that “people who are labeled as deviant and treated as deviant become deviant.” This statement can be broken down into two processes, one that involves the effects of self-labelling and the other differential treatment from society based on the individual’s label. Therefore, if society sees mentally ill individuals as unpredictable, dangerous and reliant on others, then a person who may not actually be mentally ill but has been labelled as such, could become mentally ill.

The label of “mentally ill” may help a person seek help, for example psychotherapy or medication. Labels, while they can be stigmatising, can also lead those who bear them down the road to proper treatment and (hopefully) recovery. If one believes that “being mentally ill” is more than just believing one should fulfill a set of diagnostic criteria (as Scheff would argue; see above), then one would probably also agree that there are some who are labelled “mentally ill” who need help. It has been claimed that this could not happen if “we” did not have a way to categorise (and therefore label) them, although there are actually plenty of approaches to these phenomena that do not use categorical classifications and diagnostic terms, for example spectrum or continuum models. Here, people vary along different dimensions, and everyone falls at different points on each dimension.

Proponents of hard labelling, as opposed to soft labelling, believe that mental illness does not exist, but is merely deviance from norms of society, causing people to believe in mental illness. They view them as socially constructed illnesses and psychotic disorders.

The “Homosexual”

The application of labelling theory to homosexuality has been extremely controversial. It was Alfred Kinsey and his colleagues who pointed out the big discrepancy between the behaviour and the role attached to it. They had observed the often negative consequences of labelling and repeatedly condemned labelling people as homosexual:

It is amazing to observe how many psychologists and psychiatrists have accepted this sort of propaganda, and have come to believe that homosexual males and females are discretely different from persons who respond to natural stimuli. Instead of using these terms as substantives which stand for persons, or even as adjectives to describe persons, they may better be used to describe the nature of the overt sexual relations, or of the stimuli to which an individual erotically responds.… It would clarify our thinking if the terms could be dropped completely out of our vocabulary.

Males do not represent two discrete populations, heterosexual and homosexual.… Only the human mind invents categories and tries to force facts into pigeonholes. The living world is a continuum in each and every one of its aspects.

The classification of sexual behavior as masturbatory, heterosexual, or homosexual, is, therefore, unfortunate if it suggests that only different types of persons seek out or accept each kind of sexual activity. There is nothing known in the anatomy or physiology of sexual response and orgasm which distinguishes masturbatory, heterosexual, or homosexual reactions.

In regard to sexual behavior, it has been possible to maintain this dichotomy only by placing all persons who are exclusively heterosexual in a heterosexual category and all persons who have any amount of experience with their own sex, even including those with the slightest experience, in a homosexual category.… The attempt to maintain a simple dichotomy on these matters exposes the traditional biases which are likely to enter whenever the heterosexual or homosexual classification of an individual is involved.

Erving Goffman’s Stigma: Notes on the Management of Spoiled Identity distinguished between the behaviour and the role assigned to it:

The term “homosexual” is generally used to refer to anyone who engages in overt sexual practices with a member of his own sex, the practice being called “homosexuality.” This usage appears to be based on a medical and legal frame of reference and provides much too broad and heterogenous a categorization for use here. I refer only to individuals who participate in a special community of understanding wherein members of one’s own sex are defined as the most desirable sexual objects, and sociability is energetically organized around the pursuit and entertainment of these objects.

Labeling theory was also applied to homosexuality by Evelyn Hookerand by Leznoff and Westley (1956), who published the first sociological study of the gay community. Erving Goffman and Howard Becker used the lives of gay-identified persons in their theories of labelling and interactionism. Simon and Gagnon likewise wrote: “It is necessary to move away from the obsessive concern with the sexuality of the individual, and attempt to see the homosexual in terms of the broader attachments that he must make to live in the world around him.” British sociologist Mary McIntosh reflected the enthusiasm of Europeans for labelling theory in her 1968 study, “The Homosexual Role:”

“The vantage-point of comparative sociology enables us to see that the conception of homosexuality as a condition is, itself, a possible object of study. This conception and the behavior it supports operate as a form of social control in a society in which homosexuality is condemned.… It is interesting to notice that homosexuals themselves welcome and support the notion that homosexuality as a condition. For just as the rigid categorization deters people from drifting into deviancy, so it appears to foreclose on the possibility of drifting back into normalcy and thus removes the element of anxious choice. It appears to justify the deviant behavior of the homosexual as being appropriate for him as a member of the homosexual category. The deviancy can thus be seen as legitimate for him and he can continue in it without rejecting the norm of society.”

Sara Fein and Elaine M. Nuehring (1981) were among the many who supported the application of labelling theory to homosexuality. They saw the gay role functioning as a “master status” around which other roles become organized. This brings a whole new set of problems and restrictions:

Placement in a social category constituting a master status prohibits individuals from choosing the extent of their involvement in various categories. Members of the stigmatized group lose the opportunity to establish their own personal system of evaluation and group membership as well as the ability to arrive at their own ranking of each personal characteristic.… For example, newly self-acknowledged homosexual individuals cannot take for granted that they share the world with others who hold congruent interpretations and assumptions; their behavior and motives, both past and present, will be interpreted in light of their stigma.

Perhaps the strongest proponent of labelling theory was Edward Sagarin. In his book, Deviants and Deviance, he wrote, “There are no homosexuals, transvestites, chemical addicts, suicidogenics, delinquents, criminals, or other such entities, in the sense of people having such identities.” Sagarin’s position was roundly condemned by academics in the gay community. Sagarin had written some gay novels under the pseudonym of Donald Webster Cory. According to reports, he later abandoned his gay identity and began promoting an interactionist view of homosexuality.

A number of authors adopted a modified, non-deviant, labelling theory. They rejected the stigmatic function of the gay role, but found it useful in describing the process of coming out and reconciling one’s homosexual experiences with the social role. Their works includes:

  • Homosexuals and the Military (1971);
  • Coming Out in the Gay World (1971);
  • Homosexual Identity: Commitment, Adjustment, and Significant Others (1973);
  • Male Homosexuals: Their Problems and Adaptations (1974);
  • Identity and Community in the Gay World (1974);
  • Components of Sexual Identity (1977);
  • Homosexualities: A Study of Diversity Among Men and Women (1978);
  • On ‘Doing’ and ‘Being’ Gay: Sexual Behavior and Homosexual Male Self-Identity (1978);
  • Homosexual Identity Formation: A Theoretical Model (1979, Cass identity model);
  • Becoming Homosexual: A model of Gay Identity Acquisition (1979);
  • Sexual Preference: Its Development in Men and Women (1981); and
  • Developmental Stages of the Coming Out Process (1982).

Barry Adam (1976) took those authors to task for ignoring the force of the oppression in creating identities and their inferiorising effects. Drawing upon the works of Albert Memmi, Adam showed how gay-identified persons, like Jews and blacks, internalise the hatred to justify their limitations of life choices. He saw the gravitation towards ghettos was evidence of the self-limitations:

A certain romantic liberalism runs through the literature, evident from attempts to paper over or discount the very real problems of inferiorization. Some researchers seem bent on ‘rescuing’ their subjects from ‘defamation’ by ignoring the problems of defeatism and complicit self-destruction. Avoidance of dispiriting reflection upon the day-to-day practice of dominated people appears to spring from a desire to ‘enhance’ the reputation of the dominated and magically relieve their plight. Careful observation has been sacrificed to the ‘power of positive thinking.’

Strong defence of labelling theory also arose within the gay community. Dan Slater of the Los Angeles Homosexual Information Centre said, “There is no such thing as a homosexual lifestyle. There is no such thing as gay pride or anything like that. Homosexuality is simply based on the sex act. Gay consciousness and all the rest are separatist and defeatist attitudes going back to centuries-old and out-moded conceptions that homosexuals are, indeed, different from other people.” In a later article, Slater (1971) stated the gay movement was going in the wrong direction:

Is it the purpose of the movement to try to assert sexual rights for everyone or create a political and social cult out of homosexuality? …Persons who perform homosexual acts or other non-conforming acts are sexually free. They want others enlightened. They want hostile laws changed, but they resent the attempt to organize their lives around homosexuality just as much as they resent the centuries-old attempt to organize their lives around heterosexuality.

William DuBay (1967) describes gay identity as one strategy for dealing with society’s oppression. It solves some problems but creates many more, replacing a closet of secrecy with one of gay identity. A better strategy, he suggests, is to reject the label and live as if the oppression did not exist. Quoting Goffman, he writes, “But of course what is a good adjustment for the individual can be an even better one for society.”

DuBay contends that the attempt to define homosexuality as a class of persons to be protected against discrimination as defined in the statutes has not reduced the oppression. The goal of the movement instead should be to gain acceptance of homosexual relationships as useful and productive for both society and the family. The movement has lost the high moral ground by sponsoring the “flight from choice” and not taking up the moral issues. “Persons whom we confine to back rooms and bars other societies have honored as tenders of children, astrologers, dancers, chanters, minstrels, jesters, artists, shamans, sacred warriors and judges, seers, healers, weavers of tales and magic.”

DuBay refers to the “gay trajectory,” in which a person first wraps himself in the gay role, organising his personality and his life around sexual behaviour. He might flee from his family and home town to a large gay centre. There, the bedevilling force of the stigma will introduce him to more excessive modes of deviance such as promiscuity, prostitution, alcoholism, and drugs. Many resist such temptations and try to normalise their life, but the fast lanes of gay society are littered with the casualties of gay identity. Some come to reject the label entirely. “Accomplishing the forbidden, they are neither gay nor straight. Again learning to choose, they develop the ability to make the ban ambiguous, taking responsibility and refusing explanations of their behaviors.”

John Henry Mackay (1985) writes about a gay hustler in Berlin adopting such a solution: “What was self-evident, natural, and not the least sick did not require an excuse through an explanation.… It was love just like any other love. Whoever could not or would not accept it as love was mistaken.”

There are those who reject the “gay label” for reasons other than shame or negative connotations. They do not reject their homosexuality. It is “gay” as an adjective they reject. Writer Alan Bennett and fashion icon André Leon Talley reject being labelled as a gay writer, a gay fashion designer. These men are openly gay, but believe when gay is used as an adjective, the label confines them.

Modified Labelling Theory

Bruce Link and colleagues (1989) had conducted several studies which point to the influence that labelling can have on mental patients. Through these studies, taking place in 1987, 1989, and 1997, Link advanced a “modified labelling theory” indicating that expectations of labelling can have a large negative effect, that these expectations often cause patients to withdraw from society, and that those labelled as having a mental disorder are constantly being rejected from society in seemingly minor ways but that, when taken as a whole, all of these small slights can drastically alter their self concepts. They come to both anticipate and perceive negative societal reactions to them, and this potentially damages their quality of life.

Modified labelling theory has been described as a “sophisticated social-psychological model of ‘why labels matter.'” In 2000, results from a prospective two-year study of patients discharged from a mental hospital (in the context of deinstitutionalisation) showed that stigma was a powerful and persistent force in their lives, and that experiences of social rejection were a persistent source of social stress. Efforts to cope with labels, such as not telling anyone, educating people about mental distress/disorder, withdrawing from stigmatising situations, could result in further social isolation and reinforce negative self-concepts. Sometimes an identity as a low self-esteem minority in society would be accepted. The stigma was associated with diminished motivation and ability to “make it in mainstream society” and with “a state of social and psychological vulnerability to prolonged and recurrent problems”. There was an up and down pattern in self-esteem, however, and it was suggested that, rather than simply gradual erosion of self-worth and increasing self-deprecating tendencies, people were sometimes managing, but struggling, to maintain consistent feelings of self-worth. Ultimately, “a cadre of patients had developed an entrenched, negative view of themselves, and their experiences of rejection appear to be a key element in the construction of these self-related feelings” and “hostile neighbourhoods may not only affect their self-concept but may also ultimately impact the patient’s mental health status and how successful they are.”

Book: Eliminating Race-Based Mental Health Disparities

Book Title:

Eliminating Race-Based Mental Health Disparities: Promoting Equity and Culturally Responsive Care Across Settings.

Author(s): Monnica Williams (PhD), Daniel C. Rosen (PhD), and Jonathan W. Kanter (PhD) (Editors).

Year: 2019.

Edition: First (1st).

Publisher: New Harbinger.

Type(s): Paperback and Kindle.

Synopsis:

Eliminating Race-Based Mental Health Disparities offers concrete guidelines and evidence-based best practices for addressing racial inequities and biases in clinical care.

Perhaps there is no subject more challenging than the intricacies of race and racism in American culture. More and more, it has become clear that simply teaching facts about cultural differences between racial and ethnic groups is not adequate to achieve cultural competence in clinical care. One must also consider less “visible” constructs-including implicit bias, stereotypes, white privilege, intersectionality, and microaggressions-as potent drivers of behaviours and attitudes.

In this edited volume, three leading experts in race, mental health, and contextual behaviour science explore the urgent problem of racial inequities and biases, which often prevent people of color from seeking mental health services-leading to poor outcomes if and when they do receive treatment. In this much-needed resource, you’ll find evidence-based recommendations for addressing problems at multiple levels, and best practices for compassionately and effectively helping clients across a range of cultural groups and settings.

As more and more people gain access to services that have historically been unavailable to them, guidelines for cultural competence in clinical care are needed. Eliminating Race-Based Mental Health Disparities offers a comprehensive road map to help you address racial health disparities and improve treatment outcomes in your practice.

Book: Culture and Psychology

Book Title:

Culture and Psychology.

Author(s): David Matsumoto and Linda Juang.

Year: 2012.

Edition: Fifth (5th).

Publisher: Cengage Learning.

Type(s): Paperback and Kindle.

Synopsis:

This field-leading book puts psychological theories and concepts into a cross-cultural framework that invites readers to discover, question, and ultimately, understand the relationship between culture and psychology through exploration of topics like changing gender roles, sexuality, self-esteem, aggression, personality, and mate selection.

It all adds up to a book that will leave readers with a deeper, more complex understanding of the nature of culture, its relationship to psychological processes, and the differences and similarities between cultures in the increasingly globalized world.

Book: Psychology

Book Title:

Psychology.

Author(s): G. Neil martin, Neil R. Carlson, and William Buskist.

Year: 2013.

Edition: Fifth (5th).

Publisher: Pearson.

Type(s): Paperback.

Synopsis:

Now in its fifth edition, Psychology is a comprehensive, lively and accessible introduction to the fascinating study of the subject.

It describes and explores every major area of psychology and present the latest findings, along with clear evaluation of controversial theories and models, to give a thorough and critical grounding in the subject.

Book: Psychology in Black and White

Book Title:

Psychology in Black and White – The Project of a Theory-Driven Science.

Author(s): Sergio Salvatore (Author) and Jaan Valsiner (Series Editor).

Year: 2015.

Edition: First (1st).

Publisher: Information Age Publishing, Illustrated Edition.

Type(s): Hardcover, Paperback, and Kindle.

Synopsis:

This book is long awaited within the contemporarily creative field of cultural psychologies. It is a theoretical synthesis that is at the level of innovations that Sigmund Freud, James Mark Baldwin, William Stern, Kurt Lewin, Jean Piaget, Lev Vygotsky and Jan Smedslund have brought into psychology over the past century. Here we can observe a creative solution to integrating cultural psychology with the rich traditions of psychodynamic perspectives, without repeating the conceptual impasses in which many psychoanalytic perspectives have become caught.

CONTENTS

  • Series Editor’s Preface.
  • New Synthesis: A dynamic theory of Sense-Making Introduction.
  • Psychology as the science of the explanandum.
  • PART I – MICRO-PHYSICS OF SENSEMAKING:
    • Chapter 1. The meaning of our discontent.
    • Chapter 2. The Semio-Dynamic Model of Sensemaking (SDMS).
    • Chapter 3. Micro-dynamic of sensemaking.
    • Chapter 4. The semiotic Big Bang.
  • PART II. THEORETICAL EXPLORATIONS:
    • Chapter 5. The contextuality of mind.
    • Chapter 6. Beyond subject and object.
    • Chapter 7. Affect and desire as semiotic processes.
    • Chapter 8. Exercises of semiotic reframing.
  • PART III. A NEW METHODOLOGICAL APPROACH:
    • Chapter 9. Field dependency and abduction.
    • Chapter 10. The modelling of sensemaking.
    • Chapter 11. Models and strategies of empirical investigation.
    • Chapter 12. Studies of sensemaking.
  • Epilogue.
  • References.

Overcoming Communication Difficulties

Communicating with People from Different Cultures

Any successful communication recognises the uniqueness of every culture, every relationship, and every individual – including you.

Some forms of verbal and non-verbal communication are appropriate and others are not appropriate. For instance, some individuals may regard prolonged eye contact as rude. We all have different ways of communicating our fears and needs when we become unwell. Invite the person to tell you about their life experiences, values, and belief systems. Also, ask them how they feel about asking for care and support.

Establish what is realistic for the individual, as well as what is culturally acceptable. Some cultures encourage the use of silence, whereas in others it creates embarrassment or awkwardness. In the French, Spanish, and Eastern European cultures, the presence of silence is a sign of agreement.

Working with an Interpreter or a Bilingual Worker

When an individual does not speak English at all, has limited English, or chooses to communicate their distress in their mother tongue, the best solution is to use a professional interpreter. The choice to use a trained interpreter or a family member must be made by the individual who is experiencing problems. Being able to do so will help the individual to fell that they are in control of the situation.

Language holds and creates the individual’s reality, experience, culture, and world view. A good interpreter will concentrate on accurately conveying equivalent meaning as well as reporting the direct answers to your questions and other responses offered. You should also be aware that the interpreter may bring their own bias to the situation.

Working with a British Sign Language Interpreter for the Deaf

There are very few services available for deaf people with mental health problems, although recently some deaf workers have been trained in mental health first aid.

If no deaf mental health first-aider is available, you may need to use an interpreter. In this case, you should take care to always face the deaf person when speaking and respond as though it is the deaf person speaking to you when the interpreter speaks. Remember that the interpreter is being the deaf person’s voice. Maintain good eye contact and show your feelings through your facial expressions. Deaf people do much of their communication through body language and facial expression, and are therefore skilled at reading feelings.

If no interpreter is available, you can still offer support and concern by showing your willingness to communicate. Deaf people can often lip read and can vocalise using English. Be patient and try hard to understand. Show your concern as you would with anyone in distress and ask the person who you can call for help.

Important Note

If you need to use a pen and paper to ask the person who they would like you to call for help or support, use very simple English.

British Sign Language is a different language to English – a person who was born deaf may not have English as their first language.

Society, Culture & Diversity

Current thinking on mental health suggests that it is best to consider the whole person – rather than try to separate mental health from other areas of life. Each of us is a complex blend of physical, emotional, social, cultural, and spiritual factors.

The way we cope with life and respond to life events is affected by our experiences, and individual characteristics such as personality. This means that there is no such thing as equality where mental health is concerned. Some people are disadvantaged by emotional or social deprivation. Others are disadvantaged by the fact that they are perceived as being different, and they experience discrimination as a result. Some people appear to have a greater risk of developing mental health problems or a serious mental illness for no obvious reason.

There is a lot of evidence to suggest that social and economic deprivation makes a person more susceptible to all kinds of ill health, including mental ill health.

Mental health problems are more common in socially disadvantaged populations and in areas of deprivation. They are associated with unemployment, low education levels, low income, and a poor standard of living. This same underprivileged population experiences the highest prevalence of anxiety and depression.

There is strong evidence of a connection between poverty, unemployment, social isolation, and schizophrenia. Deprivation is also associated with a number of negative experiences, such as having symptoms for longer, experiencing more frequent episodes of illness, having a poorer quality of care, and having a lower chance of recovery.

In the United Kingdom (UK), we need to pay proper attention to positive mental health and well-being. We can do this by promoting positive mental health, providing support so that the quality of life is improved, acting against social exclusion, and promoting the rights of people by addressing inequalities in mental health.

Being perceived as different to the majority of people around you has an impact on mental health. This means that people with physical disabilities, gay, lesbian, bisexual or transgender people, people with learning difficulties and people from black and minority ethnic groups are all more likely to experience mental health problems.

There is substantial literature regarding the impact of health of all forms of discrimination, whether on the grounds of race and ethnicity, age, gender, religion or sexual orientation. It adversely impacts mental health, affecting a person’s dignity and self-esteem. It can lead to a sense of alienation, isolation, fear, and intimidation. It can make it difficult for individuals to feel socially included and to integrate into society.

Difference is a problem not because of the perceived difference itself, but because of the attitude of the majority of the population towards people who appear different. We live in a culture that encourages similarity. We notice when people dress differently, live differently, or act differently. Western culture has been slow to recognise how badly people are affected by being treated less favourably because of perceived difference.

The law now protects certain people and groups from discrimination and disadvantage. However, in order to foster positive mental health in society, we all need to think about our attitudes and find ways to treat one another with equal respect and care.

Mental health first aid training can make an enormous difference to the mental health of society because it models good practice, by offering kindness and support to people in mental distress – regardless of their ethnic heritage, sexuality, religion, economic status, health, ability, age, or gender.