The Opposite of Labeling: Normalizing Treatment

draft paper by Thomas Scheff

At their inception, studies of social management of mental illness had considerable public impact. My first professional study concerned diagnosis in Wisconsin (Scheff 1962). It showed that the medical-legal system in most of the counties rubber-stamped commitment, allowing the mental hospitals to become warehouses for the old, the poor and non-English speaking immigrants

The Wisconsin legislators who received my findings were so shocked that they dismissed them as unreliable. However, an unusually energetic and intelligent California legislator, the late Jerome Waldie, tracked down the study. He arranged for me to testify in the first hearing of his committee on commitment of the mentally ill (California Assembly 1965). When he had my study repeated in California, the findings were the same. His description of the situation led the legislature to pass the Lanterman-Petris-Short Act (Crown et al 1966; Bardach 1972). This law made it difficult to detain mental patients for long periods of time. It ultimately was adopted by every state, including Wisconsin, resulting in either closure or considerable downsizing of state mental hospitals.

These findings didn’t require much imagination to understand, because the system was so flagrantly fraudulent and unjust. Taking a step further, labeling theory sought to replace, or at least supplement the medical model of mental illness. There is evidence that supports critical parts of the theory (see, for example, Link 1989; Link 2001). However, the theory did not provide sufficient concrete instances for envisioning a social model. The original theory particularly provided few concrete episodes of non-labeling, at the core of the theory. It appears that the idea of residual rule-breaking was little understood, even by the supporters of the theory. The work of Goffman on unstated rules, discussed below, was not enough.

I must include myself among those who didn’t understand, at least the non-labeling part. Until I examined the instances of labeling and normalizing dialogues discussed at the end of this paper, I hadn’t realized the crucial role that normalization plays, translating discourse out of the labeling idiom, in the theory and practice of social treatment. Nor did I realize the enormous pressure on physicians to label rather than normalize. The central purpose of this paper is to develop that aspect of the theory further than the original, using specific instances to make the abstract concepts more understandable. The central ideas of the theory will first be reviewed.

One source of immediate embarrassment to any social theory of "mental illness" is that the terms used in referring to these phenomena in our society prejudge the issue. The medical metaphor "mental illness" suggests a determinate process that occurs within the individual: the unfolding of disease. Sociological rather than medical terminology avoids this problem. Particularly crucial to the formulation of the problem is the idea of psychiatric "symptoms," which is applied to the behavior that is taken to signify the existence of an underlying mental illness. Since in the great majority of cases of mental illness, the existence of this underlying illness is unproven, we need to discuss "symptomatic" behavior in terms that do not involve the assumption of illness.

Two concepts seem to be suited best to the task: rule-breaking and deviance. Rule-breaking refers to behavior that is in violation of the agreed-upon rules of the group. These rules are usually discussed by sociologists as social norms. If the symptoms of mental illness are to be construed as violations of social norms, it is necessary to specify the type of norms involved. Most norm violations do not cause the violator to be labeled as mentally ill, but as ill-mannered, ignorant, sinful, criminal, or perhaps just harried, depending on the type of norm involved.

There are innumerable norms, however, over which consensus is so complete that the members of a group don’t realize they exist. This is the territory that Erving Goffman explored, the underlife of human beings.

A universe of norms surrounds even the simplest conversation: a person engaged in conversation must face toward the other person, rather than directly away from him/her. If one’s gaze is toward the partner, one is expected to look toward the other's eyes, rather than, say, toward the forehead or ear; to stand at a proper conversational distance, neither one inch away nor across the room, and so on. A person who often violated these expectations might not thought to be merely ill-bred, but as strange, bizarre, and frightening. Breaking these kinds of norms violates the assumptive world of the group, the world that is taken for granted to be the only one that is natural, decent, and possible.

The concepts of rule-breaking and deviance used here will follow Becker's (1963) usage. He argues that deviance can be most usefully considered as a quality of people's response to an act, rather than as a characteristic of the act itself:

Social groups create deviance by making the rules whose infraction constitutes deviance, and by applying those rules to particular people and labeling them as outsiders. . . . Deviance is not a quality of the act the person commits, but rather a consequence of the application by others of rules and sanctions to an "offender." The deviant is one to whom that label has successfully been applied; deviant behavior is behavior that people so label, (Becker 1963, p. 9)

By this definition, deviants are not a group of people who have committed the same act, but are a group of people who have been stigmatized as deviants.

Becker argues that the distinction between rule-breaking and deviance is necessary for scientific purposes. This discussion will conform to Becker's separation of rule-breaking and deviance. Rule-breaking will refer to a class of acts, violations of social norms, and deviance to particular acts that have been publicly and officially labeled as violations.

Using Becker's distinction, we can categorize most psychiatric symptoms as instances of residual rule-breaking. The culture of modern societies provides a lexicon of terms for categorizing many norm violations: crime, perversion, drunkenness, and bad manners are familiar examples. Each of these terms is derived from the type of norm broken and, ultimately, from the type of behavior involved.

After exhausting these categories, however, there is always a residue of the most diverse kinds of violations for which the culture provides no explicit general label. For example, although there is great cultural variation in what is defined as decent or real, each culture tends to reify its definition of decency and reality and so provides no way of handling violations of its expectations in these areas. The typical norm governing decency or reality, therefore, literally "goes without saying," and its violation is unthinkable for most of its members.

For the convenience of the society in construing those instances of unnamable rule-breaking that are called to its attention, these violations may be lumped together into a residual category: witchcraft, spirit possession, or, in our own society, mental illness. In this discussion, the diverse kinds of rule-breaking for which our society provides no explicit label and that therefore sometimes lead to the labeling of the violator as mentally ill, will be termed residual rule-breaking.

Let us consider further some of the implications of a definition of psychiatric symptoms in this light. In Behavior in Public Places, Goffman (1964) developed the idea that there is a complex of social norms that regulate the way in which a person may behave when in the presence, or potentially in the presence, of other persons. Goffman's discussion of the norms regarding "involvements," particularly, illustrates how such psychiatric symptoms as withdrawal and hallucinations may be regarded alternatively as violations of residual rules.

Noting that lolling and loitering are usually specifically prohibited in codes of law, Goffman points out that there is a much more elaborate set of norms centering around the expectation that a person appearing in public should be involved or engaged in doing something:

"The rule against "having no purpose," or being disengaged, is evident in the exploitation of untaxing involvements to mask desired lolling— a way of covering one's presence in a situation with a veneer of acceptable visible activity. Thus when individuals want a "break" in their work routine, they may remove themselves to a place where it is acceptable to smoke and there smoke in a pointed fashion.

Certain minimal "recreational" activities are also used as covers for disengagement, as in the case of "fishing" off river banks where there are no fish, or "getting a tan" on the beach—activity that shields reverie or sleep. As might be expected, when the context firmly provides a dominant involvement that is outside the situation, as when riding in a train or airplane, then gazing out the window, or reverie, or sleeping may be quite permissible. In short, the more the setting guarantees that the participant has not withdrawn from what he ought to be involved in, the more liberty it seems he will have to manifest what would otherwise be considered withdrawal." (1964, pp. 58-59)

The rule requiring that an adult be "involved" when in public view is unstated in our society, yet so taken for granted that individuals almost automatically shield their lack of involvement in socially acceptable ways, as illustrated in the quotation. Thus the rule of involvement would seem to be a residual rule.

Two types of involvements that Goffman discusses are particularly relevant to a discussion of residual deviance: "away" and "occult involvements." "Away" is described in this manner:

"While outwardly participating in an activity, an individual can allow his attention to turn from what he and everyone else considered the real world, and give himself up for a time to a play-like world in which he alone participates. This kind of inward emigration from the gathering may be called "away," and we find that strict regulations obtain regarding it. Perhaps the most important kind of away is that through which the individual relives some past experiences or rehearses some future ones, this taking the form of what is called reverie or daydreaming. At such times the individual may demonstrate his absence from the current situation by a preoccupied, faraway look in his eyes, or by a sleeplike stillness of his limbs, or by that special class of side involvements that can be sustained in an abstracted manner—humming, doodling, drumming the fingers on a table, hair twisting, nose picking, scratching." (1964, pp. 69-70)

This discussion is relevant to the psychiatric symptoms that come under the rubric of "withdrawal," showing that the behavior that is called withdrawal in itself is not socially unacceptable. An "away" is met with public censure only when it occurs in a socially unacceptable context. This is to say that there are residual rules governing the context in which "aways" may take place. When an "away" violates these rules, it is apt to be called "withdrawal" and taken as evidence of mental illness.

"Occult involvement" is defined as a subtype of awayness:

"There is a kind of awayness where the individual gives others the impression, whether warranted or not, that he is not aware that he is "away." This is the area of what psychiatry terms "hallucinations" and delusionary states. Corresponding to these "unnatural" verbal activities, there are unnatural bodily ones, where the individual's activity is patiently task-like but not "understandable" or "meaningful." The unnatural action may even involve the grasping of something, as when an adult mental patient retains a tight hold on a doll or a fetish-like piece of cloth. Here the terms "mannerism," "ritual act," or "posturing" are applied, which, like the term "unnatural," are clear enough in their way but hardly tell us with any specificity what it is that characterizes "natural" acts." (1964, pp. 75-76)

At first glance, it would seem that if there were ever a type of behavior that in itself would be seen as abnormal, it would be "occult involvements." As Goffman notes, however, there is an element of cultural definition even with "occult involvements": "There are societies in which conversation with a spirit not present is as acceptable when sustained by properly authorized persons as is conversation over a telephone in American society" (1964:79). Furthermore, he points out that even in American society, there are occasions in which "occult involvement" is not censured: "Those who attend a séance would not consider it inappropriate for the medium to interact with 'someone on the other side,' whether they believe this to be staged or a genuine interaction. And certainly we define praying as acceptable when done at proper occasions" (1964, p. 79). Thus, talking to spirits and praying to God are not improper in themselves.

Two significant implications follow from this discussion of involvement. The first is that such psychiatric symptoms as withdrawal, hallucinations, continual muttering, and posturing may be categorized as violations of certain social norms—those norms so taken for granted that they are not explicitly verbalized, which may be called residual rules. In the particular instances discussed here, the residual rule concerned involvement in public places. It is true, of course, that various specific aspects of the involvement rule occasionally are found, for example, in books of etiquette. Here, for example, is a typical proscription concerning involvement with one's own person in public places:

"Men should never look in the mirror nor comb their hair in public. At most a man may straighten his necktie and smooth his hair with his hand. It is probably unnecessary to add that it is most unattractive to scratch one's head, to rub one's face or touch one's teeth, or to clean one's fingernails in public." (Fenwick 1948, p. 11; quoted in Goffman 1964, p 66)

Although we could point to many such informal rules, it is important to note that they are all situationally specific. There is nowhere codified a general principle of involvement or even self-involvement. Unlike codified principles, such as the Ten Commandments, it is one of those expectations that it is felt should govern the behavior of every decent person, even though it goes unsaid. Because it goes unsaid, we are not equipped by our culture to smoothly categorize violations of such a rule but rather may resort to a residual catchall category of violations (i.e., symptoms of mental illness).

This idea points to the profoundly conservative tendency of the medical model of mental illness. By putting the causes of residual deviance inside the deviant, it protects the current emotional/relational status quo. Since most people are highly invested in this realm and unwilling to countenance it, the concept of mental illness offers them a way of avoiding considering the quality of their actions, feelings and relationships.

If "symptoms of mental illness" can be classified as violations of culturally particular normative networks, then these symptoms may be removed from the realm of universal physical events, where they are placed by psychiatric theory, along with other culture-free symptoms such as fever, and may be investigated like any other item of social behavior.

A second implication of the redefinition of psychiatric symptoms as residual deviance is the great emphasis that this perspective puts on the context in which the "symptomatic" behavior occurs. As Goffman repeatedly shows, "aways" and "occult involvements," do not in themselves bring forth censure; it is only when socially unqualified persons perform these acts or perform them in inappropriate contexts. That is, these acts are objectionable when they occur in a manner that does not conform to the unstated, but nevertheless operative etiquette that governs them.

Some recent discussions of symptoms have begun to display interest in the social context (for example, the attempt to infuse a social dimension into diagnosis by Karls and Wandrei. 2008). However, it is still true that psychiatric diagnosis tends to focus on the pattern of symptomatic behavior itself, to the neglect of the context in which the symptom occurs. Next to be considered are the origins, prevalence, and course of the behavior that we have defined here as residual rule-breaking.

It is customary in psychiatric research to seek a single generic source or at best a small number of sources for mental illness. The redefinition of psychiatric symptoms as residual deviance suggests, however, that there should be an unlimited number of sources.

Proposition 1: Residual rule-breaking arises from fundamentally diverse sources.

Four distinct types of sources are discussed here: organic, psychological, external stress, and volitional acts of innovation or defiance. The organic and psychological origins of residual rule-breaking are widely noted and are not discussed at length here. It has been demonstrated repeatedly that particular cases of mental disorder had their origin in genetic, biochemical, or physiological conditions. Psychological sources are also frequently indicated: upbringing and training have been reported often, particularly in the psychoanalytic literature. The great majority of precise and systematic studies of causation of mental disorder have been limited to either organic or psychological sources.

It is widely granted, however, that psychiatric symptoms can also arise from external stress: drug ingestion, the sustained fear and hardship of combat, and deprivation of food, sleep, and even sensory experience. Reports on the consequences of stress will illustrate the rule-breaking behavior that is generated by this less familiar source.

Physicians have long known that toxic substances can cause psychotic-like symptoms when ingested in appropriate doses. A wide variety of substances have been the subject of experimentation in producing "model psychoses." Drugs such as a mescaline and LSD-25, particularly, have been described as producing close replicas of psychiatric symptoms, such as visual hallucinations, loss of orientation to space and time, and interference with thought processes. Time disorientation is a familiar psychiatric symptom, as is ideational pressure, which is usually described as a feature of manic excitement.

Combat psychosis and psychiatric symptoms arising from starvation and sleeplessness have been repeatedly described in the psychiatric literature. A number of studies have shown that deprivation of sensory stimulation can cause hallucinations and other symptoms. Merely monotonous environments, as in long-distance driving or flying, are capable of generating symptoms.

In all of the laboratory studies, the persons who have had "psychotic" experiences are reassured; they are told, for example, that the experiences they had were solely due to the situation that they were placed in, and that anyone else placed in such a situation would experience similar sensations. In other words, the implications of the rule-breaking for the rule-breaker's social status and self-conception are "normalized."

Suppose, however, for purposes of argument, that a diabolical experiment was performed in which subjects, after having exhibited model psychotic symptoms under stress, were "labeled." That is, they were told that the symptoms were not a normal reaction, but a reliable indication of deep-seated psychological disorder in their personality. Suppose, in fact, that such labeling was continued in their ordinary lives. Would such a labeling process stabilize rule-breaking that would have otherwise been transitory?

Returning to the consideration of origins, rule-breaking finally can be seen as a volitional act of innovation or rebellion. Two examples from art history illustrate the deliberate breaking of residual rules. The early reactions of critics and the public to the paintings of the French impressionists were disbelief and dismay; the colors, particularly, were thought to be so unreal as to be evidence of madness.

The Dada movement provides an example of an art movement deliberately conceived to violate, and thereby reject, existing standards. The jewel-encrusted book of Dada, which was to contain the treasures of contemporary civilization, was found to be filled with toilet paper and grass. A typical objet d'art produced by Dadaism was a fur-lined teacup.

A climactic event in the movement was the Dada Exposition given at the Berlin Opera House. All of the celebrities of the German art world and dignitaries of the Weimar Republic were invited to attend the opening night. The first item of the evening was a poetry-reading contest, in which there were fourteen contestants. Since the fourteen read their poems simultaneously, the evening soon ended in a riot.

Of the many questions of a more general nature that are posed by these examples, one of the more interesting is Are the "model psychoses" produced by drugs or food, sleep, or sensory deprivation actually identical to "natural" psychoses or, on the other hand, are the similarities only superficial, masking fundamental differences between the laboratory and the natural rule-breaking?

The controversy over model psychoses provides evidence of a basic difficulty in the scientific study of mental disorder. Although there is an enormous literature on the description of psychiatric symptoms, at this writing scientifically respectable descriptions of the major psychiatric symptoms, that is to say, descriptions that have been shown to be precise, reliable, and valid, do not exist.

In the absence of scientifically acceptable evidence, we can only rely on our own assessment of the evidence in conjunction with our appraisal of the conflicting opinions of the psychiatric investigators. In this case, there is at present no conclusive answer, but the weight of evidence seems to be that there is some likelihood that the model psychoses are quite similar to ordinary psychoses. Therefore, it appears that the first proposition, that there are many diverse sources of residual rule-breaking, is supported by available knowledge.

The second proposition concerns the prevalence of residual rule-breaking in entire and ostensibly normal populations. This prevalence is roughly analogous to what medical epidemiologists call the "total" or "true" prevalence of mental symptoms.

Proposition 2: Relative to the rate of treated mental illness, the rate of unrecorded residual rule-breaking is extremely high.

There is evidence that gross violations of rules are often not noticed or, if noticed, are rationalized in some way, for example, as eccentricity. Apparently, many persons who are extremely withdrawn or who "fly off the handle" for extended periods of time, who imagine fantastic events, or who hear voices or see visions, are not labeled as insane either by themselves or others. Their rule-breaking, rather, is unrecognized, ignored, or rationalized. This pattern of inattention and rationalization is called normalization.

There are a number of epidemiological studies of total prevalence. There are numerous problems in interpreting the results of these studies; the major difficulty is that the definition of mental disorder is different in each study, as are the methods used to screen cases. These studies represent, however, the best available information and can be used to estimate total prevalence.

The existing weight of evidence appears, however, to support Proposition 2.

In most epidemiological research, it is assumed that treated prevalence is an excellent index of total prevalence. Yet community studies suggest that the majority of cases of "mental illness" never receive medical attention. This finding has great significance for a crucial question about residual deviance: given a typical instance of residual rule-breaking, what is its expected course and consequences? Or, to put the same question in medical language, what is the prognosis for a case in which psychiatric signs and symptoms are evident?

The usual working hypothesis for physicians confronted with a sign or symptom is that of progressive development as the inner logic of disease unfolds. The medical framework thus leads one to expect that unless medical intervention occurs, the signs and symptoms of disease are usually harbingers of further, and more serious, consequences for the individual showing the symptoms. This is not to say, of course, that physicians think of all symptoms as being parts of a progressive disease pattern; witness the concept of the "benign" condition. The point is that the imagery that the medical model calls up tends to predispose the physician toward expecting that symptoms are initial signs of further illness.

The idea that the great majority of persons displaying psychiatric symptoms go untreated leads to the third proposition.

Proposition 3: Most residual rule-breaking is normalized and is of transitory significance.

The high rates of total prevalence suggest that most residual rule-breaking is unrecognized or rationalized away. For this type of rule-breaking, which is amorphous and uncrystallized, Lemert used the term "primary deviation" (Lemert 1951, Chapter 4) He went on to write that if the rule-breaker accepts the deviant, role, his or her behavior may stabilize in the form of "secondary deviance". Balint (1957) described similar behavior as "the unorganized phase of illness" (p. 18). Although Balint assumed that patients in this phase ultimately "settle down" to an "organized illness," other outcomes are possible. A person in this stage may "organize" his deviance in other than illness terms (e.g., as eccentricity or genius), or the rule-breaking may terminate when situational stress is removed.

The experience of battlefield psychiatrists can be interpreted to support the hypothesis that residual rule-breaking is usually transitory. The military has learned that combat neurosis is often self-terminating if the soldier is kept with his unit and given only the most superficial medical attention.

Descriptions of child behavior can be interpreted in the same way. According to these reports, most children go through periods in which at least several of the following kinds of rule-breaking may occur: temper tantrums, head banging, scratching, pinching, biting, fantasy playmates or pets, illusory physical complaints, and fears of sounds, shapes, colors, persons, animals, darkness, weather, ghosts, and so on (llg and Ames 1972, 138-188; Laing 2009). It appears that in the great majority of instances, however, these behavior patterns do not become stable.

There are, of course, conditions that do fit the model of a progressively unfolding disease. In the case of a patient exhibiting psychiatric symptoms because of general paresis, the early signs and symptoms appear to be good, though not perfect indicators of later more serious deterioration of both physical health and social behavior. Conditions that have been demonstrated to be of this type are relatively rare, however. Paresis, which was once a major category of mental disease, accounts today for only a tiny proportion of mental patients under treatment. Proposition 3 would appear to fit the great majority of mental patients, in whom external stress such as family conflict, fatigue, drugs, and similar factors are often encountered.

Of the first three propositions, the last is both the most crucial for the theory as a whole and the least well supported by existing evidence. It is not a matter of there being great amounts of negative evidence, showing that psychiatric symptoms are reliable indicators of subsequent disease, but that there is little evidence of any kind concerning development of symptoms over time.

There are a number of analogies in the history of physical medicine, however, that are suggestive. For example, until the late 1940s, histoplasmosis was thought to be a rare tropical disease with a uniformly fatal outcome. It was later discovered that it is widely prevalent and with fatal outcome or even impairment extremely unusual. It is conceivable that most "mental illnesses" may prove to follow the same pattern when adequate longitudinal studies of cases in normal populations have been made.

If residual rule-breaking is highly prevalent among ostensibly normal persons and is usually transitory, as suggested by the last two propositions, what accounts for the small percentage of residual rule-breakers who go on to deviant careers? To put the question another way, under what conditions is residual rule-breaking stabilized? The conventional hypothesis is that the answer lies in the rule-breaker himself.

The hypothesis suggested here is that an important factor (but not the only factor) in the stabilization of residual rule-breaking is the societal reaction. Residual rule-breaking may be stabilized if it is defined to be evidence of mental illness and/or the rule-breaker is placed in a deviant status and begins to play the role of the mentally ill (Lemert’s idea of secondary deviance). On the other hand, if the rule-breaking is normalized, it may be transitory or at least not interfere with the rule-breaker’s life.

This latter idea so far has not seen any research to test it empirically. It is also the most difficult part of labeling theory to even visualize in concrete cases. For example, how can the behavior of a person in the grip of a delusion or runaway restlessness be normalized? For illustrative purposes a fictional instance from a film and a real instance will be presented next.

Illustrative Episodes of Non-labeling

Lars Lindstrom is the protagonist of an unusual comedy, Lars and the Real Girl (Oliver 2007). It details, second by second, the process of normalization and non-labeling. Lars is a 27-year-old unmarried man who lives in his brother and sister-in-law’s garage in a small town in northern Wisconsin. (Ironic, since my 1962 study suggested that northern Wisconsin would be one of the last places for this kind of episode to occur).

Lars shies away from everyone. His sister-in-law often invites him to dinner, but he resists. Although amiable, he is isolated. He does his job but keeps his distance from his co-workers, including a woman who is interested in him.

A strenuous testing of Lars’ ties to his community occurs after he overhears a conversation between two men in the office. They are discussing a full-size, anatomically correct female doll for sale online. Lars orders it, and when delivered, he tells his sister-in-law that he wants to bring his girlfriend, Bianca, to dinner.

They are delighted until he brings the doll, talking to her as if she were real. They realize that he is deluded. He is not only deluded, but also innocent; rather than using the doll as a sex toy, he respects it as his fiancée.

The family doctor, who name is Dagmar, is consulted. She suggests they stay connected by respecting Lars’s delusion. Initially the townspeople, like his brother, are aghast. But gradually they agree. The plan also leads to Lars having regular, if informal, therapy sessions with the doctor. His belief that Bianca is sick leads him to bring her regularly to the hospital. The doctor tells him that he might as well chat with her whilst Bianca is supposedly getting physical treatments.

Other citizens of the town also enter affectionately into Lars’s world: the hospital staff and the whole church. At the end of the film, Lars is taking a first step toward recovery.

What are we to make of this fable? One possibility is the idea that "it takes a village." An investigation by a journalist (Neugeboren 1999) is relevant. He described many cases in which there was great improvement or complete recovery from what had been diagnosed as "serious mental illness." The common thread he found was that at least one person treated the patient with respect, sticking by him or her through thick or thin.

The biography (Nasar 1998) of John Nash, a Nobel Prize winner, is similar. Although Nash is not included in Neugeboren’s book, the biography shows that Nash’s mother and wife aided his recovery, since they never gave up on him.

However, A Beautiful Mind, a film purportedly based on Nash’s biography, misinformed on the drug issue. Nash, played by Russell Crowe, attributes his complete recovery to "the newer antipsychotic drugs." But the biography states that Nash refused to take drugs after 1970, long before the newer antipsychotics. Indeed, the biographer states that his refusal may have been fortuitous, enabling his complete recovery (1998, p. 353).

The Societal Reaction to Residual Rule-breaking

Some of the early incidents in the film about Lars can be used to flesh out a key idea in labeling theory: a non-labeling societal reaction. After Lars and Bianca leave their first dinner, his brother (Gus) and sister-in-law (Karin) talk.

Karin: The doctor will tell us what to do.

Gus: But she’s family practice. We’re gonna need a shrink. (Gus has already labeled Lars).

Karin: No, she is. She’s a psychologist too.

Gus: What’ll people think?

Karin: We can’t worry about that.

Gus: Right. (Sarcastic and exasperated)

Gus: Karin, I’m telling you he belongs in a hospital.

Karin: No, my Uncle Garth went to one of those places and he never came back.

Gus: Yeah, but he needs more help than you and I are able to give him.

Interrupting their conversation, the Doctor says: If I may—has Lars been functional, does he go to work, wash, dress himself?

Gus: So far.

Doctor: Has he had any violent episodes?

Karin: Oh no, no never. He’s a sweetheart—he never even raises his voice.

Gus: Okay, we got to fix him. Can you fix him?

Doctor: I don’t know, Gus. I don’t believe he’s psychotic or schizophrenic. I don’t think this is caused by genes or faulty wiring in the brain. (Preliminary normalizing statement, rejecting a diagnosis)

Gus: So then what the hell is going on then?

Doctor: He appears to have a delusion.

Gus: A delusion? What the hell is he doing with a delusion for Christ’s sake?

(Gus emphatically implies that Lars’s behavior is abnormal)

Doctor: You know, this isn’t necessarily a bad thing. What we call mental illness isn’t always just an illness. It can be a communication, it can be a way to work something out.

Gus: Fantastic, when will it be over?

Doctor: When he doesn’t need it anymore.

Karin: How can we help?

Doctor: Go along with it.

Karin: Oh no, no, that’s…

Gus: Oh my, no, no, no, no. No, I mean, pretend that she’s real? I’m not gonna do that—I mean I can’t—I’m just not gonna do it.

Gus: Well…

Doctor: I mean, she’s right out there.

Gus: Right, right, I get that—but I’m just not gonna, you know, I’m just not gonna, I’m not gonna do it, so…

Doctor: You won’t be able to change his mind anyway. Bianca’s in town for a reason.

Gus: Right, but, but—

Doctor: It’s not really a choice. (The doctor is surprisingly forceful at this point, since in real life a doctor can easily be sued for not medicating).

Karin: Okay, okay, alright then we’ll do it. Whatever it takes.

Gus: Oh yeah, yeah, yup. And everyone’s gonna laugh at him.

Having the entire community unite in refusing to label Lars makes for comedy and drama, but in real life probably would never happen. To avoid secondary deviance, (the rule-breaker taking on the deviant role as his or her own real self), it might be necessary for only key people in his life to stick by him, as apparently happened in Neugeboren’s cases. Even one person might be enough.

Discussion

My comments on these concrete instances suggest that until examining them, I didn’t fully understand the non-labeling part of my own theory. I hadn’t realized that in the actual dialogue, in order to normalize suspect behavior, the healer must specifically translate the discourse out of the labeling mode and into the normalizing mode, and be prepared to accept the consequences from the world of automatic labeling. In the fictional case, the doctor said, in effect, you are not mentally ill, you are just communicating. In the real case, the psychiatrist said, you are not mentally ill, you are just drugged. It seems to me now that these concrete dialogues were needed in order for me to complete the theory and its recommendations for practice.

Inadvertent Normalization

It is ironic that because I didn’t understand the key role of normalization in non-labeling, I didn’t recognize it occurring before my very eyes. At the time that my book was being published (1966), I observed a series of brief recoveries from depression. As a visiting researcher at Shenley Hospital (UK) in 1965, I was present for all intake interviews of male patients for 6 months: 83 patients in all. Of this number 70 patients were sixty or older.

The comments that follow concern the older men. Every one of the men presented as deeply depressed in their speech and manner. However, to my surprise, there were moments in some of the interviews that seemed to be miracles of recovery. It took many years for me to understand what I had observed.

Many of the patients were virtually silent, or gave one-word answers. Before I came, some of the interviewing psychiatrists had found a way of getting more talk. In the interviews I observed, 41 of them were asked about their activity during WWII. For 20 of those asked this question, their responses shocked me. As they begin to describe their activities during the war, their behavior and appearance underwent a transformation.

Those who changed in the greatest degree sat up, raised their voice to a normal level instead of whispering, held their head up and looked directly at the psychiatrist, usually for the first time in the interview. The speed of their speech picked up, often to a normal rate, and became clear and coherent, virtually free of long pauses. Their facial expression became lively and showed more color. Each of them seemed like a different, younger, person.

The majority changed to a lesser extent, but in the same direction. I witnessed 20 awakenings, some very pronounced, however temporary. The psychiatrists told me that they had seen it happen many times. After witnessing the phenomenon many times, like the psychiatrists, I also lost interest.

Many years later, because of my work on shame, I proposed an explanation (2001): depression involves the complete repression of painful emotions (such as shame, grief, fear, and anger), and lack of a single secure bond. The memory of the patients’ earlier acceptance as valued members of a nation at war relived the feeling of acceptance. This feeling generated pride that counteracted the shame part of their depression.

Telling the psychiatrist about belonging to a community during WWII had been enough to temporarily remove the shame of being outcasts. Conveying to the psychiatrist that "once we were kings," had relieved their shame and therefore their depressive mood.

Self-concept and Community

The historian Lucy Dawidowicz (1989) reported a parallel response to severed bonds by survivors of the Holocaust:

…the survivors liked best of all to talk about their former lives, the houses they lived in, the family businesses, their place in the community. By defining themselves in their previous existence, they were confirming their identity as individuals entitled to a place in an ordered society. They had not always been outcasts (303).

Because Virginia Woolf’s writing, even her novels, was based on her own memories, she devoted some attention to the role of memory in sustaining the self. This passage, by her editor, prefaces Woolf’s autobiographical essays:

…memory is the means by which the individual builds up patterns of personal significance to which to anchor his or her life and secure it against the "lash of random unheeding flail." (Shulkind, in Woolf, 1985, p. 21).

Woolf herself made the point forcefully: "…the present when backed by the past is a thousand times deeper than the present when it [the present] presses so close that you can feel nothing else." (Woolf 1985, p. 98).

When the psychiatrists asked the depressed outcast men about their experience during WWII, they were inadvertently normalizing the patients, returning them, for just a few moments, in to what it felt like to be an accepted member of society, rather than labeled and rejected. My recent article on depression (2009) explained some of the implications for social, rather than medical treatment of mental illness.

However, because I had not used concrete instances in my theory, I still had not recognized the full meaning of these surprising recoveries. A further thought: if a brief normalizing question leads to brief recovery, how much more could be accomplished by hours of normalizing therapy?

Conclusion

The need for concrete instances to develop a theory points toward the idea of part/whole relationships (Scheff 1997). Of course the ultimate purpose of abstract theories is be tested, to see if they are true. However, a transitional methodology may be needed before that, what the philosopher of science Spinoza called "least parts and greatest wholes" (Sacksteder 1991). What he called "least parts" are concrete examples, "greatest wholes" are abstract concepts. To go back and forth between the parts and wholes, even with mere examples, enables one to get some understanding of both the concrete instances and the abstract concepts. The poet William Blake hinted at the importance of least parts when he wrote that poetry and science both depend on "minute particulars" (see also Wrong 2005).