My first thought when I received this book to review was to look to see if Thomas Scheff had a web site. He does, but I was not prepared for what I found. Prominently displayed is a full-length picture of him in formal attire. His beard is neatly trimmed, he appears lean and fit, and altogether he gives an elegant impression. This is far different than I remembered him when I went to Santa Barbara in 1969 to meet him after having read and been impressed by the first edition of this book. My recollection is that he looked every bit the part of a 1960s professor challenging the conventional wisdom of the day.

In any case, I thought he had much to say that was important—I still do—and I quoted him extensively in subsequent publications. Briefly, he believes that the presence of mental illness is determined by societal labeling. How does a person become labeled as mentally ill? First of all, symptoms of mental illness are viewed as violations of social norms. Such behavior as rambling or disorganized speech, unprovoked violent outbursts, delusions, attempts at suicide, bizarre facial grimacing, and extreme anxiety are clearly abnormal by most social standards. However, many such gross violations are not noticed, are ignored, or are rationalized as eccentricity. A close look at any neighborhood in any community will reveal large numbers of seriously disturbed persons who have never come to the attention of a psychiatrist. The violation of the social norm in itself, therefore, does not necessarily cause a person to be labeled as mentally ill. The person is labeled, rather, when circumstances bring about public and official recognition of aberrant behavior—for example, when a request is made that the person be committed to a mental hospital. The result? The person is stigmatized and labeled as mentally ill.

Scheff points out that labeling of a person as mentally ill is facilitated by stereotyped imagery learned in early childhood and continually reaffirmed, inadvertently, in ordinary social interaction and through the mass media. Thus, when a person’s violation of social norms or deviance becomes a public issue, the traditional stereotype of "crazy person" is readily adopted both by those reacting to the deviant person and, often, by the deviant person as well. A person completes the process of acquiring the label "mentally ill" when the stereotyped imagery becomes part of the person’s self-concept and begins to guide the person’s behavior. In a crisis, when the gross violator of social norms is publicly recognized, the person is profoundly confused, anxious, and ashamed. The deviant person may be highly suggestible and may accept the proffered label of mentally ill as the only way to get out of an intolerable situation. The person may prefer being taken to a hospital as crazy to being taken to jail as a shoplifter. Later on, the person finds that playing the stereotyped deviant role of being mentally ill provides such rewards as hospitalization, where the person is taken care of, and relief from having to fulfill normal social and vocational roles. Once having been labeled "mentally ill," the person may find it difficult to become delabeled.

Scheff himself observes that these theories were taken seriously in the 1960s and 1970s, began to wane in the 1980s, and had been all but dismissed by the mainstream disciplines by the 1990s. A major reason was biological psychiatry, with its emphasis on biological etiology, more scientific classification, and effective treatment with psychoactive drugs. Other major reasons were critiques within Scheff’s own field of sociology, which proposed that since labeling theory was not substantiated by empirical studies, it should be abandoned.

The book, therefore, begins with a counterattack on both biological psychiatry, which has largely ignored not only labeling theory but sociological theories generally, and on those who specifically have attacked labeling theory. Scheff then goes on to reiterate the labeling theory of mental illness with substantial elaboration and clarification and places more emphasis on the contributions of psychological approaches.

Although some of Scheff’s critiques of biological psychiatry have merit, in some ways they also seem to me to be a distraction. The most important new contribution of the third edition of this book, in my opinion, is that Scheff more strongly emphasizes than he did before that the labeling theory of mental illness is only one of many points of view and that it will be necessary to integrate the differing standpoints of the psychological, sociological, and biological approaches.

Scheff’s labeling theories were an important contribution when they were originally proposed, although, unfortunately, they have been misused by some in the antipsychiatry movement. In my opinion, Scheff’s theories remain important and add to our understanding of mental illness. The tremendous advances in biological psychiatry should not be minimized. On the other hand, if we are to have a truly biopsychosocial approach to mental illness, contributions such as those of Scheff remain essential.