planation of mental illness, especially with respect to schizophrenia. These cross-cul- tural investigations suggest that relativism has been exaggerated by labeling theorists and that in widely different cultural and environmental situations sanity appears to Psychiatric Labeling in be distinguishable from insanity by cues that are very similar to those used in the Cross-Cultural Perspective Western world.

Similar kinds of disturbed behavior appear The Labeling Orientation to be labeled abnormal in diverse cultures. As Edwin Schur (8) points out, if label- ing theory is conceived broadly it is the ap- plication of 's theo- Jane M. Murphy ries about self-other interactions to a defi- nition of social extended to in- clude human problems ranging from to blindness. Labeling theory emphasizes In recent years labeling (or societal reac- support from a study reported in Science the social meanings imputed to deviant be- tion) theory has aroused strong interest by David Rosenhan (6), based on the expe- havior and focuses on the unfolding pro- among people concerned with mental ill- riences of eight sane subjects who gained cesses of interaction whereby self-defini- ness. From the perspective of labeling the- admission to psychiatric hospitals, were tion is influenced by others. Further, "it is ory, the salient features of the behavior diagnosed as schizophrenic, and remained a central tenet of the labeling perspective patterns called mental illness in countries as patients an average of 19 days until dis- that neither acts nor individuals are where Western psychiatry is practiced ap- charged as "in remission." Rosenhan ar- 'deviant' in the sense of immutable, 'objec- pear to be as follows: (i) these behaviors gues that "we cannot distinguish insanity tive' reality without reference to processes represent deviations from what is believed from sanity" (6, p. 257). He associates his of social definition." Schur states that on March 13, 2014 to be normal in particular sociocu!Yral work with "anthropological consid- "'this relativism may be viewed as a major groups, (ii) the norms against which the de- erations" and cites Ruth Benedict (7) as an strength" of labeling theory (8, p. 14). viations are identified are different in dif- early contributor to a theme he pursues, \Edwin Lemert's concept of secondary ferent groups, (iii) like other forms of de- which is that "what is viewed as normal in deviance (9) is of critical importance in viation they elicit societal reactions which one culture may be seen as quite aberrant linking self-other considerations to devia- convey disapproval and stigmatization, (iv) in another" (6, p. 250). I: indicates that tions. Secondary deviation occurs when a a label of mental illness applied to a person the perception of behavior as being schizo- person learns the role and accepts the iden- whose behavior is deviant tends to become phrenic is relative to context, for "psychi- tity of a deviant as the basis of his life- fixed, (v) the person labeled as mentally ill atric diagnosis betrays little about the style. It is a response to a response; nega- www.sciencemag.org is thereby encouraged to learn and accept a patient but much about the environment in tive feedback from significant others rein- role identity which perpetuates the stigma- which an observer finds him." He argues forces and stabilizes the behavior that ini- tizing behavior pattern, (vi) individuals that, despite the effort to humanize treat- tially produced it. Applied to criminality, who are powerless in a social group are ment of disturbed people by calling them this idea has created general awareness of more vulnerable to this process than others patients and labeling them mentally ill, the a process whereby a young person on being are, and (vii) because social agencies in attitudes of professionals and the public at labeled a juvenile delinquent may enter a

modern industrial society contribute to the large are characterized by "fear, hostility, network of contingencies that lead ulti- Downloaded from labeling process they have the effect of aloofness, suspicion, and dread." Once the mately to his learning criminal activities creating problems for those they treat label of schizophrenia has been applied, and "hardening" as a criminal rather than rather than easing problems. the "diagnosis acts on all of them"- to the correction of behavior. This school of thought lemerged mainly patient, , and relatives-"as a self- In The Making of Blind Men, Robert within , as an extension of studies fulfilling prophecy. Eventually, the patient Scott points to a similar process regarding of social deviance in which crime and de- himself accepts the diagnosis, with all of its a very different type of deviance (10). If a linquency were originally the major focus surplus meanings and expectations, and person is labeled blind by certain adminis- (1). It is also associated with psychiatry behaves accordingly" (6, p. 254)- trative criteria he is likely to become en- through, for example, Thqmas Szasz and The research to be described here meshed in care-giving agencies that en- R. D. Laing (2). These ideas have come to presents an alternative perspective derived courage him to accept a definition of him- be called a "sociologicgi model" of mental from cross-cultural comparisons, mainly self as helpless and to learn to play the role illness, for they center jj learning and the of two widely separated and distinctly con- of the blind man. These experiences may social construction of norms. They began trasting non-Western groups, Eskimos of even inhibit the use of residual vision. to be formulated about 25 years ago (3), northwest Alaska and Yorubas of rural, Scott shows that institutions for the blind commanded growing attention in the late tropical Nigeria. It is concerned with the vary in the degree to which they encourage 1960's, and have-been influential in recent meanings attached to behaviors which acceptance or rejection of the deviant role major changes in public programs for psy- would be labeled mental illness in our so- and that these differences are related to chiatric care, especially the deinstitutional- ciety. I interpret these data as im- raising The author is associate professor of anthropology in ization which is occurring in a number of portant questions about certain assump- the Harvard School of Public Health, Boston, Massa- in chusetts 02115. A portion of this article was presented states (4, 5). tions the labeling thesis and therefore as at the 1973 meeting of the Atlantic Provinces Psychiat- Several aspects of the theory receive casting doubt on its validity as a major ex- ric Association in Halifax, Nova Scotia. 12 MARCH 1976 1019 differences in the life-style of blind men. nent in what used to be called the culture- contributors to labeling theory: Scheff, Er- Insofar as the labeling concept has been personality studies of anthropology. In ving Goffman, Theodore Sarbin, and Da- employed in this way I believe it is sound fact the influence of culture-personality on vid Mechanic. These references do not en- and has disclosed new and valuable infor- labeling theory is explicitly stated by Le- compass the breadth and elaboration of mation. mert, who was trained jointly in sociology each contributor's own approach to the The application of labeling ideas to and anthropology and who has drawn on problem of mental illness, but they do re- mental illness has tended to take a differ- non-Western studies throughout his career. flect the view of cultural relativity which ent course (11) and has aroused consid- The influence is equally acknowledged by runs throughout the labeling orientation. erable controversy, as indicated, for ex- Rosenhan (6). It seems to me that numbers Scheff says that "the culture of the ample, in the continuing exchange between of proponents of labeling theory assume group provides a vocabulary of terms for Thomas Scheff and Walter Gove et al. (12- that the expanding body of data from non- categorizing many norm violations" (11, 15). One question in this controversy is Western areas has supported the relativist pp. 33, 82). These designate deviations whether mental illness should be consid- propositions put forth by Benedict and such as crime and drunkenness. There is a ered a "pure case" of secondary deviation others in the 1930's and '40's (16). Indeed, residual category of diverse kinds of devia- or a more complex case. Lemert's formu- it was my own assumption when I began -tions which constitute an affront to the un- lation of the concept of secondary devia- anthropological work with Eskimos. I conscious definition of decency and reality tion was influenced by his investigation of thought I would find their conception of uniquely characteristic of each culture. stuttering, and he suggests that stuttering normality and abnormality to be very dif- Scheff posits that the "culture provides no represents the pure case: "Stuttering thus ferent, if not opposite, from that held in explicit label" for these deviations but they far has defied efforts at causative ex- Western culture. This did not prove to be nevertheless take form in the minds of so- planation.... It appears to be exclusively a the case, and my experience is not unique. cietal agents as " of insanity." process-product in which, to pursue the Anthropologists who have been conducting When people around a deviant respond to metaphor, normal speech variations, or at field research in recent years using more him in terms of these stereotypes, "his most, minor abnormalities of speech (pri- systematic methods but continuing to amorphous and unstructured rule-break- mary stuttering) can be fed into an inter- work on the relations between individual ing tends to crystallize in conformity to actional or evaluational process and come behavior and cultural context tend to hold these expectations." Scheff further sug- out as secondary stuttering" (9, p. 56). a greatly modified view of the extent of in- gests that these cultural stereotypes tend to The important point here is that primary dividual plasticity and the molding force of ~produce uniformity of symptoms within a deviance is considered to be normal varia- culture (17, 18). cultural group and "enormous differences tion or only "minor abnormalities," and It would be misleading on my part to iiith-e-iaiiifet symptoms mirtal the influence of societal reactions is consid- imply that all theory building and investi- disorder between societies." ered genuinely causative. Societal reac- gation regarding the relation of labeling It has been pointed out that there ap- tions "work on" and "mold" normal vari- and mental illness have followed the pure- pears to be a contradiction in one aspect of ations of speech to "create" stuttering. For case model. In their studies on mental re- Scheff's theory (12, p. 876; 22). It is diffi- mental illness the labeling theorists have tardation Robert Edgerton and Jane Mer- cult to accept that a socially shared image tended to use the "pure case" model rather cer use moderate labeling ideas and show of behavior that can influence action and than the more complex model represented that social reactions are related to differ- has the concreteness of a should by blindness, where lack or loss of sight is ences in the ways subnormal individuals lack a name. It is possible Scheff meant and the role of blind man are able to function both in and outside of that in the evolution of language a label for is secondary deviance. institutions (19). A growing number of insanity was the last to emerge because it Scheff has provided the most systematic studies of alcoholism, many of them influ- refers to a residue of norm violations. The theoretical statement regarding labeling enced by labeling views, have demon- dating of words is beyond the scope of the and mental illness, and in his formulation strated that social attitudes and the vari- data to be presented here, but it will be the primary deviations that are fed into in- able meanings attached to drinking are possible to see whether an explicit label teractional processing to come out as men- correlated with marked differences in alco- currently exists in the two cultures studied, tal illness are described as "amorphous," holism rates in various cultural groups a hunting-gathering culture (Eskimo) and "unstructured," and "residual" violations (20). There are, in addition, numbers of an agricultural society (Yoruba), neither of of a society's norms (11, pp. 33, 82). Ro- studies of the social pathways leading to which developed a written language. If a senhan suggests that the behaviors labeled hospitalization, the impact of hospital- word for insanity occurs we can then inves- schizophrenic might be " 'sane' outside the ization, attitudes toward discharged men- tigate the kinds of behaviors therein de- psychiatric hospital but seem insane in it tal patients, and so on which reveal impor- noted. ... [because patients] are responding to a tant outcomes for the mentally ill without Regarding our own society, Goffman bizarre setting" (6, p. 257). Lemert says imputing to societal reactions the degree of stresses that the "perception of losing that social exclusion can "create a para- significance given them in the more de- one's mind is based on culturally derived noid disposition in the absence of any spe- terministic formulations. and socially engrained stereotypes as to the cial character structure" (9, p. 198). Fur- Most labeling studies of mental illness significance of symptoms such as hearing ther, many have posited that behavior we have been carried out in the United States voices, losing temporal and spatial orienta- call mental illness might be considered and the United Kingdom. Variations in the tion, and sensing that one is being fol- normal in a different culture or in a minor- definition and tolerance of mental illness lowed" (23). He further indicates that ity social class. Thus, the primary devia- have mainly been studied in groups at dif- there is cultural variation in this kind of tions of mental illness are held to be for the ferent social class levels in industrialized imagery and differential encouragement most part insignificant, and societal reac- society (21). Since cultural relativism is for such a view of oneself. This makes it tions become the main etiological factor. one of the main elements of the orienta- appropriate to ask whether hallucinations, This view is reminiscent of ideas about tion, it seems useful to put some of the bas- delusions, and disorientations are present human plasticity, cultural determinism, ic labeling questions to non-Western data. or absent from the conception of losing and cultural relativism which were promi- As background for this, I quote from four one's mind in Yoruba and Eskimo cul- 1020 SCIENCE, VOL. 191 tures, assuming they have a stereotype of ried, for it suggests that the social defini- human affairs. They can be treacherously insanity at all. tion of one kind of behavior can turn it into abused and lead to what we think of as Labeling theorists express considerable such opposing roles as the defamed witch cruel outcomes. Rivers says that the prac- dissatisfaction with the concept of mental or the renowned shaman. Mechanic's tice is not conceived to be cruel or degrad- illness, pointing out that it is a vague and points make it appropriate, therefore, to ing by the Melanesians because in their euphemistic metaphor and ties together ask whether the shamans in Eskimo cul- meaning the burial relieves the pe-rson of a phenomena that are neither "mental" nor- ture and the healers in Yoruba culture are worn-out earth-life so that he can enter the "illness." They argue that mental illness is thought by the people to be mentally ill higher status of the spiritual afterlife. By a myth developed in Western societies, and whether the rates of such mental ill- our standards the Melanesian inter- that the term represents an abortive effort ness in these groups are similar to or dif- pretation would nevertheless be considered to improve the treatment of people pre- ferent from those in the West. a collective rationalization of "geronti- viously called lunatics, that in the name of Scheff, Goffman, Sarbin, and Mechanic cide." Whatever the intent, the socially de- this myth we continue to incarcerate, pun- share the view that in our society the appel- fined death of elderly Melanesians is a ish, and degrade people for deviating from lation "mentally ill" is a "stigmatizing" myth and serves as a model of what I un- norms. Sarbin suggests that defining be- and "brutalizing" assessment. It robs the derstand the labeling theorists to mean by havioral aberrations as illness occurred in individual of identity through profound the "myth of mental illness." Thus a final medieval Europe as a way to relabel people "mortification" and suggests that he is a question: Do the Eskimos and Yorubas who might otherwise have been burned at "non-person." It forces him into an as- subscribe to such fictions about mental ill- the stake as witches (24). He further sug- cribed role, exit from which is extremely ness through which they perpetrate in- gests that it was during this phase of West- difficult. Thus another question is posed: If humanity and degradation? ern history that the concept of mind came Eskimos and Yorubas have a stereotype of into being. It was used as a way to explain insanity, are they less harsh than we with perplexing behavior that could not be re- those defined as insane? Method of Study lated to occurrences external to the person. To illustrate the model I have in mind It is "as if there are states of mind" that for exploring these questions I will first de- The data to be presented derive mainly cause these patterns of conduct. The "as scribe a non-Western event which suggests from a year of field work, in 1954-55, in a if" was transmuted into the myth that the that certain aspects of labeling theory are village of Yupik-speaking Eskimos on an mind exists as a real entity and can there- valid. It does not concern mental illness island in the Bering Sea, and an investiga- fore be sick or healthy. but it demonstrates the use of labels as ar- tion of similar length, in 1961 and 1963, In the data to be given, it will be possible bitrary social definitions in the labeling among Egba Yorubas. I also draw on to ask whether the idea of an inner state theory sense. The case is reported by W. H. shorter periods of field work in Gambia, that influences conduct is found in these R. Rivers in connection with his analysis of Sudan, and South Vietnam. non-Western groups and, since both the concept of death among the Melane- Some of the Eskimo data came from a groups believe in witchcraft, whether a sians (27): key informant, who systematically de- stereotype of insanity is associated with the Some persons who are seriously ill and scribed the life experiences of the 499 Eski- conduct of witches. Everywhere that witch- likely to die or who are so old that from the mos who constituted a total village census craft has been systematically studied the Melanesian point of view they are ready to over the 15 years previous to and including role of the witch involves deviances that die are labeled by the word mate, which the year of investigation. In addition, a dic- are heavily censured. The witch carries out means "dead person." They become there- tionary of Eskimo words for illness and de- practices that are believed to harm people by subjects of a ceremonial live burial. It viance was developed. Extended life histo- through supernatural means. If the insane can be argued that the Melanesians have a ries of a small number of Eskimos were person and the witch are equated in the be- concept of death which is a social fiction. It gathered. Also daily observations and liefs of non-Western groups, it would ap- embodies what they arbitrarily agree to de- comments from Eskimos about Eskimos pear to follow that in those groups mental fine as death and is a distortion of reality (both in their own village and in other illness is thought of as social deviance; and as seen by most cultural groups. The label areas known to them) were recorded for this would be a telling point for labeling mate involves a degradation ceremony in the purpose of understanding their concep- theory. which an elderly person is deprived of his tions of behavior (29). Mechanic makes the point that "al- rights and is literally "mortified." He is The approach among the Yorubas was though seemingly obvious, it is important perceived "as if dead" and then buried. different in that I worked with a group of to state that what may be viewed as The linguistic relativist might even say that three native healers and a member of an in- deviant in one social group may be toler- this use of the word mate shows that the digenous cult. Interviews were directed ated in another, and rewarded in still other Melanesians do not perceive death by toward understanding Yoruba concepts of groups" (25). He emphasizes that the so- means of the indicators of vital functioning behavior in the abstract and centered on cial response may influence the frequency applied in Western society (28). actual people only to the extent that ac- with which the deviant behavior occurs. It Rivers's own conclusion is that the Mel- quaintances and patients were brought into has been hypothesized by a number of re- anesians view death the way we do and are the discussion as illustration (30). searchers that holy men, shamans, or witch cognizant of the difference between biolog- The Eskimo data served as the base for doctors are psychotics who have been re- ical and social mate. Biological mate is by an epidemiological study of the village in warded for their psychotic behavior by far the commoner phenomenon. In their 1955, and the Yoruba data constituted one being made incumbents of highly regarded practice of live burials the Melanesians in of the first phases of a larger epidemiolog- and useful roles (26). This is the obverse of fact take close note of two typical pre- ical study carried out with a group of Ni- the possibility that the insane are thought cursors of death-old age and illness. gerian and U.S. colleagues in which we of as witches. The role of the healer carries It seems clear, however, that socially studied 416 adults, of whom 245 consti- great power and approval. The idea of so- sanctioned acts based on symbolic mean- tuted a representative sample from 14 vil- cial rewards for mental illness underscores ings, such as those involved in social mate, lages (31). the lengths to which relativity can be car- are powerful in influencing the course of In The Social Meanings of Suicide, a 12 MARCH 1976 1021 study affiliated with the labeling tradition, ceived to be that something inside the per- standing characteristic of the shaman. The Jack Douglas has shown the weakness of son-the soul, the spirit, the mind-is out people called "thin" outnumber those official statistics as a basis for judging the of order. Descriptions of how nuthkavihak called insane by at least eight to one. social significance of behavioral phenome- is manifested include such phenomena as Moreover, there were no instances when a na in groups (32). The Eskimo and Yoruba talking to oneself, screaming at someone "thin" person was called nuthkavihak. studies reflect a similar orientation about who does not exist, believing that a child or When a shaman undertakes a curing rite the inadequacies of mental hospital statis- husband was murdered by witchcraft when he becomes possessed by the spirit of an tics for the purposes at hand. As has been nobody else believes it, believing oneself to animal; he "deludes" himself, so to speak, done in many labeling studies, I relied on be an animal, refusing to eat for fear eating into believing that he is an animal. Consid- participant observation and interviewing will kill one, refusing to talk, running er this description (35): about microcultural events. The focus was away, getting lost, hiding in strange places, on indigenous meanings. These meanings The seance is opened by singing and drumming. making strange grimaces, drinking urine, After a time the shamaness falls down very hard were then used as a basis for counting sim- becoming strong and violent, killing dogs, on the floor. In a while, the tapping of her fin- ilar behavior patterns, so that they were and threatening people. Eskimos translate gers and toes is heard on the walrus skin floor. defined from within a cultural group rather nuthkavihak as "being crazy." Slowly she gets up, and already she is thought to than by imposed criteria. There is a Yoruba word, were, which is "look awful, like a dog, very scary." She crawls back and forth across the floor making growling In these studies I have considered lan- also translated as insanity. The phenomena sounds. In this state she begins to carry out the guage to be the main repository of labels. include hearing voices and trying to get various rites which Eskimos believe will cure Insofar as there is a counterpart to the offi- other people to see their source though sickness, such as sucking the illness out of the cial recognition of mental illness involved none can be seen, laughing when there is body and blowing it into the air. Following this in hospital commitment in a Western so- the shamaness falls to the floor again and the nothing to laugh at, talking all the time or seance is over. ciety, it resides in what Eskimos and Yor- not talking at all, asking oneself questions ubas say are the kinds of people treated by and answering them, picking up sticks and Compare this to the case, reported by shamans and native healers. leaves for no purpose except to put them in Morton Teicher, of a Baffin Island Eskimo a pile, throwing away food because it is who believed that a fox had entered her thought to contain juju, tearing off one's body (36). This was not associated with Labeled Behavior Patterns clothes, setting fires, defecating in public shamanizing but was a continuous belief. and then mushing around in the feces, tak- She barked herself hoarse, tried to claw The first specific question is: Do Eski- ing up a weapon and suddenly hitting her husband, thought her feet were turning mos and Yorubas have labels for psycho- someone with it, breaking things in a state into fox paws, believed that the fox was logical and behavioral differences that bear of being stronger than normal, believing moving up in her body so that she could any resemblance to what we mean by men- that an odor is continuously being emitted feel its hair in her mouth, lost control of tal illness? These groups clearly recognize from one's body. her bowels at times, and finally became so differences among themselves and describe For both nuthkavihak and were in- excited that she was tied up and put into a these in terms of what people do and what digenous healing practices are used. In coffin-like box with an opening at the head they say they feel and believe. Some of the fact, among the Yorubas some native heal- through which she could be fed. This wom- differences lead people to seek the aid of ers specialize in the treatment of were (33, an was thought to be crazy but the sha- healers and some do not, some differences 34). maness not. One Eskimo summarized the arouse sympathy and protection while oth- The profile of were behaviors is based distinction this way: "When the shaman is ers arouse disapproval, some are called not only on what the healers described in healing he is out of his mind, but he is not sickness and others health, some are con- the abstract but also on data concerning crazy." Figure 1 is a picture selected by an sidered misconduct and others good con- two members of the sample identified as Eskimo to illustrate the shaman's appear- duct. Some are described by a single word were by the village headman and a group ance during a seance (37). or nominative phrase. Some that seem to of 28 were patients in the custody of native This suggests that seei