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

348 Pages·1992·20.67 MB·English
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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

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