For your first reflection please watch the following video and res.docx

For your first reflection please watch the following video
and respond to the prompts below (length should be close to 2
pages total):
https://www.youtube.com/watch?v=18zvlz5CxPE
1) Please describe a time where you have felt that someone else
has unfairly judged you based on the way you look, or because
of a group membership you belong to (e.g., religious, political,
sexual orientation, ethnic, etc.).
2) How did this make you feel about yourself? (Please be
detailed in your response)
3) How did this make you feel about the person who incorrectly
passed judgment on you? (please be detailed in your response)
4) Describe a time when you unfairly stereotyped an individual
from a different culture? How did this make you feel once you
realized you unfairly judged them?
N
umerous studies over the past two
decades suggest that when individuals
are diagnosed with a mental illness,
they are placed into a cultural category (e.g.,
“a mentally ill person”) that damages their
material, social, and psychological well-being
(e.g., Link 1987; Link et al. 1989; Markowitz

1998; Rosenfield 1997). According to the
modified labeling theory of mental illness
(Link 1987; Link et al. 1989), the negative
consequences of psychiatric labeling arise
through two social psychological processes.
First, when an individual is diagnosed with a
mental illness, cultural ideas associated with
the mentally ill (e.g., incompetent, dangerous)
become personally relevant and foster nega-
tive self-feelings. Second, these personally rel-
evant cultural meanings are transformed into
expectations that others will reject the individ-
ual, expectations that trigger defensive behav-
iors aimed at preventing that rejection: con-
cealing treatment history, educating others
about mental illness, and/or withdrawing from
social interaction. Ironically, however, these
defensive behaviors are linked with harmful
outcomes: a reduced social network, higher
rates of unemployment, and feelings of
demoralization (Link et al. 1989, 1991).1
Thus, diagnostic labeling is predicted to have
a negative effect on self-feelings, and it is
expected to trigger defensive reactions that
create a type of “secondary deviance,” further
damaging patients’ social interactions, occu-
pational success, and self-image.
We examine the first of these two process-
es in this study. Specifically, we examine the
way that the cultural conceptions of the men-
tally ill are related to patients’ self-feelings.
And, unlike other investigations of this rela-
tionship (e.g., Kroska and Harkness 2006;

Link 1987), we explore the way that diagnos-
tic category (adjustment, affective, or schizo-
phrenic) shapes the association; that is, we
Social Psychology Quarterly
2008, Vol. 71, No. 2, 193–208
Exploring the Role of Diagnosis
in the Modified Labeling Theory of Mental Illness
AMY KROSKA
Kent State University
SARAH K. HARKNESS
Stanford University
According to the modified labeling theory of mental illness,
when an individual is diagnosed
with a mental illness, cultural ideas associated with the
mentally ill become personally rel-
evant and foster negative self-feelings. We explore the way that
psychiatric diagnosis shapes
this process. Specifically, we examine if and how psychiatric
patients’ diagnostic category
(adjustment, affective, or schizophrenic) moderates the
relationship between stigma senti-
ments and the meanings associated with self-identities (“myself
as I really am”) and reflect-
ed appraisals (“myself as others see me”). Stigma sentiments
are the evaluation, potency,
and activity associated with the cultural category “a mentally ill
person.” We find that diag-
nosis moderates several of these relationships and that the
results among patients with an
affective diagnosis best match the stigma sentiment hypotheses
derived from the modified

labeling theory. We conclude with a discussion of the
implications of these findings for the
stigma sentiment hypotheses. We also highlight several avenues
for future research.
193
We thank Bernice Pescosolido and the Indiana
Consortium for Mental Health Services Research for col-
lecting the data used in this study. We also thank David
Heise, Nancy Docherty, and the Stanford University
Social Psychology Workshop for very helpful feedback.
We presented portions of this paper at the 2007 American
Sociological Association meeting in New York, NY.
Direct correspondence to Amy Kroska, Department of
Sociology, Kent State University, Kent, OH 44242;
[email protected]
1 Link and his colleagues (1989, 1991) measure the
coping strategies as “coping orientations,” which reflect a
combination of patients’ reports of using the strategy and
their support for using it.
194 SOCIAL PSYCHOLOGY QUARTERLY
examine if and how patients’ diagnostic cate-
gory moderates the association between the
cultural conceptions of the mentally ill and
self-meaning. Given the distinct cultural
meanings and experiences associated with dif-
ferent classes of diagnoses, we consider varied
processes a possibility. We operationalize the
cultural conceptions of the mentally ill with
stigma sentiments: the evaluation (good ver-
sus bad), potency (powerful versus weak), and

activity (active versus inactive) associated
with the cultural category “a mentally ill per-
son.” And we operationalize self-meanings as
the evaluation, potency, and activity of
patients’ self-identities (“myself as I really
am”) and reflected appraisals (“myself as oth-
ers see me”).
CULTURAL CONCEPTIONS OF THE MENTALLY ILL
AND PATIENTS’ SELF-FEELINGS
According to the modified labeling theo-
ry, when a person is diagnosed with a mental
disorder, the negative cultural conceptions of
mental illness become personally relevant,
which then damages self-feelings. Link (1987)
investigated this proposition by operationaliz-
ing cultural conceptions with stigma beliefs,
beliefs that psychiatric patients are devalued
and discriminated against. Link measured
stigma beliefs with a twelve-item index that
asked respondents to report their level of
agreement with attitude statements such as
“Most people would willingly accept a former
mental patient as a close friend,” “Most people
believe that a person who has been in a men-
tal hospital is just as intelligent as the average
person,” and “Most people would accept a
fully recovered former mental patient as a
teacher of young children in a public school.”
In support of the proposition, Link found that
stigma beliefs are positively related to demor-
alization among current psychiatric patients
but unrelated among nonpatients (community
residents with and without psychiatric pathol-
ogy who had not received psychiatric treat-

ment).
We also supported this proposition in past
research (Kroska and Harkness 2006), but we
operationalized the cultural conceptions of
mental illness with stigma sentiments.
Evaluation, potency, and activity (EPA) are the
three universal dimensions of meaning identi-
fied by Osgood and his colleagues in their
cross-cultural research (e.g., Osgood, May,
and Miron 1975). We see several advantages
to this operationalization of cultural concep-
tions: (1) EPA profiles offer an established
and parsimonious technique for measuring
cultural conceptions that has been used in sev-
eral research areas, including affect control
theory (e.g., Heise 2007), the sociology of
emotions (e.g., Heise and Calhan 1995), the
sociology of meanings and attitudes (e.g.,
Langford and MacKinnon 2000), and the soci-
ology of self-identities (e.g., Lee 1998); (2)
EPA dimensions can be used to measure cul-
tural conceptions of the mentally ill in most, if
not all, populations (Osgood et al. 1975); (3)
EPA measures are unlikely to contain
researcher bias or historically or culturally
specific features; and (4) the three-dimension-
al representation of these conceptions pro-
vides a multifaceted representation of stigma
that not only distinguishes patients from non-
patients but may also help to distinguish
among the different types of stigma associated
with different diagnostic categories (Marks
1965; Nunnally 1961).

Drawing on the modified labeling theory,
we developed stigma-sentiment hypotheses
wherein each dimension of meaning associat-
ed with a “mentally ill person” is expected to
be positively related to the corresponding
dimensions of patients’ self-identity and
reflected appraisal but unrelated to the corre-
sponding dimensions of nonpatients’ self-
identity and reflected appraisal (Kroska and
Harkness 2006).2 Nonpatients, in this study,
were college students. We found support for
several of our hypotheses. For example, the
potency that patients associate with “a mental-
ly ill person” is positively related to patients’
own feelings of potency (potency of “myself
as I really am”), whereas the potency of “a
2 In Kroska and Harkness (2006), high values on stig-
ma sentiments indicated high evaluation, potency, and
activity ratings of “a mentally ill person.” To improve clar-
ity, in this study, we have inverted the direction of stigma
sentiments, so high values on stigma sentiments indicate
low evaluation, potency, and activity ratings of “a mental-
ly ill person.”
DIAGNOSIS IN THE MODIFIED LABELING THEORY 195
mentally ill person” is unrelated to the college
students’ feelings of potency.
Diagnosis as Moderator of Stigma Sentiment
to Self-meaning Relationship
We extend this line of research by explor-

ing the way that a three-category measure of
diagnosis (adjustment, affective, and schizo-
phrenic) moderates the relationship between
stigma sentiments and mental patients’ self-
meanings. Two previous studies, which used a
dichotomous measure of diagnosis (major
depression versus schizophrenia), suggest that
diagnosis does not moderate the effects of
stigma on well-being. Link (1987) found that
although a diagnosis of depression (rather
than schizophrenia) was related positively to
demoralization, diagnosis did not moderate
the influence of stigma beliefs on demoraliza-
tion. Similarly, Link and his colleagues (1989)
found that diagnosis did not moderate the
effects of stigma beliefs on the size of support
networks nor did it moderate the relationship
between the endorsement of coping strategies
(education, secrecy, withdrawal) and network
size. Yet, these studies recruited respondents
who, before diagnosis, appeared to fit only
two diagnostic groups: major depression and
schizophrenia/schizophrenia-like disorders. In
this study, by contrast, we include all available
subjects diagnosed with either a major mental
illness or an adjustment disorder, which
allows us to explore the moderator role of
diagnosis using a three-category measure:
adjustment diagnoses, affective diagnoses,
and schizophrenic diagnoses. In our sample,
the adjustment diagnoses include adjustment
disorder, grief reaction, and posttraumatic
stress; the affective diagnoses include bipolar
disorder, cyclothymia, dysthymia, and major
depression; and the schizophrenic diagnoses
include psychotic–not otherwise specified,

schizoaffective, schizophrenia, and schizo-
phreniform.
Disorders in each category are associated
with distinct symptoms and cultural meanings
and may, therefore, shape the relationship
between stigma sentiments and self-meanings
in distinctive ways. Adjustment disorders
involve distress and behavioral symptoms
experienced in response to external stressors.
Two disorders in this category–the adjustment
disorder and grief reaction disorders–are often
temporary. Affective disorders are mood disor-
ders that involve symptoms of depression and,
for bipolar disorders, symptoms of mania
(Goodwin and Guze 1996). Finally, schizo-
phrenic disorders involve impairments of per-
ceptions, including hallucinations and delu-
sions, symptoms that often impair patients’
social and occupational functioning and can
create alexithymia (Maggini and Raballo
2004; van ‘t Wout et al. 2007), an inability to
recognize one’s own feelings.
Although the symptoms within each diag-
nostic category are well known, little existing
research examines how these diagnoses affect
the association between stigma and self-mean-
ings. Therefore, we do not advance any
hypotheses regarding the direction of modera-
tion for each diagnostic group; instead, we
simply pose two research questions, one for
the relationship between stigma sentiments
and the EPA of patients’ self-identity (“myself
as I really am”) and one for the relationship

between stigma sentiments and the EPA of
patients’ reflected appraisals (“myself as oth-
ers see me”).
Diagnosis-as-Moderator Research Question 1:
Does the relationship between the evaluation,
potency, and activity of “a mentally ill person”
and the corresponding dimensions of self-identi-
ty (“myself as I really am”) vary by diagnostic
category (adjustment, affective, and schizo-
phrenic)?
Diagnosis-as-Moderator Research Question 2:
Does the relationship between the evaluation,
potency, and activity of “a mentally ill person”
and the corresponding dimensions of reflected
appraisals (“myself as others see me”) vary by
diagnostic category (adjustment, affective, and
schizophrenic)?
According to the stigma sentiment
hypotheses, each dimension of meaning asso-
ciated with “a mentally ill person” should be
positively related to the corresponding of
meaning associated with patients’ self-identity
and reflected appraisal. Therefore, positive
relationships are consistent with the stigma
sentiment hypotheses; negative relationships
are inconsistent with the hypotheses. Cross-
dimensional relationships (e.g., between the
potency of “a mentally ill person” and self-

evaluation) were not anticipated in the
hypotheses.
We examine these associations when con-
trolling for the global assessment of function-
ing, a measure of an individual’s social, psy-
chological, and occupational functioning.
Thus, our analyses examine the moderator
role of diagnosis while controlling, at least to
some extent, for symptom severity. Given the
differences in the severity of impairment
across the three diagnostic categories, this
control helps rule out the possibility that diag-
nostic category simply reflects symptom
severity.
METHODS
Data
We use psychiatric patient data from
Wave 1 of the Indianapolis Network Mental
Health Study. The data were collected at the
two largest general hospitals, one public and
one private, in Indianapolis. The patients are
individuals who made their first major contact
with the mental health system and were diag-
nosed with either a serious mental illness or an
adjustment disorder. All individuals fitting
study criteria were asked to participate
through a rolling recruitment strategy that
began in January 1990. Data were collected
from the patients within three months of their
initial contact with the mental health system.
A total of 173 patients participated in wave 1
of the Indianapolis study, representing a

response rate of 66.4 percent. We have com-
plete data for the current study for 142 of the
173 patients.
Dependent Variables
Self-meanings are the evaluation (good
versus bad), potency (powerful versus weak),
and activity (active versus inactive) of “myself
as I really am” (self-identity) and “myself as
others see me” (reflected appraisal). The
dimensions were measured with seven-point
semantic differential scales. The evaluation
scale was anchored with the adjective pairs
“good” and “bad,” the potency scale with
“powerful” and “powerless,” and activity with
“fast, noisy” and “slow, quiet.” The middle cir-
cle was marked “neutral”; the circles between
the midpoint and the endpoints were marked
with “slightly,” “quite,” and “extremely.”
These were coded with values ranging from
–3 to +3.
To reduce response sets, the direction of
the adjectives was randomized across stimuli.
The interviewer read the semantic differential
instructions, which were printed on the survey,
and the respondent could read along. The
instructions stated:
The next few pages measure your attitude about
things. The subject is printed in large type. You
rate how you feel about the subject on all three of
the scales that follow. For example, if you think
“a Riot” is quite bad, slightly powerful, and

extremely active you would mark the scales as
follows.
[“a Riot” is followed by the evaluation scale
marked at “quite bad,” the potency scale marked
at “slightly powerful,” and the activity scale
marked at “extremely fast, noisy.”]
Be careful because the Good, Powerful, and Fast
ends of the scale change from one side to the
other as you proceed from word to word.
Rate the words according to your f irst
impressions. There are no right answers other
than the answers that show how you feel.
If the respondent had difficulty with the
semantic differential scales, the interviewer
provided assistance. Table 1 shows the
descriptive statistics for these and the other
variables in the analysis.
Independent Variables
Stigma sentiments are operationalized
with the evaluation, potency, and activity
associated with “a mentally ill person,” mea-
sured with the semantic differential scales
described above. Low EPA ratings of “a men-
tally ill person” indicate high stigma senti-
ments, and high EPA ratings indicate low stig-
ma sentiments.
Diagnosis has three categories: 32 of the
142 patients (22.5%) have an adjustment diag-
nosis (adjustment disorder, grief reaction, or

posttraumatic stress), 93 (65.5%) have an
affective diagnosis (bipolar, cyclothymia, dys-
thymia, or major depression), and 17 (12.0%)
have a schizophrenic diagnosis (psychotic–not
otherwise specified, schizoaffective, schizo-
phrenia, or schizophreniform).
Global assessment of functioning scores
reflect the severity of patients’ symptoms and
can range from a low of 1 (persistent danger of
severely hurting self or others) to a high of
100 (superior functioning; no symptoms).
Scores in this sample range from 10 to 73,
with a mean of 46.55, a score that indicates
serious impairment in social, occupational, or
school functioning. A clinically trained survey
interviewer determined this score using the
patient’s answers to a series of questions and
information from the patient’s file.
RESULTS
Differences in Self-meanings by Diagnosis
Before examining our research questions,
we briefly review the self-meaning differences
across diagnoses. Table 1 displays the mean
evaluation, potency, and activity ratings of
self-identities (“myself as I really am”) and
reflected appraisals (“myself as others see

me”) in each diagnostic group. Models 1, 4,
and 7 in Tables 2 and 3 show the significance
of the differences in self-meanings by diag-
nostic group, while Models 2, 5, and 8 show
the significance of the differences when con-
trolling for symptom severity (the global
assessment of functioning), sociodemographic
characteristics, and stigma sentiments. For
simplicity, we simply highlight the means
reported in Table 1. A fuller discussion of the
significance of these differences in Tables 2
and 3 is available on the SPQ website.
Self-identity. As shown in Table 1, patients
with an adjustment diagnosis see themselves
(“myself as I really am”) as slightly good
(.53), neither powerful nor weak (–.13), and
slightly inactive (–.75). Patients with an affec-
tive diagnosis have a similar but less inactive
self-meaning (.88, –.27, –.09). Schizophrenic
patients evaluate themselves more positively
than either group (1.59) but are similar on
potency (–.35) and activity (–.41).
Reflected appraisal. As shown in Table 1,
patients with an adjustment diagnosis feel oth-
Table 1. Descriptive Statistics for Variables in the Analyses
Patients by Diagnosis
All Adjustment Affective Schizophrenic
Psychiatric Disorder Disorder Disorder
(N = 142) (n = 32) (n = 93) (n = 17)
Mean SD Mean SD Mean SD Mean SD

Self-Meanings
Evaluation .89 1.54 .53 1.44 .88 1.53 1.59 1.62
—Myself as I
Potency –.25 1.60 –.13 1.43 –.27 1.66 –.35 1.66
—really am
Activity –.27 1.60 –.75 1.55 –.09 1.54 –.41 1.87
—Myself as Evaluation .72 1.69 .41 1.36 .72 1.75 1.29 1.83
—others Potency .23 1.61 .34 1.43 .30 1.63 –.41 1.73
—see me Activity .11 1.64 .00 1.52 .17 1.69 –.06 1.71
Stigma Sentiments
—A mentally
Evaluation .06 1.33 –.03 1.15 .23 1.34 –.65 1.41
—ill person
Potency –.87 1.50 –.88 1.62 –.88 1.44 –.76 1.71
Activity –.49 1.42 –1.00 1.24 –.38 1.37 –.12 1.83
Controls
Global assessment of functioning 46.55 14.22
Female .66 .47
Age 30.26 9.62
Race (0 = white, 1 = black) .23 .42
Years of schooling 11.66 2.12
}
}
}

ers see them (“myself as others see me”) as
neutral in goodness (.41), power (.34), and
activity (.00). Affective patients have a similar
but somewhat more positive reflected
appraisal (.72, .30, .17). Schizophrenic
patients’ reflected appraisal is more positive
(1.29) and less potent (–.41) but similar in
activity (–.06) to the other patients’ reflected
appraisals.
Diagnosis as a Moderator
To assess our research questions, we
examine Models 3, 6, and 9 of Tables 2 and 3,
because these equations include the diagnosis
by stigma sentiment interactions. Because we
have a small number of cases (and hence little
statistical power) and our analyses are
exploratory, we report interactions that are
only marginally significant (p < .10). We dis-
play the interactions in Figures 1–6. “Low” on
the x-axis is 1 sd below that mean (which is
–1.26 on the evaluation of “a mentally ill per-
son” and –2.37 on the potency of “a mentally
ill person”); “high” is 1 sd above that mean
(1.39 on the evaluation of “a mentally ill per-
son” and .64 on the potency of “a mentally ill
person”). The stigma sentiment that is part of
the focal interaction is held at its high or low
point throughout the entire equation; the vari-
ables that are not part of the focal interaction
are held at their means.3 We display the signif-

icant (p < .05) slopes in bold along with their
coefficients and p-values.
Self-evaluation. Model 3 in Table 2 shows that
diagnosis moderates the relationship between
the evaluation of “a mentally ill person” and
self-evaluation. As the evaluation of “a men-
tally ill person” increases one unit, affective
patients’ self-evaluation increases .27 units (b
= .27, se = .12, p = .022), results consistent
with the stigma sentiment hypotheses. This
significant slope is displayed in bold in Figure
1. Among patients with a schizophrenic or an
adjustment disorder, by contrast, the relation-
ship is negative and not significant when these
slopes are modeled separately (adjustment: b
= –.24, se = .23, p = .302; schizophrenic: b =
–.37, se = .26, p = .150).4 Yet, when the high-
ly similar schizophrenic and adjustment
patient slopes are modeled together (not
shown), the negative slope is marginally sig-
nificant (b = –.29, se = .17, p = .086).5
Model 3 also shows that diagnosis moder-
ates the association between the potency of “a
mentally ill person” and self-evaluation. As
the potency of “a mentally ill person” increas-
es one unit among schizophrenic and affective
patients, self-evaluation increases (b = .27, se
= .10, p = .009). This slope is displayed in bold
in Figure 2. By contrast, the potency of “a
mentally ill person” is not significantly relat-
ed to self-evaluation among adjustment
patients (b = –.25, se = .16, p = .129) as shown
by the dashed slope in Figure 2. Although this

cross-dimensional result is not part of the stig-
ma sentiment hypotheses, the positive direc-
tion of the effect among affective and schizo-
phrenic patients is compatible with the
hypotheses.
Self-potency. Models 5 and 6 show that the
potency of “a mentally ill person” is positive-
3 When two diagnostic categories are grouped together
for a slope, we use the proportion of the non-omitted cat-
egory relative to the omitted for the relevant diagnosis
dummy. For example, there are 32 adjustment and 93
affective cases, so we used .256 (32/(32 + 93)) for the
adjustment dummy when generating predicted values for
the joint adjustment and affective slopes found in Figures
3 to 6.
4 Recall that the coefficient for the non-omitted cate-
gories that are part of an interaction can be determined by
adding together the category’s interaction term and the
corresponding main effect. Thus, the coefficient for the
evaluation of “a mentally ill person” for adjustment
patients (a non-omitted diagnosis) is .27 –.51 = –.24, and
the coefficient for the evaluation of “a mentally ill per-
son” for schizophrenic patients (a non-omitted diagnosis)
is .27 –.64 = –.37. We determined the standard errors and
significance of these coefficients by reversing the coding
(making the non-omitted category the omitted category)
and observing the standard error and p-value for the
appropriate main effect (evaluation of “a mentally ill per-
son” in this example).
5 This alternative equation collapses the two highly
similar slopes by changing the omitted diagnosis to schiz-
ophrenia and including only the affective � evaluation of

“a mentally ill person” and adjustment � potency of “a
mentally ill person” interactions. This equation fits the
data somewhat better as indicated by a slightly higher
adjusted R2 (.173). We do not report this equation in Table
2, because it would mean using a different omitted diag-
nosis across models. It is available on request.
ly related to self-potency at a marginally sig-
nificant level among all patients (b = .16, se =
.09, p = .093), consistent with the stigma sen-
timent hypotheses. In addition, Model 6 and
Figure 3 show another cross-dimensional
effect: diagnosis moderates the relationship
between the evaluation of “a mentally ill per-
son” and self-potency. Among schizophrenic
patients, evaluation of “a mentally ill person”
is positively related to self-potency (b = .56, se
= .28, p = .046), but among adjustment and
affective patients, evaluation of “a mentally ill
person” is unrelated to self-potency (b = .04,
se = .11, p = .751).
Self-activity. Model 9 shows that the activity
of “a mentally ill person” is positively related
to self-activity among all patients (b = .33, se
= .10, p = .001), results consistent with the
stigma sentiment hypotheses. Model 9 and
Figure 4 also show another cross-dimensional
effect. As the potency of “a mentally ill per-
son” increases among adjustment and affec-
tive patients, feelings of activity decline (b =
–.19, se = .10, p = .044), but as the potency of

“a mentally ill person” increases among schiz-
ophrenic patients, feelings of activity do not
change significantly (b = .26, se = .23, p =
.268).
Table 2. OLS Regressions of Psychiatric Patients’ Evaluation,
Potency, and Activity Ratings of “Myself As I Really
Am” on Controls and Stigma Sentiments (N = 142)
Myself As I Really Am
Independent Variables Evaluation Potency Activity
Models .1 .2 .3 .4 .5 .6 .7 .8 .9
Adjustment disorder –.35 –.06 –.52 .14 .47 .46 –.66* –.52 –.57†
(0 = affective disorder) (.31) (.33) (.36) (.33) (.35) (.35) (.32)
(.34) (.34)
Schizophrenic disorder .71† .80† .46 –.08 –.44 –.15 –.33 –.45 –
.08
(.44) (.48)
Global assessment of functioning –.01 –.01 –.02* –.02* .001
.002
(.01) (.01) (.01) (.01) (.01) (.01)
Female .05 –.003 –.61* –.55† –.10 –.14
(.28) (.28) (.30) (.30) (.29) (.29)
Age .02† .02 .01 .01 –.02 –.02
(.01) (.01) (.01) (.01) (.01) (.01)
Black (0 = white) .52 .36 .01 .02 –.31 –.42
(.32) (.31) (.33) (.33) (.32) (.32)
Years of schooling .09 .08 –.04 –.04 .08 .08

(.06) (.06) (.07) (.06) (.06) (.06)
Evaluation .14 .27* .10 .04 –.15 –.14
(.10) (.12) (.11) (.11) (.10) (.10)
A mentally ill person Potency .15† .27** .16† .16† –.14 –.19*
(.09) (.10) (.09) (.09) (.09) (.10)
Activity –.10 –.09 .10 .10 .37*** .33**
(.10) (.09) (.10) (.10) (.10) (.10)
Adjustment disorder � –.51*
—evaluation of “a mentally ill person” (.25)
Schizophrenic disorder � –.64* .53†
—evaluation of “a mentally ill person” (.28) (.30)
Adjustment disorder � –.52**
—potency of “a mentally ill person” (.19)
Schizophrenic disorder � .46†
—potency of “a mentally ill person” (.24)
Intercept .88 –.38 .10 –.27 1.35 1.37 –.09 –.27 –.23
(.16) (.94) (.91) (.17) (.99) (.98) (.16) (.96) (.95)
R2 .04 .15 .24 .002 .14 .16 .03 .18 .20
Adjusted R2 .02 .09 .17 –.01 .07 .09 .02 .12 .14
Notes: Coefficients are unstandardized; standard errors are in
parentheses. † p < .10; * p < .05; ** p < .01; *** p < .001
(two-tailed tests).
}

Reflected appraisal evaluation. Model 3 in
Table 3 and Figure 5 show that diagnosis moder-
ates the relationship between the evaluation of “a
mentally ill person” and reflected appraisal self-
evaluation. Among adjustment and affective
patients, the relationship is positive (b = .44, se =
Figure 1. Self-evaluation by Evaluation of “A Mentally Ill
Person”
Figure 2. Self-evaluation by Potency of “A Mentally Ill Person”
.11, p < .001), results congruent with the stigma
sentiment hypotheses. Among schizophrenic
patients, however, the association is negative and
not significant (b = –.33, se = .28, p = .240).
Reflected appraisal potency. Model 6 and
Figure 6 show that diagnosis moderates the
relationship between the potency of “a men-
tally ill person” and reflected appraisal poten-
Figure 3. Self-potency by Evaluation of “A Mentally Ill Person”
Figure 4. Self-activity by Potency of “A Mentally Ill Person”

cy. Specifically, the association between the
potency of “a mentally ill person” and reflect-
ed appraisal potency remains nonsignificant
for affective and adjustment patients (b = .08,
se = .10, p = .395) but is negative and signifi-
cant for schizophrenic patients (b = –.67, se =
.24, p = .006). Model 6 also shows a cross-
dimensional effect applicable to all patients:
the activity of “a mentally ill person” is posi-
tively related to reflected appraisal potency at
a marginally significant level (b = .20, se =
.10, p = .063).
Reflected appraisal activity. Model 8 shows
that the activity of “a mentally ill person” is
positively related to reflected appraisal activi-
ty at a marginally significant level (b = .21, se
= .11, p = .056), results consistent with the
stigma sentiment hypotheses. This relation-
ship does not differ by diagnosis.
DISCUSSION AND CONCLUSION
According to the modified labeling theory of
mental illness (Link 1987; Link et al. 1989), the
negative effects of psychiatric labeling are rooted
in the meanings associated with the cultural cate-
gory “a mentally ill person.” When an individual
is diagnosed with a mental illness, two social psy-
chological processes are expected to occur. First,
the cultural conceptions of the mentally ill (e.g.,
incompetent, dangerous) become self-relevant
and are transformed into negative self-feelings.

Second, the self-relevant cultural meanings gener-
ate expectations of rejection, which then trigger
defensive behaviors (concealing, educating, and
withdrawing) aimed at warding off rejection.
These coping behaviors often backfire, however,
Table 3. OLS Regressions of Psychiatric Patients’ Evaluation,
Potency, and Activity Ratings of “Myself As Others See
Me” on Controls and Stigma Sentiments (N = 142)
Myself As Others See Me
Independent Variables Evaluation Potency Activity
Models .1 .2 .3 .4 .5 .6 .7 .8
Adjustment disorder –.31 –.30 –.29 .04 .33 .43 –.17 –.07
(.37)
Schizophrenic disorder .57 1.27** .86† –.71† –.88† –1.50** –
.23 –.12
(.47)
Global assessment of functioning .003 .005 –.01 –.01 –.004
(.01) (.01) (.01) (.01) (.01)
Female .31 .22 –.57† –.50† .32
(.30) (.30) (.30) (.29) (.31)
Age –.01 –.01 .01 .01 –.03†
(.01) (.01) (.01) (.01) (.01)
Black (0 = white) –.31 –.33 –.03 .15 –.42
(.34) (.33) (.34) (.33) (.35)
Years of schooling .21** .22** .04 .05 .14*

(.07) (.07) (.07) (.06) (.07)
Evaluation .34** .44*** .09 .09 –.08
(.11) (.11) (.11) (.10) (.11)
A mentally ill person Potency .16 .16† –.01 .08 –.09
(.10) (.10) (.10) (.10) (.10)
Activity –.09 –.09 .14 .20† .21†
(.11) (.10) (.11) (.10) (.11)
Schizophrenic disorder � –.77*
—evaluation of “a mentally ill person” (.30)
Schizophrenic disorder � –.76**
—potency “a mentally ill person” (.25)
Intercept .72 –1.77 –1.79 .30 .62 .55 .17 –.62
(.17) (1.01) (.99) (.17) (1.01) (.98) (.17) (1.03)
R2 .02 .18 .22 .02 .11 .16 .003 .11
Adjusted R2 .01 .12 .16 .01 .04 .09 –.01 .04
Note: Coefficients are unstandardized; standard errors are in
parentheses; † p < .10; * p < .05; ** p < .01; *** p < .001
(two-tailed tests).
}
and fail to improve the well-being of psychiatric
patients (Link et al. 1989, 1991). Thus, according
to the modified labeling theory, psychiatric label-

ing damages patients by fostering negative self-
feelings and by prompting patients to behave in
counter-productive ways.
Figure 5. Reflected Appraisal Evaluation by Evaluation of “A
Mentally Ill Person”
Figure 6. Reflected Appraisal Potency by Potency of “A
Mentally Ill Person”
We examined the first of these processes
by examining the association between the cul-
tural conceptions of the mentally ill and
patients’ self-feelings. But, unlike other inves-
tigations, we explored the way that diagnostic
category shapes the process. We found that
both stigma sentiments (the evaluation, poten-
cy, and activity associated with the cultural
category “a mentally ill person”) and diagnos-
tic category (adjustment, affective, and schiz-
ophrenic) are related to the evaluation, poten-
cy, and activity of psychiatric patients’ self-
identities (“myself as I really am”) and reflect-
ed appraisals (“myself as other see me”).
Among affective patients, five of the six asso-
ciations between the EPA of “a mentally ill
person” and the corresponding dimension of
self-meanings were positive and hence consis-
tent with our (Kroska and Harkness 2006)
stigma sentiment hypotheses. Among adjust-
ment and schizophrenic patients, however, we

found more negative and cross-dimensional
relationships, results inconsistent with (the
negative associations) or not anticipated by
(the cross-dimensional associations) the stig-
ma sentiment hypotheses. We examined these
associations while controlling for symptom
severity and the demographic characteristics
of gender, age, race, and education. The con-
trol for symptom severity is important,
because it suggests that diagnostic category is
not simply a proxy for symptom severity.
Results Overview
We found that diagnostic category moder-
ates the relationship between stigma senti-
ments and six self-meanings. Table 4 sum-
maries the results by listing the direction of all
the stigma sentiment to self-meaning relation-
ships that are at least marginally significant.
An empty cell indicates a nonsignificant asso-
ciation. Each row shows the relationships
between the evaluation, potency, and activity
of “a mentally ill person” and each self-mean-
ing within a diagnostic category. Each column
shows the relationships for each self-meaning
across diagnoses. Positive signs in the left-
diagonal are positive, within-dimension (e.g.,
evaluation-evaluation) associations and are
consistent with the stigma sentiment hypothe-
ses. Because high values on the EPA of “a
mentally ill person” indicate low stigma senti-
ments, a positive sign in this table indicates a
negative relationship between stigma senti-
ments and self-meaning, while a negative sign

indicates a positive relationship.
Three of the six within-dimension rela-
tionships–those between a stigma sentiment
and its corresponding self-meaning–apply in
the same way to patients in all three diagnos-
tic groups (adjustment, affective, and schizo-
phrenic). Among all patients, (1) the potency
of “a mentally ill person” is positively related
to self-potency at a marginally significant
level; (2) the activity of “a mentally ill person”
is positively related to self-activity; and (3) the
activity of “a mentally ill person” is positively
related to reflected appraisal activity at a mar-
ginally significant level. Thus, diagnostic cat-
egory does not moderate these three within-
dimension associations. Instead, the stigma
sentiment hypotheses pertaining to self-poten-
cy, self-activity, and reflected appraisal activi-
ty apply to patients in all three diagnostic
groups.
In addition, we found one cross-dimen-
sional result that applies to all patients, albeit
at a marginally significant level: the activity of
“a mentally ill person” is positively associated
with reflected appraisal potency. This associa-
tion may be related to the association between
patient activity and observers’ perceptions of
danger. Riskind and Wahl (1992) showed that
observers perceive mentally ill individuals
who are highly active as more dangerous than
nonpatients engaged in the same highly active
behaviors. Given the association between dan-
ger and power, the relationship between the
activity of “a mentally ill person” and reflect-

ed appraisal power may reflect patients’
understanding of this perception.
Yet, diagnosis does moderate six relation-
ships. Three of the interactions are within-
dimensions: diagnosis moderates the relation-
ships between evaluation of “a mentally ill
person” and self-evaluation (Figure 1),
son” and reflected appraisal evaluation
(Figure 5), and between the potency of “a
mentally ill person” and reflected appraisal
potency (Figure 6). And three are cross-
dimensional: diagnosis moderates the associa-
tions between the potency of “a mentally ill
person” and self-evaluation (Figure 2),
son” and self-potency (Figure 3), and between
the potency of “a mentally ill person” and self-
activity (Figure 4). In the next three sections
we discuss the distinctive results for each
diagnostic group, highlighting the implica-
tions of the findings for the stigma sentiment
hypotheses derived from the modified label-
ing theory.
Diagnostic-specific Patterns
Affective diagnosis. Among affective patients,
five of the six within-dimension relationships
are positive and significant or marginally sig-

nificant. Thus, most of the cultural concep-
tions of the mentally ill, particularly the good-
ness and activity components, are self-rele-
vant to affective patients in the way expected
by the stigma sentiment hypotheses. Thus,
these hypotheses offer reasonable explana-
tions of some of the self and stigma processes
among individuals diagnosed with an affective
disorder.
Yet, we also found two distinctive cross-
dimensional results among affective patients.
First, the potency that patients see in “a men-
tally ill person” is positively related to self-
evaluation, indicating that patients who see the
mentally ill as especially powerful have partic-
ularly high self-esteem. This effect, also found
among schizophrenic patients, is relatively
large and significant. It may, therefore, be
appropriate to expand the stigma sentiment
hypotheses to include this cross-dimensional
effect, at least for patients with affective and
schizophrenic disorders.
Second, the potency of “a mentally ill
person” is negatively related to self-activity.
This second cross-dimensional effect, shared
with adjustment patients, is not clearly com-
patible with the stigma sentiments hypotheses,
at least not if high activity is considered a
desirable trait for all psychiatric patients.
However, as we observe (Kroska and
Harkness 2006), activity has multifaceted and
complex meanings among psychiatric
patients. For example, low activity may be a

healthy feeling for some patients, particularly
those whose mental illness induces feelings of
mania (e.g., bipolar disorder), suggesting that
the potency patients associate with “a mental-
ly ill person” may be linked with low (rather
than high) feelings of activity. This finding
Table 4. Summary of Relationships between the Evaluation,
Potency, and Activity of “A Mentally Ill Person” and Self-
meanings Reported in the Final Models of Tables 2 and 3
Affective Patients:
Myself As I Really Am Myself As Others See Me
Evaluation Potency Activity Evaluation Potency Activity
A mentally ill person Evaluation + +
Potency + + –
Activity + + +
Adjustment Patients:
A mentally ill person Evaluation – +
Potency + –
Activity + + +
Schizophrenic Patients:

A mentally ill person Evaluation – +
Potency + + –
Activity + + +
Notes: + indicates a positive relationship with at least p < .10; –
indicates a negative relationship with at least p < .10.
suggests more work may be needed to refine
the meaning of high and low levels of self-
activity within each diagnostic category.
Adjustment diagnosis. The results for adjust-
ment patients are the same as the results for
affective patients with two exceptions: the
evaluation of “a mentally ill person” is nega-
tively (not positively) related to self-evalua-
tion at a marginally significant level, and the
potency of “a mentally ill person” is unrelated
to self-evaluation. Thus, the stigma sentiments
hypotheses are somewhat less effective at pre-
dicting stigma and self-processes among
adjustment patients. The cultural conceptions
associated with the mentally ill may have less
influence on the way adjustment patients see
themselves, because adjustment disorders,
unlike most affective and schizophrenic disor-
ders, are often temporary. Future work could
explore the effect of disorder chronicity on
these processes.
Schizophrenic diagnosis. Four of the five

associations between stigma sentiments and
schizophrenic self-identity (“myself as I really
am”) meanings are positive, and two of these
four are cross-dimensional effects involving
evaluation and potency. These patterns under-
score the value of incorporating positive
potency-to-evaluation and evaluation-to-
potency effects into the stigma sentiment
hypotheses. Hence, among schizophrenic
patients, the stigma sentiment hypotheses
offer reasonable predictions regarding stigma
and self-identity processes if these hypotheses
are expanded to include positive cross-dimen-
sional relationships between potency and eval-
uation.
However, the relationships between stig-
ma sentiments and schizophrenic patients’
reflected appraisals are less consistent with
the stigma sentiment hypotheses and most dis-
tinct from the other two groups. Unlike the
other patients, schizophrenic patients’ evalua-
tion of “a mentally ill person” is unrelated to
reflected appraisal evaluation, and unlike the
other patients, the potency they see in “a men-
tally ill person” is negatively related to their
reflected appraisal potency, an effect that is
relatively large and significant. Thus, schizo-
phrenic patients’ evaluation of the mentally ill
is irrelevant to their understanding of others’
evaluation of them. And schizophrenic
patients’ view of the potency of the mentally
ill is negatively related to the power they feel
others see in them. The stigma sentiment
hypotheses, then, provide little guidance for

understanding the role of stigma in schizo-
phrenic patients’ sense of how others see
them.
Future Investigations of Diagnosis
as a Moderator
Researchers should explore the origin of
the differential relationship between stigma
sentiments and self-meaning found for each
type of psychiatric patient: adjustment, affec-
tive, and schizophrenic. We found these differ-
ential relationships when controlling for symp-
tom severity (the global assessment of func-
tioning). Thus, although future studies with
additional controls for symptom severity are
important, our results suggest that the modera-
tor role of diagnosis is not simply a function of
the severity of patients’ symptoms. Instead,
something other than symptom severity within
each diagnostic category affects the way that
stigma sentiments shape self-meanings.
We see two features of the diagnostic cat-
egory that may create these varied relation-
ships. First, the contrasting effects of stigma
sentiments on self-meaning may be due to the
unique symptoms of each type of disorder. For
example, the disordered thinking and delu-
sions that can accompany schizophrenia
(Goodwin and Guze 1996) may distort schiz-
ophrenics’ perceptions of how others see
them. And the alexithymia that can accompa-
ny schizophrenia (Maggini and Raballo 2004;
van ’t Wout et al. 2007) may inhibit these
patients’ ability to recognize and/or describe

their own self-feelings in the same way as
adjustment and affective patients. Therefore,
the cultural conceptions of the mentally ill
may only become personally relevant to schiz-
ophrenics in the expected way after extended
treatment when some of schizophrenic
patients’ distinctive symptoms are reduced.
Hence, it will be valuable in future research to
assess the relationship between stigma senti-
ments and self-meanings both before and after
psychiatric treatment. Second, the contrasting
effects of stigma sentiments on self-meaning
may be due to uncontrolled variation in the
cultural conceptions associated with each dis-
order. Each diagnosis may carry its own cul-
tural meanings that were not captured with the
broad category of “a mentally ill person.”
Future work could explore the association
between diagnosis-specific sentiments (e.g.,
the EPA of “a person with schizophrenia”) and
self-meanings.
More generally, this study suggests the
importance of examining the way that diagno-
sis moderates the effects of stigma on mental
patients. Future investigations should continue
to explore these moderated effects using at
least a three-category operationalization of
diagnosis. Our study included a small sample,
especially among schizophrenic patients (N =
17), so future studies using larger samples of

each diagnostic group will be especially
important. Future studies could also explore
these processes among patients with axis II
diagnoses (i.e., personality disorders, such as
antisocial personality disorder or avoidant per-
sonality disorder) as well as the axis I disor-
ders examined in this study.
Future Investigations of Labeling Processes
We also see fruitful avenues for future
research on the effects of stigma sentiments on
labeling processes. As noted previously, the use
of stigma sentiments to operationalize the cul-
tural conceptions of the mentally ill offers sev-
eral advantages: EPA profiles are an estab-
lished and parsimonious technique for measur-
ing cultural meanings; EPA dimensions can be
used to measure cultural conceptions cross-cul-
turally; EPA measures are unlikely to contain
historically, culturally, or researcher specific
features; and the three-dimensional representa-
tion provides a multifaceted representation of
stigma that can help distinguish among differ-
ent types of stigma. Further, our previous work
(Kroska and Harkness 2006) provides evidence
of the validity of using stigma sentiments as a
measure of stigma beliefs by showing that
scores on the stigma beliefs index (Link 1987;
Link et al. 1997) are correlated with two stigma
sentiments: evaluation and potency. A key
premise of affect control theory is that all social
cognitions evoke affective associations
(MacKinnon 1994). Our validation assessment
suggests that cognitions on the stigma beliefs

index evoke the affective meanings associated
with “a mentally ill person,” that is, stigma sen-
timents.
Future studies could use stigma sentiments
and self-meanings to explore the modified
labeling theory hypothesis that stigma beliefs
increase the use of three stigma coping behav-
iors: concealing psychiatric treatment history,
educating others about mental illness, and
withdrawing from social interaction. This
exploration could be done using Interact, a
computer program that simulates social interac-
tion using the principles of affect control theo-
ry (Heise 1979, 2007). Researchers could run
Interact simulations with actors represented by
the self-EPAs of patients with high- and low-
stigma sentiments to determine if patients with
high stigma sentiments (low EPA ratings of “a
mentally ill person”) are more likely to than
patients with low stigma sentiments (high EPA
ratings of “a mentally ill person”) to engage in
these coping behaviors. Given the varied rela-
tionships between stigma sentiments and self-
meaning within each diagnostic category, these
analyses could be further elaborated by using
diagnosis-specific self-meanings within the
high- and low-stigma sentiment categories.
Futures studies could also explore the way
that nonpatients’ stigma sentiments affect
their behavior toward mental patients. While
the cognitions that are part of the stigma
beliefs index may evoke stigma sentiments, as
we noted above, stigma sentiments may, in
turn, evoke interaction patterns consistent

with the behavioral items in the index. That is,
stigma sentiments may, in essence, “store” or
“code” the behaviors measured in that index.
Researchers could explore this idea using
Interact as well. Specif ically, researchers
could examine if nonpatients with high stigma
sentiments interact with psychiatric patients in
ways that more closely match those behaviors
(e.g., not befriending, trusting, or hiring psy-
chiatric patients) than do nonpatients with low
stigma sentiments. Such examinations would
Amy Kroska is an associate professor in the sociology
department at Kent State University. Her
research interests include social psychology, mental health,
family, and gender. Her current research
examines the effect of stigma sentiments on psychiatric
patients’ behavior, the effect of stigma senti-
ments on juvenile delinquents’ self-meanings, and the factors
that shape individuals’ gender ideology.
She is moving to the University of Oklahoma in August of 2008.
Sarah K. Harkness is a PhD Candidate in the sociology
department at Stanford University. In addi-
tion to stigma sentiments, she is currently studying status
processes and forms of exchange, with a
focus on status construction and reward expectations.
further reveal the nature of the connection
between the affective stigma sentiments and
the cognitive stigma beliefs. The research
would also show if nonpatients’ stigma senti-

ments predict the devaluation and discrimina-
tory behaviors that psychiatric patients fear.
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———. 2007. Expressive Order: Confirming
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1
Labelling Theory
(Societal Reaction Theory)
John Hamlin
Department of Sociology and Anthropology
UMD
One of the most promising approaches to develop in deviance
has been the labelling
approach. Coming into prominence in the 1960s it produced a
great deal or research and
inspired an incredible amount of debate. It has lost in recent
years much of its early luster
but so much of what it has given to theoretical criminology
remains as truisms.
Becker’s statement provides the nucleus of what has come to be
tagged the labelling or
societal reaction perspective. I will first give an overview of
the labelling approach. Second, I
will look at the notion of career deviance, and finally ;I will

look at some of the evidence,
which empirically attempts to test this theory.
The intellectual heritage of labelling is directly traceable to the
symbolic interactionist
school of thought as expressed by W. I. Thomas, G.H. Mead,
Dewey, etc. The more
immediate intellectual antecedents who, at least in part,
formulated an approach based on
labelling were Frank Tannenbaum’s use of tagging in his
analysis of Juvenile Delinquency in
1938 (same year as Merton’s Anomie Theory comes to light).
Juveniles held one conception
of their behavior and the community held another. The
community brought social control
measures to bear on the youngsters as the idea of wrong shifted
from the act to the actor.
The young person may come to see him/herself as delinquent.
The young person begins to
act even more delinquent and the community reacts reinforcing
that identity even more.
Second, Lindesmith’s study of opiate use demonstrated how
persons became aware of their
addiction. In essence it is not the drug that makes the person an
addict, rather addiction is a

social definition. When a significant other (another user) labels
him/herself as an addict, the
person comes to define him/herself as an addict.
2
The labelling perspective had a large number of followers in
the 1960s and early
1970s. Some of the more notable members who came to define
and outline most of the
major tenants of this approach were Edwin M. Lemert, Howard
S. Becker, Kai Erikson, and
John Kitsuse.
Labelling theory as those scholars elaborated it was sociology
of the underdog. As
Becker expressed it in his presidential address to the Society for
the Study of Social Problems,
we have to proclaim whose side we are on. The persons who
are considered deviant are
actually victims ‘more sinned against than sinning.’ Persons
are not inherently deviant nor is
deviance inherent in any particular behavior as noted by Erikson
in his “notes on deviance”

and again the introduction to Wayward Puritans, stressing the
point that the social audience
confers the label deviance on behavior. This social audience
could be the community in
general or particular agents of social control, e.g. the police (or
teachers). In other words
behavior is not inherently deviant or normal but is defined and
labeled that way by people in
charge of defining and labelling. The key component of the
process is the social audience,
regardless of how social audience comes to be defined.
There are two aspects of becoming deviant we can see in
Erikson and which are clearly
stated by Becker. The social group creates deviance. The
group makes the rule and then
applies it to the person labelling that person and ‘outsider.’
Even though there is a
connection between norm violation and being labeled deviant, it
need not be a direct one.
For example, in order for someone to be labeled a shoplifter
there must be a norm
prohibiting shoplifting. If private property did not exist,
shoplifting would not exist and
neither could the deviant label of shoplifter. Just because a

norm does exist does not mean
everybody labeled shoplifter has actually violated the norm.
There is a basic difference
between rule breakers/rule breaking behavior and deviants/
deviant behavior. The term
deviant is reserved for those who have had the label
successfully applied to him and deviant
3
behavior is that behavior so labeled regardless of whether or not
any norms had actually been
violated. An example of this might be people who have been
placed in mental institutions
and labeled mentally ill when they were really only hard of
hearing, a case of the ’bum rap.’
(Becker by 1970 scraps the use of the terminology rule-
breaking, instead relying on the term
commission.)
If the social rules are made in an interaction process as Lemert
maintains, it is one of
unequal interaction. Becker clearly states that in order for ones
views to be enforced they
must have economic or political power. There is not one

particular power elite forcing their
will on others. There are many imperatively coordinated
associations. In looking at the
Marihuana Tax Act of 1937, Becker analyzes how political
power works. The Bureau of
narcotics, then part of the Treasury Department saw marihuana
as coming under their
jurisdiction and by working with others who saw it in their
interests to have laws regulating
the weed, e.g. legitimate hemp growers, marihuana use as a
deviant label, was created. The
powerful as Becker talks about them are moral entrepreneurs.
These guardians of moral
order are found in two types, those who create or destroy laws
and those who apply the laws.
The two groups may not have the same outlook on the rules.
One may be dedicated to the
morality of the rules while the other, e.g. a police person, may
be more concerned with
having a job.
The effects of being labeled are numerous but of primary
concern for many theorists in
this tradition, for example Lemert, are the effect being labeled
has on the sense of self or

identity. Primary deviance happens for a number of reasons and
has very little effect on self.
Secondary deviance comes about as a response to societal
reaction to primary deviance. The
self-concept is change from normal to deviant. The person
takes on a new identity or
acquires a stigma, in Goffman’s terms; the person becomes a
shoplifter first and foremost
even in his or her own mind.
4
This portrayal of labelling is essentially the theoretical
implications of the second part
of Becker’s quote. The brief discussion of primary and
secondary deviance provides an
entrance point for stating the implications of the first part of
Becker’s quote. For here he
begins to carry the implications of secondary deviance to the
next logical step, that is, career
deviance. Becker is not concerned with primary deviance. He
like Lemert sees primary
deviance occurring for many reasons. It is much more
important to look at career deviance.

Becker’s own study of marihuana users is an example of this
process. One of the most
important steps of becoming deviant is being publicly labeled as
deviant. For being such a
key component of labelling theory it is also one of the hardest
to pin down. A person does
not really have to be publicly labeled but may label him/herself.
The labelling process
becomes hard to disprove as the process moves from public to
self-application. It is even
harder to disprove as the conception of subconscious desire (in
terms of being caught and
labeled) is added in. In any case being caught ad labeled
deviant leads to a change in
identity. The deviant acquires a new master status such as
homosexual (perhaps touching
someone’s foot with your own). The master status carries with
it a number of secondary
statuses, which seem to always be associated with it. It creates
problems for people when
the status doesn’t match up. For example, when the homosexual
turns out to be a big,
strong husky voiced football player, or a long time husband or
wife. The problem is that

master status characterizes one’s life rather completely rather
than merely being part of
one’s identity. The process of a self-fulfilling prophecy begins
as it becomes harder and
harder for the person to act contrary to or associate with, other
people than the social
reaction expects. The last step in the making of a career deviant
comes about when the
deviants are organized into a group. A deviant subculture is
produced. Once the person
becomes a member his/her deviant identity becomes solidified,
one prime example is
becoming being part of a juvenile gang.
5
Although it often seems as if there is never enough empirical
testing of theories, there
has actually been quite a bit done on labelling theory in
comparison to many others. Some of
the empirical findings are supportive while others are not.
Labelling theory states that there are a multitude of factors that
affect who gets labeled

and treated as deviant. There appears to be a great deal of
support for this contention. It
ranges from characteristics of the actor, see Pivliavin and briar,
“Police encounters with
Juveniles” to characteristics of the audience, Defleur’s work on
biasing influences on the
records of those arrested for drugs, to characteristics of the
victim, see Cohen ,Deviance and
Control.
The importance of the label for career deviance can be seen in
the work of Goffman
when he looks at how stigmas like ‘crippled’ or ‘blind’ effects
social behavior. Much of the
research done has been in terms of criminal labels. Schwartz
and Skolnick in two studies of
legal stigmas found that being legally accused will most likely
affect a persons chances of
finding employment, result in a loss of social status, and
consequently bring on further
contact with law enforcement personnel. Similarly Chiricos,
Jackson, and Waldo, found that
persons with previous criminal records are treated differently
supplying more of an
opportunity for those persons to transform their identities and

become career deviants. So
there does seem to be support in the contention that being
labeled does lead to career
deviance at least in terms of criminal labels.
However there are those studies that bring into question the
idea that the label is a key
aspect of becoming a career deviant. Oddly enough, work done
by two major proponents of
labelling, Lemert and Becker (although it appears that Lemert
has given up on this approach)
raise doubts about this labelling contention. Lemerts study of
check forgers show that often
they take part in systematic and habitual behavior long before
they are caught and labeled as
deviant or criminal. In other words, their career was
established before the labelling process
6
took place. Becker’s example of marihuana users seems to
indicate that it is not the creation
of a new identity, which results in career smoking. Rather in
the process of finding pleasure
in smoking, as Mankoff points out, one becomes a career

deviant. There are other studies,
which indicate that labelling has little effect. Robins, Deviant
Children Grow Up, shows that
the impact of being labeled mentally ill or having some sort of
psychiatric diagnoses when
young had very little connection (16%) with being labeled after
becoming an adult. Cameron
points out how being caught shoplifting and labeled a thief
resulted in people easing that
behavior rather then the labeled person becoming a career
deviant.
Evidence does not conclusively support labelling theories
contentions. It appears as if
the effect of a label on self identity applies more to specific
situations in the labelling
process, all else is still highly questionable.
Becker, Howard S. Outsiders: Studies in the Sociology of
Deviance. New York: Free Press,
1963.
——————, ed. The Other Side: Perspectives on Deviance.
New York: The Free Press, 1964.
Braithwaite, John. Crime, Shame, and Reintegration.
Cambridge, MA: Cambridge University
Press, 1989.

Erickson, Kai T. "Notes on the Sociology of Deviance." [1962].
In The Other Side: Perspectives
on Deviance, edited by Howard S. Becker. New York: The Free
Press, 1964.
Goffman, Erving. Asylums: Essays on the Social Situation of
Mental Patients and Other
Inmates. New York: Anchor Books, 1961.
——————. The Presentation of Self in Everyday Life. New
York: Anchor Books, 1961.
——————. Stigma: Notes on the Management of Spoiled
Identity. New York: Simon and
Schuster, 1963.
Kitsuse, John I. "Societal Reaction to Deviant Behavior:
Problems of Theory and Method."
[1960]. In The Other Side: Perspectives on Deviance, edited by
Howard S. Becker. New York:
The Free Press, 1964.
Lemert, Edwin M. "Beyond Mead: The Societal Reaction to
Deviance." Social Problems 21 (April
1974): 457-68.
7
——————. Human Deviance, Social Problems and Social
Control. Second Edition. Prentice
Hall, 1972.

——————. Social Pathology. New York: McGraw-Hill,
1951.
Liazos, Alexander. "The Poverty of the Sociology of Deviance:
Nuts, Sluts, and Perverts." Social
Problems 20, Summer (1972): 103-20.
Manders, Dean. "Labelling Theory and Social Reality: A
Marxist Critique." Insurgent Sociologist
6 no. 1 (1975): 53-66.
Mead, George Herbert. Mind, Self and Society: From the
Standpoint of a Social Behaviorist,
edited by Charles W. Morris. Chicago: University of Chicago
Press, 1934.
Petrunik, Michael. "The Rise and Fall of ‘Labelling Theory’:
The Construction and Destruction
of a Sociological Strawman." Canadian Journal of Sociology 5
no. 3 (1980): 213-33.
Tannenbaum, Frank. Crime and the Community. Boston: Ginn
and Co., 1938.
Substance Use & Misuse, 43:1704–1728
Copyright © 2008 Informa Healthcare USA, Inc.
ISSN: 1082-6084 (print); 1532-2491 (online)
DOI: 10.1080/10826080802285489
Views and Models About Addiction: Differences
Between Treatments for Alcohol-Dependent People
and for Illicit Drug Consumers in Italy

ALLAMAN ALLAMANI
Centro Alcologico, Gruppo Prevenzione e Ricerca, Florence
Health Agency,
Florence, Italy
Treatment of people who are alcohol-dependent and treatment
of users of illicit drugs
differ remarkably in Italy, in keeping with the perception of the
general public that
drinking alcoholic beverages is a time-honored behavior, while
consumption of illicit
drugs is a deviant behavior. From a clinical perspective, the
treatment for alcoholism
essentially stands on the principle of free choice, motivation to
change, and a family
approach, while the treatment of people who are illicit drug
users is characterized by
control, pharmacotherapy, and individual therapy approaches.
From a socio-political
viewpoint both were established in the 1970s, the former being
a “bottom-up” movement
that started as “spontaneous” responses that mutual help groups
and a few clinicians
and institutions gave to alcoholics and their families; while the
latter was provided “top-
down” as a political response of the Government confronting
the increase of illegal drug
consumption among youngsters.
Keywords addiction; alcohol addiction programs; illegal drug
addiction units; cultural
viewpoints; mutual help groups
“A te convien tenere altro viaggio”

Rispose poi che lagrimar mi vide
Se vuoi campar d’esto luogo selvaggio.
. . . Ond’io per lo tuo me’ penso e discerno
Che tu mi segui, ed io sarò tua guida
E trarrotti di qui per loco eterno
Ove udirai le disperate strida. . . ”
(Dante Divina Commedia, Inferno, I, 91–93;112–115)
“Thee it behoves to take another road,”
Responded he, when he beheld me weeping,
“If from this savage place thou wouldst escape.
Thanks to editors, Alexandra Laudet and Shlomo Einstein for
their patience and competence
in reading the manuscript and suggesting many appropriate
changes. This article is therefore luckily
affected by a challenging dialogue with the editors, while its
weakness is entirely due to the author.
Also, thanks to Donald Bathgate for his support in the English
translation, and to Ivana Pili for her
help in plotting the figures.
Address correspondence to Dr. Allaman Allamani, Centro
Alcologico, Gruppo Prevenzione e
Ricerca, Agenzia Sanitaria Locale, Villa Basilewsky, Firenze,
Italy. E-mail: [email protected]
1704
Views and Models About Addiction 1705
..Therefore I think and judge it for thy best
Thou follow me, and I will be thy guide,
And lead thee hence through the eternal place,
Where thou shalt hear the desperate lamentations”

(Dante’s Comedy with the Henry W. Longfellow trans.
DIGITALDANTE Institute for Learning Technologies
[email protected]
Copyright 1992—97
Last Modified November, 1997)
Viewpoints on Addiction
The aim of this paper is to describe the striking differences
between the treatment of
people who are alcohol-dependent and the treatment of illicit
drug users in Italy. In the last
analysis such differences, we posit, draw on the different
meanings that alcoholic beverage
consumption and illegal drug use have among the general public
and, more specifically,
on the values that alcoholic beverages—namely wine—
traditionally maintain among the
Italian population and among politicians and health
professionals as well. Also, in Southern
Europe, alcohol beverages are mainly drunk daily or nearly
daily at meals by the majority of
population, and are generally endowed with the aspects of taste,
pleasure, and conviviality.
Intoxication, or loosening of tensions, as it is typical in
Northern Europe or in United States,
is not generally sought by Italian drinkers. On the other hand
consumption of illicit drugs
is clearly considered to be a deviant behavior, as it is the case
all over the western world.
This paper discusses the different viewpoints existing in Italy
regarding addictions and
their treatment, how Italians and particularly clients and
caregivers perceive the problems

related to alcohol beverage, and drug consumption, and how
programs have been created
to respond to them and their various needs.
This section introduces the idea that there is no single
perspective with which one can
adequately understand the addiction phenomena; one needs to
consider several relevant
viewpoints including the clinical, the psycho-social, the moral,
the socio-political, and the
spiritual.
Indeed our conceptualization or view of reality, and of problems
of behavior, in partic-
ular, can be broadened by resorting to models of interpretation
that may reflect the different
aspects of human beings. These views are based on values with
different cultures—specific
to countries, communities, sectors, and professions, over time—
attribute to activities or
objects and, in the case of substances used, to the substances
themselves and the behaviors
by means of which people interact with them.
The Moral Viewpoint
There are certain circumstances in which these views are
obviously “graded”—a substance
which is acceptable in certain quantities becomes unacceptable
in higher quantities, such
as food, alcoholic beverages, and medicinal products. In other
circumstances, by contrast,
usage is not acceptable in any quantity, shape, or form such as,
for example, illicit drugs.
There are also considerations such as frequency of use, context
of use, meanings attributed

to the substance as well as its use and users or nonuse and
nonusers (i.e., being a temperate
person). With some minor variations, substance use in the
western world can be variously
perceived as being socially acceptable and good, or indicating
problematic acts, behavior
and even lifestyles, with medical, psychological and deviancy
implications, or immoral ones.
1706 Allamani
The Social Viewpoint
Considering the social aspects (one of the exogenous facets) of
substance use and misuse
with regard to the population as a whole it behooves us to ask:
Why should the social side
concern us when one considers the need for intervention
(treatment, prevention, control,
policies, research, etc.)? It can be, and is, perceived, for
example, as being an improvement
on the more traditional individual endogenously driven,
clinical-oriented approach. Indeed
the one-on-one clinical approach is still prevalent in the western
world especially in the
professional treatment1 of substance addiction, despite its
obvious limitations in dealing
with substance use and abuse2 on the one hand and on the other
its rigidity and repetitiveness
and consequent incapacity to produce or incorporate innovation,
hemmed in as it is between
the conception of biological medicine and psychological
causality.3

As a point of fact, in 1970s research in the systemic, family-
oriented approach in the
United States, successfully diffused in Italy in the 1980s, paved
the way for change of the
typical clinical one-on-one approach (see Kaufman and
Kaufmann 1979; Steinglass, 1987).
This perspective translated the alcoholism of the individual into
the “alcoholic family,”
changing the individual-oriented perception of the medicalized
“alcoholism” problem into
a family and social issue. Indeed, the Al-Anon, or family
members of alcoholics’ groups,
developed in 1952 in the United States, were the first means for
drawing attention to the
problems and symptoms of family members being involved in
and with the problems of the
“tagged” alcoholic individual.
In general, contextualizing addiction behavior implies
considering the parts and roles
which family, environment, and society can and do play in the
actual phenomenon of
addiction. For example, how each of these separately and in
combination are able to exert
some informal control on those modes of behavior and the
critical conditions which are
necessary for such behaviors to operate or not to operate. The
“tagged” substance, per se, is
unable to define the problem, e.g., detoxifying an individual
from heroin does not guarantee
that relapsing into dependence on alcohol, or medications—used
for nonmedical reasons and
purposes—will not occur.4 A reasonable explanation for this is
that whereas a detoxification
process “cleans” systems of the living organisms, abstinence—
however defined—harm

reduction, and quality-of-life based treatment goals and models
are behavioral and life-
style processes and outcomes.
1Treatment can be briefly and usefully defined as a planned,
goal-directed change process,
of adequate quality and appropriateness, which is bounded
(culture, place, time, etc.) and can be
categorized into professional-based, tradition-based, mutual-
help-based (AA, NA, etc.), and self-help
(natural recovery) models. There are no unique models or
techniques used with substance users—of
whatever types—and non-substance users. In the West, with the
relatively new ideology of “harm
reduction” and even the newer quality of life (QOL) treatment-
driven model, there are now a new
set of goals in addition to those derived from/associated with
the older tradition of abstinence-driven
models. Editor’s note.
2The journal’s style utilizes the category substance abuse as a
diagnostic category. Substances
are used or misused; living organisms are and can be abused.
Editor’s note.
3Sir Bradford Hill published the following nine criteria in 1965
to help assist researchers and
clinicians determine whether risk factors were causes of a
particular disease or were outcomes or
merely associated. The nine criteria include: strength of
association, consistency between studies,
temporality, biological gradient, biological plausibility,
coherence, specificity, experimental evidence,
and analogy. and are defined below (Hill, 1965). Editor’s note.
4One or few trials learning, in humans, is quite rare complex,

dynamic, multidimensional,
phase/level-structured, nonlinear processes/phenomenon—which
are also bounded (culture, time,
place, etc.). Thus a “lapse” or “relapse” may be a necessary
dimension for initiating, sustaining, and
integrating a change process. Editor’s note.
According to the system approach, a family is a system of
relationships which is based
upon how interaction is organized among its members. In such a
process, it continuously
determines and implements its own characteristics, dynamics,
and values. Family pathology
kicks in when family interactions become and/or show up to be
rigid. This means that even
when some values are discovered to be inadequate in certain
phases of family development,
they are perceived as, and all too often are experienced as
being, the only possible reality
with no other viable alternatives being deemed possible.
The main conflict of an “alcoholic family” occurs in the marital
arena with the actual
pharmacological as well as the anticipated effects5 of alcohol
consumption allowing emo-
tions to be expressed. Family members often are affected by
“co-dependency,” a relatively
recent “diagnosis”6 which has been characterized by a
pathologized addiction—like over
involvement with and a continuous “caring” about and a
concern for their alcoholic family
member who is a patient. In a paradoxical sense the concerned

family system needs the
person to continue being the family alcoholic, and s/he remains
in the family by playing
out this role; the system remains stable with clear role and
behavior definition. How-
ever, if the identified and “tagged” family member, but also a
so-called “healthy” mem-
ber, accepts help, e.g., by attending a therapeutic group or
program, a positive behavioral
change can be initiated. In this case, one or more family
members can be transformed into
needed therapeutic resources both for the individual “alcoholic”
as well as for the “sick”
system.
Thus, the behavior of the identified alcoholic person and his/her
family members man-
ifests itself either as being dependency-driven or as a reaction
to dependency.
In dependency, the individual complies with and depends on
others. In reaction to
dependency, the individual claims to be “dominant” or
“independent.”
Dependency is experienced as a weakness to reproach and is
likely to be connected to
the feeling of shame. Dominance, both by the individual and of
his/her family member, is
experienced as strength, which, however, is also to be
reproached since it is linked to the
feeling of guilt. Shame (concept, process, and outcome), which
in the United States is often
used interchangeably as guilt, is a powerful experience that has
been considered to contribute
to the development of as well as to the maintenance of

addiction-related problems; according
to a cyclical pattern humiliation and shame, because of loss of
control, are “sedated” by
the use of a substance, and the addiction to the substance
triggers increasing shame with
consequent use of the substance (Wiechelt, 2007), Such
behavior is rooted in the fact that
Western culture has developed a tendency to hide shame, or to
be ashamed of feeling shame
(Wiechelt, 2007). The psychology of shame and its theoretical
development is connected
with the issues of one’s struggle for identity, that is one of the
recurring problems of our age
(Kaufman, 1985). The case of Italy is peculiar since while in the
Italian culture the feeling of
guilt appears particularly underdeveloped, the shame seems a
much more diffused feeling,
5The effects of psychoactive substances in humans have been
categorized as being due to the
“drugs” chemical action (which has to do with a chemically
active substance entering an organism,
getting to a receptor, being metabolized, and then being
excreted) and what has been coded a “drug
experience”, which is the outcome of the interactions between
the human and his expectations, the
active chemical, and where this complex process is taking place.
Humans do and have described “drug
experiences” from nonpharmacological “drugs”. Editor’s note.
6Any diagnosis is a data gathering process designed to help
make needed decisions and is based,
medically, upon at least three bits of information: etiology,
process, and prognosis of that which
is being diagnosed. Whereas a “diagnosis” is part of a
nosological system all nosologies are not

diagnostic. The relatively recent diagnosis “substance use
disorder” can easily be understood by
“labeling theories” given its limitations of evidence-based
etiology, process, and prognosis. Editor’s
note.
1708 Allamani
linked as it is to the condition of not to being perceived as
being part of the social group
(Battacchi and Codispoti, 1992).
It was the family-based perspective that, together with
epidemiological studies in-
dicating a link between the various forms of substance abuse,2
especially the use of il-
legal drugs, alcohol, and food (see, e.g., Krahn, 1991; Schuckitt
et al., 1996), laid the
theoretical foundation for developing the concept of
transmission down through the gen-
erations, especially the intergenerational theory of substance
use (Framo, 1992). Obvi-
ously, this thesis also has to consider recent investigations
about genetic alterations in-
ducing addiction and their capability of being transmitted (see,
e.g., Begleiter and Kissan,
1995).
If we take one step back from the more traditional medical–
pharmacological approach
with its classical concepts and derived processes of diagnosis
and therapy, we can better
appreciate and understand how medications and physicians
have, in fact, been used and

co-opted as a means of keeping a tight rein on behaviors related
to pleasure-seeking
and on posited illness outcomes chronic in nature—which have
been and continue to be
deemed as unchangeable over time.7 In such a “substance use
disorder” illness, relapses
are considered to be predictable manifestations of the
underlying illness which emerge
from time to time. We may reflect on how the different
therapeutic communities in Italy
became a means for a total, purifying re-education against the
problematic behaviors of
“homogenized” and all too often stigmatized individuals who
are atoning for society’s
problems (Picchi and Caffarelli, 1991).
From a more traditional perspective substance
addiction/dependency/habituation have
become a “consensualized” scapegoat of our modern family
and/or globalized society and
are linked to the guilt or shame feelings which are generated
within our culture (Steinglass,
1979).
The Socio-Political Viewpoint
Politics and general awareness of social problems turn our
attention to the task of safeguard-
ing the disadvantaged. The social-political approach may
therefore be used to view and give
a macro-perspective to the world of addiction with its
“narcoscapes,” social networks of
users, and a range of stakeholders and gatekeepers.
However, the socio-political arena may not be “an appropriate
domain for understanding

the substances” (Kleinig and Einstein, 2006). It is much more a
site of “political power and
dominance” where “more or less restrictive ideologies” are
enshrined in legal format and the
fear of the substance consumers “leads to their disempowering,
marginalization, and stereo-
typing” (Kleinig and Einstein, 2006). Reflecting on the
meanings that politics and society
attribute to substance use, misuse, and addiction—when they
place it among the objectives
which they intend tackling—we can again refer to S. Einstein
who, summarizing his views
on the characteristics of “substance use disorder” treatment,
posits that “drug treatment”
and “alcohol treatment” are unethical given that (1) there are no
unique and/or specific
treatment models for substance users and non-substance users;
(2) there are many vested
interests opposed to needed change; (3) scientific veracity has
been turned into slogans;
(4) new and generalizable findings are generally not introduced
into viable intervention
efforts; and (5) substance users, representing a heterogeneous
group of people and patterns
7Readers interested in either of these processes are referred to
Brandt, A. M. and Rozin, P. (1997)
Morality and Health Routledge NYC, particularly to their
concept of secular morality as well as to
the recent literature about “disease mongering” which is easily
found on Google. Editor’s note.

of use, continue to be treated in “specialized” programs which
are distanced from the main-
stream of the treatment of non users—“normed treatment of
normed diseases”—all too
often manifesting imparity in availability and delivery of
needed services (Einstein, 2006).
The Recovery
The recovery may be defined as a “complex interaction of
mental, physical, and spiritual
actions that leads to living a conscious and sane life” (Schaub
and Schaub, 1997). Such con-
cept is influenced by the view of Alcoholic Anonymous (AA)
and implies a process or a path
that may be well described by the verses from Dante’s Divine
Comedy that opens this paper,
which define how to face your problems is not to escape fear—
as Dante appeared to do at the
moment he found himself in the deep forest—but to face it and
get in touch with it, with the
help of a guide, that is the Latin poet Virgil. Actually the whole
Divine Comedy is a metaphor
of the recovery process, as it is shown by a recent book by
Schaub and Schaub (2003).
The term recovery (recupero) is not common among Italian
Public Health Care Ad-
diction professionals who prefer the more neutral word
treatment (trattamento). This is in
keeping with the usual expectation in Italy that patients—the
diagnosed, chronic substance
use disorder—are to be treated for the rest of their lives by
health workers by means, e.g.,
of long-term methadone maintenance, the treatment being
essentially to control clients; or

that, notwithstanding the posited chronicity of their disease,
they will quit “illicit drug use”
completely by following the therapeutic community-based life
style. . . having sufficiently
matured. However, “recupero” is a usual term among Italian AA
members. The issues of
“natural recovery” (see Einstein, 2006) and of spontaneous
remissions (see Klingemann
et al., 2001) point to an as yet unresolved dilemma which
continues to exist. The broad “re-
covery” literature has not adequately considered and integrated
the documented processes
and outcomes of substance use cessation by a broad range of
types of users and patterns
of “drug” consumption without the use and help of tradition-
based, professional-based,
and/or mutual-help based treatment and support. How did they
“exit” from a posited, di-
agnosed, chronic disease and remain “recovered” in a field
which does not use the concept
“in remission?”
The “Risk”
Another aspect of “recovery” meriting consideration is the
perception of “risk” and its mea-
surable expression within and by society-at-large, and its health
workers. Worries about
risks seem to occur cyclically across years or even centuries,
independently from current
scientific information. For example, the report on the disasters
wreaked by alcohol con-
sumption in Italy that Guido Garofolini wrote about in 1887
(Garofolini, 1887) may be
identical to today’s pronouncements by the Ministry of Public
Health in Rome (see Italian

Ministry of Health, 2005). Or, going further back, the
exhortation of the Rule of St. Benedict
of the sixth century A.D. which provided that monks in good
health should not drink more
than a hemina (quarter litre) of wine, predates the preventative
recommendations of the
WHO by 1300 years.
. . . bearing in mind the condition of the weakest, we believe
that a quarter litre
of wine a day is sufficient. (Rule of Saint Benedict, 1985)
. . . Epidemiological data suggest that the risk of alcohol-related
problems grows
significantly when consumption is greater than 20 grams of pure
alcohol a day
(World Health Organisation, 2000)
1710 Allamani
The Spiritual Viewpoint
The spiritual aspect of substance use perceives the so-called
illness of addiction as being
actually a spiritual illness. In more specific terms, it is a
disturbance of the relationship
between body and spirit in which the individual lacks the
capacity to interpret or integrate.
In alcoholism, for example, this means that the individual seeks
the spirit of the grape or
the grain forgetting the Higher Spirit. The program of spiritual-
based therapy stems from
acknowledging the limits or fallacies of professional-based
models of therapy. This program

was established on the advice that the psychiatrist C. G. Jung
gave to an alcoholic patient
of his at the end of a psychotherapy process which was crowned
with failure.
In Bill’s words, Jung stated that “The healing process could not
be activated
by further medical and psychiatric treatment, but there could be
a hope only on
condition that the alcoholic could become the subject of a
spiritual or religious
experience—in short a genuine conversion”. (Alcoholics
Anonymous, 1984,
p. 382)
And according to a letter that Jung wrote as a reply to Bill,
“The only right and
legitimate way to such an experience is that it happens to you in
reality, and it
can only happen to you when you walk on a path which leads
you to higher
understanding. You might be led to that goal by an act of grace
or through a
personal and honest contact with friends, or through a higher
education of the
mind beyond the confines of mere rationalism”. (Alcoholic
Anonymous, 1984,
p. 384)
Perception of Alcoholic Beverages and of Related Problems in
the Italian
Society
Italy, like some other Latin populations, has a certain
sociological specificity compared to
the other European countries, especially north European ones,

in terms of family ties and
family dependency, which are a major accepted fact of Italian
society (see the chapter on the
“Mediterranean Mother” in Bernhard, 1969). Autonomy of the
individual on the other hand
is not such an eagerly sought-after asset as in other cultures.
This is likely to have effects in
a range of “addiction” behavior manifestations, albeit in an
increasingly globalized culture
that tends toward uniformity with the other cultures of the
western world.
The models for understanding substance addiction-dependency
generally and alcohol
misuse in its various categories in particular, have been
developed over time, beginning
with the perception, established at the end of the 1800s, that
alcohol misuse had become a
social issue which on the one hand was linked to the rise of the
urban proletariat and on the
other hand with the development of the temperance movement
from its north European and
north American counterparts, which in Italy was becoming
fairly well known for some time
(Cottino and Morgan, 1985). The onset and evolution of
Fascism in the 1920s and 1930s
stressed a moralistic model, that of the Italian male, strong and
virtuous, and those years
saw the earliest legislation sanctioning drunkenness.
In the 1970s, a well-defined, health-related perception of
alcohol “abuse” emerged
deriving mainly from the birth of specialization in hepatology
and gastroenterology and
the almost contemporary shut-down of the psychiatric hospitals
by the 1978 law tabled by

Franco Basaglia, to which alcoholics had been traditionally
confined up to the previous
decade (Cottino and Morgan, 1985). Whereas hospitalization in
psychiatric wards gave a
connotation of deviancy to the behavior of “the alcoholic,”
hospitalization in a medical
hospital first “normalized” the alcoholic who, here, shared
equal rights with other patients.
However, experience over time has adequately documented that
treating liver cirrhosis did
not mean treating “alcoholism” but only a few selected effects
of it. The need to diversify
treatment in order to tackle the issue of addiction and its
medical manifestations leads to
the present situation where hospital Toxicology Units, middle-
or long-term hospital pro-
grams, Emergency Departments have supervened with their in-
patient treatment programs.
Nevertheless, hospitalization in Italy is now less frequent, out-
patient community services
and community mutual help and volunteer resources being a
more frequent option for
individuals affected by alcohol addiction dependency.
AA drew Italy’s attention to the fact that alcoholism can be and
is conceptualized as
being an existential sickness which can be intervened with
separately from the health system
by group mutual help treatment support which is characterized
by spiritual rebirth. The first
public conference of AA in Italy was held in Palazzo Capponi,

in Florence, in July 1974
when addiction to illicit drugs and their use was beginning to
take root, and the television
film “Silvia è sola [Sylvia is on her own]” was broadcasted
some years later telling the
story of alcoholism of a woman who went on to join AA. This
drew Italy’s attention to
the fact that alcoholism is an existential sickness and can be
tackled by group treatment.
In a time when Italian culture was immersed in the values of
post-Fascism, post-Idealism,
and Marxism, the self-generation and the spirituality-based
model typical of AA took time
to gain ground. However, AA has a higher profile now than it
did 30 years ago, while the
12-step program brought about a turnaround in the approach to
addiction treatment in Italy,
too, as it became applicable to almost every posited
“addiction”: food, drugs, gambling, etc.
In short, alcoholism had been perceived for years as being the
problem of an unfortunate,
fairly easily identifiable few in a country or neighborhood. The
idea of becoming “one of
them” struck one with fear or shame, a moralistic-based
perception which continues to exist,
but less so over time. The fact that more women as compared to
those in the past are attending
alcohol addiction treatment services and groups like AA is a
sign that they, their husbands,
fathers, and sons, and our society as a whole, are less branded
by shame and are seeking
ways forward rather than sticking to the traditional behavior of
denial—covering up and not
seeing. Today, there are even fewer program administrators and
politicians getting waylaid

on this issue. Alcoholism is not perceived as being “the
problem” of a few, but rather is now
considered to somehow be an issue of social relevance for the
Italian community as a whole.
Accessible resources are now available in contemporary Italy to
treat persons mani-
festing problems related to their consumption of alcohol
beverages as well as for those who
are involved with such persons and who seek help and support.
Some cities have developed
needed services including alcohol addiction treatment facilities
as well as mutual help and
volunteer groups.
Today’s inadequacies are also visible. The media often confuses
alcoholism with the
misuse of alcohol by young people or members of the immigrant
community, associating
such use with causing road accidents or acts of violence, as well
as with illegal drug use.
These are surely significant problems, but information of this
kind contributes to lowering
concern about alcohol addiction, its consequences to and
implications for individuals and
systems by associating alcohol addiction and misuse to a certain
age-group or culture;
perceiving it as being something “separate from us” in the same
way as we talk about “drugs.”
Epidemiological research, instead, tells us that alcoholism is not
infrequent. Even if
reliable information about the number of individuals who are
affected by alcoholism in
Italy does not exist, according to the observatory on smoking,
alcohol, and drugs of the

Italian High Institute on Health, they are estimated to be
approximately 2% of the general
1712 Allamani
Table 1
Program sources to treat substance consumers and misusers in
Italy.
Professional 12-Step Voluntary Religious
Community Alcoholics Clubs for Therapeutic
programs Anonymous Alcoholics in Communities
Hospital beds Al-Anon Treatment
University beds Narcotics
Anonymous
Overeaters
Anonymous
population of Italians (approaching 60,000,000), namely
approximately 1 million (Scafato,
2005). Some other experts claim that they are 0.5%, and others
up to 5% of the total
population (cf. Voller, 2007). In two national surveys carried
out on the general population
by the Osservatorio Giovani e Alcool in 2000 and 2005,
attempts were made to measure
the dimension of alcohol dependence through the CAGE
questionnaire, and the results may
be considered as being consistent with the above-mentioned
rates. The results of the 2005
survey revealed that the number of people who gave three or
more positive answers to the

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