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Predicting dangerousness: The social construction of psychiatric reality
BOOK
123
REVIEWS
read by every serious student and practitioner, whether he be attorney, mental health professional or judge. Although this book is now over three years old and may seem ancient history in this rapidly changing field, it is necessary history on which to base important concepts for future implementation.
PREDICTING DANGEROUSNESS: THE SOCIAL CONSTRUCTION OF PSYCHIATRIC REALITY By Stephen Pfohl. Lexington, Massachusetts: D. C. Heath, 1978, 250 pp. Reviewek
Ottawa,
Michael Petrunik, Canada.
Research
Division, Solicitor
General’s Department,
In Predicting Dangerousness, Dr. Stephen Pfohl, a sociologist at Boston College, takes an innovative approach to the diagnosis of mental disorder and the assessment of dangerousness. Guided by the ethnomethodological approach in sociology (essentially the study of the assumptions and methods by which people interpret situations and make their decisions appear reasonable to themselves and others), Pfohl asks a different order of question. Rather than looking at the outcomes of diagnoses and predictions and their validity and reliability, Pfohl focuses on the process by which mental health professionals actually do assessments of dangerousness. His basic concern is to illustrate how decisions of mental health specialists which putatively rest on expert knowledge are guided to a large degree by a variety of practical, cultural, and idiosyncratic considerations. Pfohl, it should be noted, is not an ethnomethodological purist. His is an “unconventionally sentimental” sociology of the underdog. He uses the ethnomethodological approach in conjunction with the insights of labelling theory to critique the practices of mental health diagnosticians. The setting for Pfohl’s study was the Lima, Ohio state maximum security forensic psychiatric institution whose approximately 700 inmates were popularly believed to be the most dangerous persons filtered through the state’s criminal justice and mental health systems. About one third were persons found incompentent to stand trial and one third were prison transfers. The remainder were psychopathic offenders and a small number of persons found not guilty by reason of insanity. Following reports of overcrowding, harsh conditions, physical abuse and the absence of professional treatment, a right to treatment suit was made on behalf of all Lima patients. In September 1974, an Ohio Federal District Court ordered the state to continue to confine only those found to require maximum security on the basis that they were either “immediately dangerous” or “psychopathic offenders requiring further treatment.” Qualified mental health experts were asked to reassess each patient according to “valid” clinical standards established by their disciplines. Twelve teams were set up, each one consisting of a psychiatrist, a clinical psychologist, and a psychiatric social worker. Pfohl, along with six other sociological researchers, undertook a study of the clinical decision-making process. Tape recordings and observations were made of 130 diagnostic sessions. The sociologi-
124
BOOK REVIEWS
cal observer took note of what went on before, during, and after each patient interview. Each mental health expert was also interviewed at the end of the entire reassessment process with regard to his or her impressions concerning the diagnostic sessions and the presence of observers. The bulk of the book contains an analysis of the transcripts of the diagnostic sessions. Pfohl concretely illustrates the verbal and non-verbal means by which team members displayed their theorizing about the patient’s mind and their concerns to affirm and protect their professional identities vis-&vis other team members. He documents their assumptions and preconceptions about mental disorder and the ways in which these assumptions guided clinical inferences about the significance of the patient’s recorded past and his verbal and non-verbal behavior and appearance during the session. He shows how, although the team members were in principle to be equals in arriving at a diagnosis, authority or expertise was typically claimed or imputed by the different types of professionals and had a significant impact on the ultimate decision. The heart of the book is chapter nine, an anlysis of the assumptions, methods, and “rules” the clinicians used to transform “ad hoc” clinical reasoning into “objective” findings. Pfohl shows the logic of justification at work and the methods used to neutralize, transform, or modify “contradictory” information. A major finding was the tendency to routinely discredit the validity of social accounts for patients’ situations that stemmed from culture, class and the patient’s level of power and authority in social relationships. Pfohl shows how the members of the team transformed what they did and concluded from a variety of seemingly vague “hunches,” “theories” and “impressions” into objective and expert sounding descriptions formulated in the specialized professional terminology of syndromes and symptoms. In short, what went on in the interactive process between mental health specialists appears to have had as much, if not more, importance than the patient’s behavior in shaping diagnostic recommendations to the court. Here lies what Pfohl sees as the profound political significance of the diagnostic practices of mental health experts and where his sociology of the underdog comes into play. Pfohl argues that the clinical interpretation of dangerousness as rooted in individual pathology is a “political act by which accounts of violence are stripped of their political and social meaning.” He views the ilinical prediction process and the principle of individual pathology as reinforcing a criminal justice system that systematically perverts the realization of social justice by emphasizing individuals rather than social systems as the real perpetrators of violence and harm. Although Pfohl is certainly making a valid point, particularly if his analysis is extended to political radicals or members of oppressed racial or ethnic minorities, he is treading on somewhat dangerous ground in making such an interpretation for mentally disordered offenders as a class. While pathological explanations of individual behaviour can indeed strip behavior of its political relevance and unwarrantedly reduce collective problems to individual causes, the opposite process can also be seen at work in radical or unconventionally sentimental critiques, i.e., the unwarranted politicization and collectivist interpretation of violence which might be more accurately viewed as a product of individual adaptations to frustrations or situations which are not social class or social system induced.
BOOK REVIEWS
125
For the sociologist specializing in deviance and social control or mental health issues, Pfohl’s book is certainly a worthwhile addition to the literature and is to be highly recommended. A caveat is in order, however, for legal and mental health professionals, and even social scientists, with little acquaintance with ethnomethodological analysis. While Pfohl’s descriptive chapters are lucid, the denseness of his writing coupled with his use of ethnomethodological jargon (terms like “reflexivity,” “indexicality,” and “members”) are likely to be troublesome. It is to be hoped that readers will not be overly discouraged, for Pfohl has important insights to offer to those engaged in the construction of psychiatric or legal reality as a practical task.
123
REVIEWS
read by every serious student and practitioner, whether he be attorney, mental health professional or judge. Although this book is now over three years old and may seem ancient history in this rapidly changing field, it is necessary history on which to base important concepts for future implementation.
PREDICTING DANGEROUSNESS: THE SOCIAL CONSTRUCTION OF PSYCHIATRIC REALITY By Stephen Pfohl. Lexington, Massachusetts: D. C. Heath, 1978, 250 pp. Reviewek
Ottawa,
Michael Petrunik, Canada.
Research
Division, Solicitor
General’s Department,
In Predicting Dangerousness, Dr. Stephen Pfohl, a sociologist at Boston College, takes an innovative approach to the diagnosis of mental disorder and the assessment of dangerousness. Guided by the ethnomethodological approach in sociology (essentially the study of the assumptions and methods by which people interpret situations and make their decisions appear reasonable to themselves and others), Pfohl asks a different order of question. Rather than looking at the outcomes of diagnoses and predictions and their validity and reliability, Pfohl focuses on the process by which mental health professionals actually do assessments of dangerousness. His basic concern is to illustrate how decisions of mental health specialists which putatively rest on expert knowledge are guided to a large degree by a variety of practical, cultural, and idiosyncratic considerations. Pfohl, it should be noted, is not an ethnomethodological purist. His is an “unconventionally sentimental” sociology of the underdog. He uses the ethnomethodological approach in conjunction with the insights of labelling theory to critique the practices of mental health diagnosticians. The setting for Pfohl’s study was the Lima, Ohio state maximum security forensic psychiatric institution whose approximately 700 inmates were popularly believed to be the most dangerous persons filtered through the state’s criminal justice and mental health systems. About one third were persons found incompentent to stand trial and one third were prison transfers. The remainder were psychopathic offenders and a small number of persons found not guilty by reason of insanity. Following reports of overcrowding, harsh conditions, physical abuse and the absence of professional treatment, a right to treatment suit was made on behalf of all Lima patients. In September 1974, an Ohio Federal District Court ordered the state to continue to confine only those found to require maximum security on the basis that they were either “immediately dangerous” or “psychopathic offenders requiring further treatment.” Qualified mental health experts were asked to reassess each patient according to “valid” clinical standards established by their disciplines. Twelve teams were set up, each one consisting of a psychiatrist, a clinical psychologist, and a psychiatric social worker. Pfohl, along with six other sociological researchers, undertook a study of the clinical decision-making process. Tape recordings and observations were made of 130 diagnostic sessions. The sociologi-
124
BOOK REVIEWS
cal observer took note of what went on before, during, and after each patient interview. Each mental health expert was also interviewed at the end of the entire reassessment process with regard to his or her impressions concerning the diagnostic sessions and the presence of observers. The bulk of the book contains an analysis of the transcripts of the diagnostic sessions. Pfohl concretely illustrates the verbal and non-verbal means by which team members displayed their theorizing about the patient’s mind and their concerns to affirm and protect their professional identities vis-&vis other team members. He documents their assumptions and preconceptions about mental disorder and the ways in which these assumptions guided clinical inferences about the significance of the patient’s recorded past and his verbal and non-verbal behavior and appearance during the session. He shows how, although the team members were in principle to be equals in arriving at a diagnosis, authority or expertise was typically claimed or imputed by the different types of professionals and had a significant impact on the ultimate decision. The heart of the book is chapter nine, an anlysis of the assumptions, methods, and “rules” the clinicians used to transform “ad hoc” clinical reasoning into “objective” findings. Pfohl shows the logic of justification at work and the methods used to neutralize, transform, or modify “contradictory” information. A major finding was the tendency to routinely discredit the validity of social accounts for patients’ situations that stemmed from culture, class and the patient’s level of power and authority in social relationships. Pfohl shows how the members of the team transformed what they did and concluded from a variety of seemingly vague “hunches,” “theories” and “impressions” into objective and expert sounding descriptions formulated in the specialized professional terminology of syndromes and symptoms. In short, what went on in the interactive process between mental health specialists appears to have had as much, if not more, importance than the patient’s behavior in shaping diagnostic recommendations to the court. Here lies what Pfohl sees as the profound political significance of the diagnostic practices of mental health experts and where his sociology of the underdog comes into play. Pfohl argues that the clinical interpretation of dangerousness as rooted in individual pathology is a “political act by which accounts of violence are stripped of their political and social meaning.” He views the ilinical prediction process and the principle of individual pathology as reinforcing a criminal justice system that systematically perverts the realization of social justice by emphasizing individuals rather than social systems as the real perpetrators of violence and harm. Although Pfohl is certainly making a valid point, particularly if his analysis is extended to political radicals or members of oppressed racial or ethnic minorities, he is treading on somewhat dangerous ground in making such an interpretation for mentally disordered offenders as a class. While pathological explanations of individual behaviour can indeed strip behavior of its political relevance and unwarrantedly reduce collective problems to individual causes, the opposite process can also be seen at work in radical or unconventionally sentimental critiques, i.e., the unwarranted politicization and collectivist interpretation of violence which might be more accurately viewed as a product of individual adaptations to frustrations or situations which are not social class or social system induced.
BOOK REVIEWS
125
For the sociologist specializing in deviance and social control or mental health issues, Pfohl’s book is certainly a worthwhile addition to the literature and is to be highly recommended. A caveat is in order, however, for legal and mental health professionals, and even social scientists, with little acquaintance with ethnomethodological analysis. While Pfohl’s descriptive chapters are lucid, the denseness of his writing coupled with his use of ethnomethodological jargon (terms like “reflexivity,” “indexicality,” and “members”) are likely to be troublesome. It is to be hoped that readers will not be overly discouraged, for Pfohl has important insights to offer to those engaged in the construction of psychiatric or legal reality as a practical task.