Labeling Theory honors that the individual on the tape was “a very interesting man because he looked John Ruscio neurotic, but actually was quite psychotic.” The College of New Jersey, U.S.A. The clear implication was that the expert had access to more information about this man In 1966, Thomas Scheff published a landmark than participants would view on the tape. After book entitled Being mentally ill: A sociologi- they watched it, participants chose a diagnosis cal theory (Scheff, 1966). Scheff introduced a from a list of 30 choices that included 10 psy- labeling theory of mental illness grounded in chotic disorders, 10 neurotic disorders, and 10 a distinction between primary and secondary miscellaneous personality types. “Normal or deviance. In contrast to the violation of explicit healthy personality” was an option in the latter rules, which Scheff attributes to the actions category, and Temerlin believed this was the of criminals or delinquents, psychopathology correct choice on the grounds that the actor or aberrant behaviors that violate implicit portrayed a mentally healthy person. A major- rules are referred to as primary deviance. This ity (60%) of the psychiatrists, along with 28% primary deviance can lead an individual to of the clinical psychologists and 11% of the be diagnosed with a mental disorder. Society graduate students, chose a diagnosis from the members’ reactions to the diagnostic label pro- psychotic disorders. By comparison, none of duce what Scheff called secondary deviance, the participants in the four control groups (e.g., the additional pathology or behavioral dis- no suggestion, suggestion of mental health) turbance that can cause or worsen mental diagnosed this individual as psychotic. illness. The novelty of labeling theory lies in Temerlin (1968) concluded that suggestions itsemphasisontheimportanceofsecondary influenced clinicians’ diagnostic judgments, deviance, and this has sparked considerable and this seems indisputable. Others interpret debate and empirical research. this finding as support for labeling theory on the grounds that the suggested label of Influential Labeling Studies psychosis affected participants’ judgments. It is not clear how this interpretation relates to Three studies continue to exert a dispro- the theory, however, as there is no indication portionate impact on the contemporary of any role played by secondary deviance in understanding and assessment of the merits thisstudy.Themanonthetapewasinstructed of labeling theory: Temerlin’s (1968) study of to portray a mentally healthy person, and suggestion effects in diagnosis, Langer and there was no opportunity for participants to Abelson’s (1974) study of labeling bias, and reacttothelabelinwaysthatmightaffecthis the Rosenhan (1973) pseudopatient study. behavior. Another problem is that the observed Temerlin (1968) had psychiatrists, clinical suggestion effect itself is arguably a reasonable psychologists, and clinical psychology grad- response to a situation in which participants uate students watch a videotape of an actor hadtocombinetwosourcesofinformation, portraying a mentally healthy physical sci- one of some validity and one of little or none, entist and mathematician who had read a to reach a judgment. First, participants were book about psychotherapy and wanted to told by a qualified expert that although the discuss it with a psychologist. Before they manonthetapewouldnotappeartobeso,he watched this, participants were informed by was in fact “quite psychotic.” Next, they were an esteemed colleague with many professional shown a tape that contained largely irrelevant The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld. © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc. DOI: 10.1002/9781118625392.wbecp452 2 LABELING THEORY behavior. Seeking to discuss a book with some- information that vary in their validity is often one knowledgeable on the subject is not a ignored in labeling research. Most investigators context in which one might expect to observe appear to presume that a diagnostic label does evidence strongly indicative of the presence not denote any empirically relevant behavioral vs. absence of any mental disorder. Partici- information. This assumption seems incon- pants had no reason to discount the expert’s sistent with Scheff’s original conception of opinion, particularly given that they were led labeling theory, in which he maintained that to believe this expert possessed more valid primary deviance leads to a diagnostic label. information than what was shown on the tape. Given this foundation, one can reasonably Therefore, it seems unreasonable to expect infer some level of primary deviance from the participants to completely override the expert’s existence of a diagnostic label. The key ques- judgment and select “normal or healthy per- tion, unaddressed by Temerlin or Langer and sonality”astheirbestguessdiagnosis.Taking Abelson, is whether a label leads to secondary the expert’s input into account is arguably the deviance that in turn causes or worsens mental more sensible response to a highly ambiguous illness. Receiving a suggestion, watching a situation. videotape, and making diagnoses or ratings In the second influential study of labeling, of a target does not constitute a paradigm Langer and Abelson (1974) had clinicians capableoftestingthelabelingtheoryofmental watch a videotape of a job interview with the illness. sound removed. Half the participants were The third influential study of labeling is told in advance that the interviewee was a described in Rosenhan’s (1973) classic paper patient, the other half that he was a job appli- “On being sane in insane places.” Eight men- cant. After watching the tape, participants tally healthy individuals, including Rosenhan responded to a series of open-ended questions himself, requested admission at mental hos- about the interviewee that blind raters later pitals based on a complaint of distressing scored along a 10-point scale of psychological auditory hallucinations. Specifically, they adjustment. Among psychoanalytically ori- reported hearing the words “empty,” “hol- ented participants, ratings were more negative low,” or “thud.” Some of the participants for patients than for job applicants, whereas visitedmorethanonehospital,foratotal among behaviorally oriented participants, of 12 “pseudopatient” experiences. In each ratings were comparable across experimental instance, the pseudopatient was admitted to conditions. the hospital and diagnosed with a mental Langer and Abelson (1974) concluded that disorder. Schizophrenia was diagnosed 11 whereas behavioral therapists were immune times and manic depression once. Once admit- totheinfluenceofa“merelabel,”psychoana- ted, each pseudopatient stopped faking any lytictherapistswerebiasedbythislabel.This symptoms. Though they took extensive notes interpretation of the results once again con- to record their observations, pseudopatients tains a problematic assumption. Referring to wereinstructedtoactinanotherwisenormal “mere labels,” Langer and Abelson presumed fashionandtorespondhonestlytoquestions that patients and job applicants experience so that the research team could determine equivalent levels of adjustment and therefore whether hospital staff would discover their that the label was in fact irrelevant. In the “sanity” and release them. After an average stay absence of data on the actual adjustment of of 19 days, each pseudopatient was discharged patients and job applicants, which Langer and with his or her original diagnosis reclassified Abelson did not provide, there is no defensible as “in remission.” criterion against which to evaluate partici- Selecting from the observations recorded by pants’ judgments. Unfortunately, the challenge the pseudopatients, Rosenhan (1973) asserted of how best to integrate multiple sources of that“psychiatricdiagnoses...carrywiththem LABELING THEORY 3 personal, legal, and social stigmas” (p. 252). He serious threat to Rosenhan’s (1973) central wrote that “the data speak to the massive role conclusions. Spitzer collected data suggest- of labeling in psychiatric assessment. Having ing that an “in remission” classification was once been labeled schizophrenic, there is noth- used only rarely when patients were dis- ing the pseudopatient can do to overcome the charged from psychiatric hospitals. Given this tag. The tag profoundly colors others’ percep- contextual information, the uniform applica- tions of him and his behavior” (pp. 252–253). tion of such an unusual diagnostic qualifier Rosenhan surmised that “the label sticks, a demonstrates how attentive professionals were mask of inadequacy forever” (p. 257). The final to the pseudopatients’ behaviors. To the extent sentence unifies the paper by implying that that this study addresses labeling theory at diagnostic labels led to the abusive practices all, it provides little support for it. The initial observed by the pseudopatients: “In a more diagnoses of psychosis appear not to have benign environment, one that was less attached unduly clouded diagnosticians’ subsequent to global diagnosis, [the staff’s] behaviors and judgments, for in every case the staff correctly judgments might have been more benign and observed the absence of signs or symptoms of effective” (p. 257). psychopathology prior to discharge. Though Many commentators have argued that theprimarydevianceresponsiblefortheirini- Rosenhan had used faulty methodology, tial diagnoses