Deviance and Medicalization: From Badness to Sickness : With a New Afterword by the Authors - 2nd Expanded edition

348 Pages·1992·20.67 MB·English

by  Peter Conrad

DEVIANCE AND MEDICALIZATION
FROM BADNESS TO SICKNESS

DEVIANCE AND
MEDICALIZATION
FROM BADNESS TO SICKNESS
EXPANDED EDITION,
WITH a NEW AFTERWORD by the AUTHORS
PETER CONRAD
JOSEPH W. SCHNEIDER
Foreword by Joseph R. Gusfleld
Illustrated
Recipient of 1981 SSSI
Charles Horton Cooley Award
TEMPLE UNIVERSITY PRESS
Philadelphia
Temple University Press, Philadelphia 19122
Copyright © 1992 by Temple University
All rights reserved
Copyright © 1980 by The C. V. Mosby Company
Copyright © 1985 by Merrill Publishing Company
Printed in the United States of America
The paper used in this publication meets the minimum
requirements of American National Standard for Information
Sciences-Permanence of Paper for Printed Library
Materials, ANSI Z39.48-1984 §
Library of Congress Cataloging-in-Publicafion Data
Conrad, Peter, 1945-
Deviance and medicalization : from badness to sickness:
with a new afterword by the authors IPeter Conrad, Joseph
W. Schneider; foreword by Joseph R. Gusfield.
p. cm.
Originally published: St. Louis: Mosby, 1980.
"Recipient of 1981 SSSI Charles Horton Cooley
Award. "
Includes bibliographical references (p. ) and indexes.
ISBN 0-87722-998-8 (cloth). -. ISBN 0-87722-999-6
(paper)
1. Deviant behavior. 2. Social control.
3. Mental illness. 4. Mental health policy.
5. Social ethics. I. Schneider, Joseph W.,
1943- . II. Title.
[HM291.C64 1992]
302.5'42-dc20 92-13441
FOREWORD
The idea of progress is by no means spent. granted." Before they can be explored, their
Western societies, and the United States in par status as problems must be understood. This
ticular, retain the optimism of the Enlighten challenge to the attribution of "deviance" as
ment in the belief that in science and technology something clear and unambiguous to the sociol
will be found the means for achieving good and ogist has been the central note i!1 the loud chal
avoiding evil. There is hardly a chapter in the lenge to past theories and studies of crime,
history of the achievements of science as glori mental health, 'and the other social problems
ous as that of bacteriology's defeat of infectious that make up the content of undergraduate texts.
diseases. Where today is the fear of diphtheria, In the writings of influential sociologists such
typhoid, smallpox, or poliomyelitis? The tech as Howard Becker, Eliot Freidson, Erving
nical apparatus of medicine and its practitioners Goffman, Thomas Scheff, and others, loosely
have been the recipients of that beneficial called "labeling theorists," the approach
movement in the eradication of human woes. stressed the ways in which one group used
That such diseases have become the metaphor "deviance" to define another. More recently,
for many other, perhaps less tractable, woes is in the hands of sociologists with a greater inter
the major thought of this volume. Peter Conrad est in the construction of cognitive categories,
and Joseph Schneider have given a clear and there is a deeper interest in the ways in which
definitive description and analysis of how the categories are articulated and utilized. Here
"medical model" has become so much of the such sociologists as Aaron Cicourel, Jack
reality of contemporary public problems. The Douglas, Harold Garfinkel, and David Sudnow
contribution is both to the general sociological are predominant. Most recently the entire tradi
analysis of social problems and to the specific tion has moved toward an even more historical
debate and discussion of medicine as a para concern for the development of social prob
digm with which to understand and respond to lems, as indicated in Malcolm Spector and John
public problems usually termed "deviance." Kitsuse's work, Constructing Social Problems.
During the past two decades, sociology has As Conrad and Schneider indicate, they agree
begun to return to its historic emphasis on the with these two authors that "the process by
socially shared character of human problems. In which members of groups or societies define a
a stress on human events as interpreted phe putative condition as a problem . . . is the dis
nomena rather than objectively and abstractly tinctive subject matter of the sociology of social
viewed, this past generation of sociologists has problems. ,,*
called attention to the necessity for an analysis A belief in the multiplicity of ways to con
of public problems to explain the reality of the ceive the world of nature and of humans and a
problem itself. How is it that a particular phe skepticism about the claims of the medical
nomenon comes to be considered "problemat model to greater validity underlie this signifi-
ic" and invested with a certain nature? Alcohol
ism, homosexuality, racial conflict, rebellions, * Spector, M., and Kitsuse, J. Constructing social
child abuse, and the many situations seen as problems, Menlo Park, Calif.: The Benjamin/Cum
public problems are not to be "taken for mings Publishing Co., 1977, p. 415.
v
vi FOREWORD
cant book. The recent public attention to the atlVlzmg light of social anthropology in the
mass suicide of the People's Temple at Jones hands of sociologists.
town, Guyana, is an example of the opposing In at least two significant ways this book
character of popular thought. After the news of greatly advances our use of social construction
Reverend James Jones and his followers, the ist perspectives. First, it emphasizes the history
media of communication searched out many ex of particular problems. Alcoholism, homosex
perts for public guidance and an explanation of uality, child abuse and child hyperactivity, opi
how the mass suicide of 900 people could oc ate addiction, and mental disturbance-the spe
cur. Most often television, radio, newspapers, cific cases studied here-have not been constant
and magazines turned to psychiatrists, psychol phenomena. They have changed through history
ogists, and sociologists with the assumption and even now are in the process of being as
that this bizarre behavior was a sign of sickness, well as having become. This attentiveness to
of abnormality. It could only be explained as the history of problems is crucial to any under
something that "normal" people could never standing of the cultural and social framework
do. within which public problems and public issues
Such interpretations lost sight of the multi are discussed. History is, at least here, also a
fold histories of the normalization of many sim relativizing device. It gives distance and
ilar phenomena. The Charge of the Light Bri strangeness to what is otherwise seen as near
gade or the stubborn refusal of military heroes and familiar. The medicalization of social prob
to surrender, as at the Alamo, seems "normal" lems, in each of the cases, is not the culmina
to those who have rehearsed such actions as the tion of a movement to find a solution to the
response to the rules of their societies. The problems but only another period in which one
hara-kiri of the traditional Japanese ritual sui imputed reality is substituted for another.
cide seems understandable to Western minds There is in this stance a certain ironic
who have come to know something of Japanese mood-a distancing of the observer from the
history and culture. In view of the fact that the observed. Those being analyzed-the members
members of the People's Temple were isolated of the society, official agents, major spokes
from continuous outside contacts, imbued with men-are caught up in the Enlightenment view
a sense of beleaguerment, and had an authori of history as evolution toward progress. Science
tarian social organization, the Jonestown mass is, in this formulation, outside of history-not
suicide may be unusual or bizarre, but it can be itself a target of study. Those doing the analyz
seen as normalized within that social existence ing-the sociologists themselves-are not so
and not a sign of sickness. The Indian suttee is caught up. They will not give medicine and its
only "sick" to the stranger who fails to recog claim to authority through science any special
nize the preparation for it in Indian socialization consideration or status. They take it as topic
and the difficult life the widow faced if she did rather than resource.
not immolate herself on her husband's funeral The second aspect of Conrad and Schneider's
pyre. work that is significant is that they take serious
Implicit in all of us who are identified with ly the perspective that public definitions of
studying social problems as social constructions public problems are the outcomes and continual
is a deep-seated belief in the relativism of fact. objects of claims that interested groups put forth
There is no "true" problem or "true" solution. in public arenas. Homosexuality is the clearest
Reality, like morality, is subject to explanation instance of how the nature of the problem has
and analysis. It is, but it need not be. At least been fought about in public places. The appella
in many of the realms customarily studied by tions of sin, illness, and alternative sexual pref
sociologists, not only is "one man's moral tur erence all indicate different ways of "seeing"
pitude another man's innocent pleasure" but the phenomena of homosexual relationships.
what is fact today and may never have been Organizations, groups, and individual persons
fact until today may be fiction tomorrow. Sci seek to influence the definition of the problem
ence and medicine are not exempt from the rel- and the belief in the "facts" about it. Some of
FOREWORD vii
their claims receive greater support by the pub both obligated and entitled to be helped. De
lic than others. In 1979, laws concerning homo fined as having medical problems, they are fit
sexuality were objects of elections in several objects of treatment by medical institutions.
states, and opposing groups debated, discussed, They can be cured and helped by a technical
and even fought about these issues. * The same knowledge.
has certainly been the case in other areas of so It is this shift in moral and institutional set
cial concern, especially alcoholism, drug addic tings that has been the occasion for so much of
tion, and child abuse. What is essential to Con the recent debate about the acceptance or rejec
rad and Schneider's perspective is that these tion of the medical model in what have been de
conflicts involve claims to have factual belief fined, in public arenas and in social studies, as
as well as moral judgment accepted or rejected. problems of deviance. Conrad and Schneider
In the eyes of many self-designated "homosex are adept in describing and analyzing this issue
uals," to be seen as "ill" is to be derogated. and its development. Solutions to human prob
Hence they struggle to achieve a "normaliza lems often create new problems in solving ini
tion" rather than a "sick role." They liken tial ones. This has been the case with the use of
themselves to participants in the black and medicine in the public problems described in
the civil rights movements and not to the this volume. The transformation of problems
mentally ill and the struggle for institutional from ones of badness to ones of sickness has a
facili ties. ring of humanitarian concern. The love of man
This focus on a "politics of reality" is part of for man or woman for woman, the wildness of
the importance of Deviance and Medicaliza children, or the desire to continually use opiates
tion. It is essential to the third significant fea comes to be seen in neutral, amoral terms. The
ture of the book and to its special importance: onus of being "bad people" is cast off when the
the specific analysis of how the medical model same phenomena are now viewed as "disease."
has been used in the social construction of the It makes it less possible for morally upright
reality of social problems. Looking at medi people to ignore these people's "problems"
cine as only another form of constructing social and makes feasible development of institutional
solutions has the consequence of raising ques and public facilities for their care.
tions concerning the adequacy of that model But in the wake of this change came at least
and the possibility of alternatives to it. three new issues that raise significant questions
Conrad and Schneider have given us a three concerning the application of the medical meta
fold conception of the metaphor of medicine in phor. The concept of compulsive behavior sug
contemporary public problems. "Sickness" has gests helplessness and loss of control that is it
a cognitive, a moral, and an institutional di self an unflattering self-portrait to which many
mension. To define people who behave object. Better to be thought a sinner, but re
"strangely" -homosexuals, opiate addicts, hy sponsible for myself, than to be a victim of the
peractive children, and child abusers-as "sick fates! There is a moral connotation to sickness
people" changes their role in society and their that underlies the humanitarian perception of
status as deviants. "Illness" puts the object of the deviant as victim.
concern under a different moral light than does There is also another meaning implicit in
"sin" or "preference." It introduces an ele compUlsion, although also contained in the idea
ment of compulsion into the cognitive reality of of sin. Accepting this concept is an admission
the phenomenon. As Talcott Parsons suggested, of deviance; a way of agreeing with the label
my slipped disc is a legitimate excuse for not ers. One says, "I am thus and so, and I should
giving that lecture today. The "sick" are nei wish to be otherwise [what I have elsewhere
ther criminal nor morally responsible for their called the' 'reluctant deviant"]; if I am not bad
"disease." However, as sick people, they are because I am sick, my supposed affliction is
bad." Homosexuality, addiction to opiates, and
* Gusfield, 1. California ceremony. The Nation, Dec. drinking too much are "deviant" with all the
9, 1978, 227, 633-635. moral connotations that term implies. It is this
viii FOREWORD
consideration that leads many arrested and solution to social problems on individual treat
drinking drivers to object to the label "alcohol ment. The face-to-face model of the physician
ic." In recent years the struggle of homosex patient is considered the model of how to deal
uals to shed the label of "sickness" for the with the cases described in Deviance and Med
status of an accepted alternative form of sex icalization. This psychologizing of social prob
similarly indicates that the medical metaphor is lems leads away from the analyses of the social
not as neutral and as amoral as it seemed in its structure of culture-the socially shared in
inception. stitutions and meanings in the society as ele
These two considerations of the moral status ments in the problems. The problems of alco
of compulsion are foundations for the second hol use are located in the alcoholic. The al
problem of medical metaphors as public issue. cohol industry, the governmental policies of
With the attribution of disease, the individual is legal and tax programs, and the structure of
delivered up to a body of institutional experts work are all ignored. In my current interest in
psychiatrists, child guidance counselors, physi drinking and driving, I have been impressed by
cians, alcohol treatment practitioners, social the enormous emphasis on drinking and the
workers-who seek the person's rehabilitation. drinker as causal elements while such institu
In becoming technical objects, the deviants give tional aspects as lack of alternate means of
rise to a new group of control agents and agen transportation are ignored both as causal agents
cies whose power is suspect. The basis of this and as possible considerations in providing ave
suspicion is partly the general fear of being nues of solution. Sociological definitions of
powerless and partly the suspicion, much sup public problems, unlike psychological ones,
ported by historical outcomes and the social raise issues of group interests and moral com
constructionist analysis presented here, that the mitments and move into public and political
supposed technical expertise is both shaky as arenas.
fact and not very successful in its outcomes. In this analysis of medicalization, where is
The application of social and medical science to the sociologist? What does the sociologist bring
the range of issues described has not been salu to the ongoing understanding and even the solu
tary. tion of public problems? I believe that the so
Last, as Conrad and Schneider emphasize, ciologist brings the stance of the ironist to pub
the effect of medicalizing public problems is lic phenomena. "The aim of the Ironic state
their depoliticization. By removing the prob ment," writes Hayden White, "is to affirm
lems as ones on which honest and reasonable tacitly the negative of what is on the literal level
people might differ and in presenting one defi affirmed positively." * This is exactly what
nition as inherently and "really" preferential, Conrad and Schneider do. They treat the medi
the medicalization of social problems depoliti cal model as something strange, not as some
cizes them and diminishes the recognition of thing that is "taken for granted" as "normal."
differences in moral choices that they represent. When a body of thought or a phenomenon is
Again, the recent movement for homosexual taken as problematic, as something to be ex
rights or the redefinition of mental illness im plained, its naturalness, its claim to "reality,"
plied in the works of R. D. Laing and Thomas is called into account. Thus to choose to exam
Szasz have given clear recognition of this. Sim ine the way in which homosexuality was trans
ilarly, the tendency to "blame the victim," in formed from sin to sickness or heavy drinking
William Ryan's words, carries this conception from evil to addiction is to make the medical
even further. * model itself less than accepted on the strength
There is another aspect to the depoliticizing of its correctness-its greater grasp of the real
effect of medicalization. It puts the responsibil ity of its object. This examination is in the
ity for the problem on individual causes and the
* White, H. Metahistory: the historical imagination
*Ryan, W. Blaming the victim. New York: Vintage in nineteenth century Europe. Baltimore: Johns Hop
Books, 1971. kins University Press, 1973, p. 37.
FOREWORD Ix
classic tradition of the sociologist as exposer of cial character of what purports to be universal,
ideology who, in an ironic stance toward human sociology can contribute to public life what the
behavior, uncovers what purports to be truth arts contribute to human life-the visions of
and finds beneath the sheet of universalistic other realities, other ways of conceptualizing
science the particular bed of specific cultures, human actions, other possible ways of inventing
groups, and human interests. * human institutions.
The implications of sociological irony for However, is all a ceaseless and fluid process
public problems are vastly significant. The in of multiple realities in which any situation may
tervention of science into human affairs has car be defined in any fashion? Is there amidst the
ried the hope that human problems might be skepticism of the sociologist any "realer reali
susceptible to solution by technical knowledge ties," or are all systems equally possible? The
and skill as some problems of nature have been. sociologist may dodge the metaphysical diffi
(The tremendous effect of bacterial knowledge culties of the ironic stance by claiming finite,
is the commanding case in point.) In being although mUltiple, possibilities in nature. We
skeptical about the source of technical knowl cannot completely dodge the charge of a cruel
edge and the definition of social problems as Olympianness. Conrad and Schneider, like
technical, medical ones, the authors of Devi many of us who affect the sociological disposi
ance and Medicalization cannot escape the tion, offer no way by which the sufferers can
charge of undermining the authority of the cope with their suffering. Mental illness has in
technical treatment and therapy professions. deed undergone a variety of definitions through
Fortunately, the Socratic hemlock is not avail out history. How does that realization enable a
able. society or an individual to face the phenomena
On another level, the ironist has also been a that the definitions encompass? Are Conrad
moralist of sorts, and the sociologist here fol and Schneider telling us that there is no "men
lows. In displaying the ways in which the medi tal illness" problem? That any conception of
cal metaphor of sickness depoliticizes moral excessive drinking is only the particular con
and social conflicts, the sociological analyst struction of a time and a place? What happens
brings moral choice into the foreground. The to the urgency and exigency of the situation?
sociologist makes it necessary for the partici To be sure, it seems easier to accept this view
pants in public problems to confront them as when the problem is homosexuality, or even
issues, as matters of choice, unconstrained by opiate addiction, but are we not again in danger
the natural order of things. As long as men and of making another metaphor under which to in
women could believe that some persons were clude phenomena whose differences are also
by nature slaves and others free, slavery need significant?
not have been faced by slaveholders as a moral An earlier, more positivistic social science
choice. The way in which homosexuality is be knew where it stood. Less ironic, it sought an
ing redefined is indicative of the process by engineering solution to known social problems.
which the transformation from a technical to a Convinced that one could find a science for
nontechnical formulation repoliticizes the issue. understanding social life and a technology for
As a society, we shall have to decide the moral acting toward it, it possessed a mission, a stand
status of homosexuality if it is not construed as from which to address the society. Can the
illness. We shall have to decide whose side we sociological perspective embodied in this book,
are on. as in a good deal of the work of others I have
The irony of the sociologist has much in mentioned, including myself, find any such
common with the imagination of the artist. Like platform, or is our relation to social policy
the artist, the sociologist indicates that there are that of the "disinterested observer of the pass
alternatives to the present. In showing the spe- ing scene" whose skepticism and irony lead to
understanding, powerlessness, and escape from
commitment? Can we only echo Freud's state
*Brown, R. H. A poetic for sociology. Cambridge:
Cambridge University Press, 1977. ment? "I have not the courage to rise up before