Labeling Effects in Psychiatric Hospitalization
A Study of Diverging Patterns of Inpatient Self-LabelingProcesses
Edmund G. Doherty, PhD
This report explores two theoretical positions regarding psychiat-
ric inpatient self-labeling processes over time. One position suggests
that acceptance of the deviant label "mentally ill" is benign; the
other suggests that such label acceptance may be harmful to pa-
tients. Employing empirical, longitudinal data from a sample of 43
inpatients, three complex, but discernible, patterns of "acceptance,"
"rejection," or "denial" of the "deviant" label of mental patient
emerged over time within a short-term hospital setting.
The three patient groups varied on Minnesota Multiphasic Person-
ality Inventory scales, staff behavioral ratings over time, involvement
in approved ward activities, and length of hospitalization. Results
were discussed in terms of patient-staff interaction and its possible
relation to patient self-labeling.
recent years, the "societal reaction," or "label¬
In
ing theory" approach to mental illness has generated a
wide variety of reports, both theoretical and empirical,
both pro and con, and varying in methodological quality.
Presented originally in works by Lemert,1 Becker,2
Scheff,3 Goffman" and others, several current reviews of
the multifaceted literature on labeling theory and mental
illness are available.58
Labeling theory has often been juxtaposed to tradi¬
tional, clinical models of mental illness in which "mental
illness is regarded as arising from within the individual."9
By contrast, labeling theory proponents suggest that "so¬
cial groups create deviance by making the rules whose in¬
fraction constitutes deviance, by applying those rules to
particular people and labeling them as outsiders."2 Becker2
suggested also that "deviance is not a quality of the act
the person commits, but rather a consequence of the appli¬
cation by others of rules and sanctions to an 'offender.'
The deviant is one to whom that label has successfully
been applied; deviant behavior is behavior that people so
label."
In labeling theory generally considered, Gove6 has sug¬
gested that labeling theorists have by and large "under-
emphasized the importance of acts of primary deviance"
(those acts that may lead a person to be labeled as
deviant), while overemphasizing the "importance of the
forces promoting secondary deviance" (behavior produced
by being placed in a deviant role).
By contrast, in a more recent review of aspects of the
labeling theory literature, Scheff8<p450) concluded that
based on 18 systematic studies of labeling theory, "13 sup¬
port labeling theory, and five fail to. Although the studies
vary in reliability and precision, the balance of evidence
Accepted for publication Sept 9, 1974.
From the Department of Sociology, Wayne State University, Detroit.
Reprint requests to the Department of Sociology, Wayne State Univer-
sity, Detroit, MI 48202 (Dr.Doherty).
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seems to support labeling theory."
While diverging opinions over the validity and useful¬
ness of the labeling perspective as applied to mental ill¬
ness abounds, it may be well to keep in mind that
Scheff81p448> has described his version of labeling theory as
suggesting "that the patient's condition is only one of a
number of contingencies affecting the societal reaction
and therefore, the patient's fate." Earlier, Scheff3,pp25-27)
has clearly stated that the purpose of labeling theory was
"to develop a model which will complement the individual
system model by providing a complete and explicit con¬
trast. ...
By allowing for explicit consideration of these
antithetical models, the way may be cleared for a syn¬
thesis. ."
. .
Suffice it to say, perhaps simplistically, that one central
tenet of the labeling approach suggests that by virtue of
having acquired a deviant label such as "mental patient,"
that label will become a "master status" that determines
and overrides how others will react to the labeled person.7
The purpose of the present report is to explore an aspect
of the acquisition of a "master status"; ie, the extent to
which a group of labeled persons accept or reject the label
of "mentally ill" over time and some correlates or conse¬
quences of label acceptance or rejection for these in-
patients.
The issue of deviant label acceptance/rejection by pa¬
tients becomes important to the study of mental hospital
patients because it has become generally linked with a va¬
riety of factors that have been considered potentially as
"countertherapeutic" for psychiatric inpatients: "power-
lessness, depersonalization, segregation, mortification."10
But, institutions that aim to produce major changes in hu¬
man behavior often produce certain of these effects, at
least initially, in their resocialization effort.11 They with¬
draw supports for past identity and roles, redefine or rela¬
bel the individual, segregate him from others, and put him
into a somewhat passive, helpless position vis-a-vis insti¬
tutional authority. Then, the promise of a new identity or
new roles is held out, and new behavior thought desirable
by the institution is reinforced. To varying degrees, this
process may be seen in military academies or boot camps,12
therapeutic community drug treatment centers,13 gradu¬
ate schools,11 and mental hospitals.4
What then may be specifically "countertherapeutic"
about a mental hospital? One point of view would suggest
that after having been formally designated as a "mental
patient" by de facto admission to a hospital, then the mas¬
ter status "mental patient" will negatively affect how the
patient is perceived and responded to by others. Second,
beyond the immediate effects of the label on others, is the
potential negative effect on the patient himself. Schur7<p71)
 Table 1.—Corrected Mean Minnesota Multiphasic
social psychological position, accepting the label of 'men¬
Personality Inventory Scores tal patient' freezes pathology and stabilizes an otherwise
temporary condition."5 If the patient comes to agree with
Group 1 Group 2 Group 3 the societally prescribed label with the attitude that "if
(N = ll) (N 21)
=
(N = ll)
Label Label Label they say I'm sick, then I guess I must be sick," he may
Scales "Rejectors" "Acceptors" "Deniers" take on a deviant identity and behave accordingly. More
?—Based on no. of times technically known as "role engulf ment." Schur7""i9,
person replies, suggested that "one major consequence of the processes
"cannot say"
L—Lie 53.1 50.4 53.3 through which deviant identity is imputed is the tendency
-False 62.2 68.4 59.7
of the deviator to become 'caught up' in a deviant role, to
—Self-effacing (low score) 54.1 51.7 56.7 find that it has become highly salient in his overall per¬
Hs—Hypochondriasis 63.2 67.5 56.0 sonal identity (or concept of self), that his behavior is in¬
D—Depression* 78.3 91.11| 67.9|| creasingly organized 'around' the role, and that cultural
Hy—Hysteriat 72.8 71.6fl 62.6fl expectations attached to the role have come to have prece¬
Pd—Psychopathic deviate 72.3 71.7 66.6 dence, or increased salience relative to other expecta¬
Pa—Paranoiat 68.6 71.711 60.2H tions_"Ina sense, this is not dissimilar from Scheff's hy¬
Pt—Psychasthenia* 71.8 84.4||fl 64.9|| pothesis that "in the crisis occurring when a primary
Sc—Schizophrenia4: 71.9 84.5fl 66.3fl deviant is publically labeled, the deviant is highly suggest¬
Ma—Hypomania 61.9 56.6 59.7
Si—Shyt 58.0 66.6# 58.3# ible, and may accept the proffered role of the insane as
Factor A—High scorers
the only alternative."14
tend to be inhibited These two seemingly diverging possibilities appear
& overcontrolled amenable to empirical enquiry. Indeed, Petroni and Grif-
vacillators§ 58.1 65.9fl 52.8ÏÏ fin5(p245' concluded from their literature review that little
Factor R—High scorers
tend to be conventional empirical research has been specifically conducted on these
& submissive 55.8 59.4 54.3 apparently diverging theoretical views: "empirical data
*
One-way ANOVA, <.005 (D, F = 6.48; Pt, F 6.13). linking the acceptance or rejection of the patient label to
t One-way ANOVA, -C025 (A, F = 4.53). -

recovery from 'mental illness' is conspicuous by its ab¬

t One-way ANOVA, <.05 (Pa, F = 3.49; Se, F = 4.02). sence."
§ One-way ANOVA, <.10 (Hy, F = 2.71; Si, F = 2.39).
In this report, data are presented on 43 inpatients ob¬
|| Neuman Keuls test of individual mean differences, <.01. On
D and Pt, groups 2 and 3 differed. served during the first four weeks of an average seven-
fl Neuman Keuls test, P<.05. On Hy, Pa, Sc, and A, groups 2 week period of hospitalization. Three patterns of self-la¬
and 3 differed; on Pt, groups 1 and 2 differed.
# Neuman Keuls test, P<.10. On Si, groups 2 and 3 differed. beling at three points in time were delineated. Data on
patients who were within the three self-labeling groups
were examined regarding the following: (1) self-descrip¬

has hypothesized that following hospitalization for mental tive personality profiles derived from the Minnesota Mul-
illness, the patient "can thus hardly help but see himself tiphasic Personality Inventory (MMPI); (2) staff-rated pa¬
in new terms." tient behavior over a time; (3) patient involvement in
normatively prescribed and approved ward activities, such
Self-Labeling as patient government; (4) length of hospitalization; and

However, this and other views of labeling and self-la¬
beling are at least problematic. Particularly regarding
self-labeling, the topic of this report, Petroni and Griffin5
have articulated two seemingly opposing viewpoints on
the correlates and meaning of patient acceptance or rejec¬
tion of a psychiatric label, or the definition of one's self as
mentally ill.
The first, the medical/clinical "labeling-as-benign" per¬
spective, suggests that successful hospital treatment may
be precluded if the patient does not accept the idea that he
has problems that may be amenable to treatment. By ac¬
cepting this, he also accepts the mental patient role and
its by-product the label of mental patient. The notion here
is that the person must perceive his problem as resulting
from his own behavior and define himself, rather than oth¬
ers, as a primary source of his problem before he is moti¬
vated to change. From this perspective, as Petroni and
Griffin5 <p239> have put it: "acceptance of a definition of self
as 'mentally ill' is believed to be a sine qua non" to suc¬
cessful treatment.
The second, the "labeling-as-malevolent" perspective,
suggests that label acceptance may be harmful: "from a
(5) outcome of hospitalization (referral to additional in-
patient treatment or outpatient treatment) and biograph¬
ical variables. Staff expectations of the ideal way in which
patients ought to label themselves are presented and con¬
trasted with patient self-labeling.
Overall, the data analyses suggest that initial accept¬
ance of the label of "mental patient" did not necessarily
"freeze" either self-concept or behavior into a deviant or
pathological mode. Different kinds of patients reacted dif¬
ferently to a short-term, treatment-oriented, mental hos¬
pital setting; and different career pathways may be delin¬
eated with somewhat different results for the patient.
METHODS
Setting
A 16-bed, short-term therapeutic community unit provided the
setting. This unit was a part of a private, psychoanalytically ori¬
ented hospital located in the capítol city of a Midwestern state.
The unit's average patient length of stay was seven weeks; staff
ratio to patients was about 2:1, including four half-time psychia¬
trists and three half-time psychiatric residents. The unit staff, as
with Rosenhan's10(''257, sample, could be described as "people who
...
really cared, who were committed, and who were uncommonly in-

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 telligent." Nearly all doctoral staff had been (or were being)
psychoanalyzed. Many aides were either attending or had gradu¬
ated from college. Within this particular unit, great emphasis was
placed on patient openness, self-disclosure, participation, and re¬
sponsibility. Extensive group work dominated treatment; about 20
hours per week were distributed among small group therapy, pa¬
tient-family-staff meetings, community meetings, and patient
council meetings. Many nursing staff dined with patients; infor¬
mal interaction was quite frequent. A formal goal of treatment
was to return the patient to the community within the shortest
possible time, with an appropriate recommendation for additional
psychiatric treatment (which all patients received-inpatient or
outpatient referral). Patients recommended for additional hospi¬
talization could not remain on this short-term unit; rather, they
were referred to another section of the hospital or to some other
facility.
Subjects
Forty-three patients sequentially admitted to and discharged
from the unit with medical advice were subjects in this report. Of
these, 20 remained less than seven weeks; 23 remained seven
weeks or longer. Twenty were men; 23 were women. Their aver¬
age age was 35.2 years; average number of years of education
completed was 15.8. Sixteen were single; 22 were currently mar¬
ried; and five were divorced. Fourteen patients had conditions
diagnosed as schizophrenic; 12 as neurotic; and 17 as personality
disorder. All patients were voluntary admissions and travelled an
average of 625 miles from their community of origin to gain ad¬
mittance.
Instruments and
Design
Patient self-labeling data, and staff perception of ideal patients'
labeling responses, were drawn from an instrument devised by
Almond." Embedded within that questionnaire, the following
simple and direct 7-point agree-disagree item was used to repre¬
sent patient acceptance or rejection of the patient label: "In your
opinion, are you mentally ill?" The Almond questionnaire was ad¬
ministered first (T-l) within 36 hours following admission; second
(T-2) on the eighth day; and third (T-3) on the 29th day of hospi¬
talization. Instructions to all patients stressed that they respond
as they currently felt.
At the study's beginning, the staff also indicated the way in
which they perceived an "ideal" patient would respond on the Al¬
mond scale.
Data on patient self-reported pychopathological disorder con¬
sisted of the MMPI socred for the standard clinical and correction
scales and factors "A" and "R."16 The MMPI was administered
routinely by the unit clinical psychologist during the patient's
first ten days of hospitalization.
Each patient's behavior was rated on five behavior-rooted, ex¬
ample-anchored rating scales by members of his treatment team
(his psychiatrist, social worker, and several nurses and aides) at
the following points in each patients' hospitalization: T-l, one
week following admission; T-2, two weeks following admission;
and T-3, four weeks following admission. The general method for
example-anchored scale construction has been presented by Tay¬
lor." In this study, the following five ratings per week per patient
were made: (1) trust in the treatment program; (2) anger expres¬
sion; (3) contact with reality and responsibility for self; (4) extent
of participation in the treatment program; and (5) the Health-
Sickness Rating Scale, constructed by Luborsky, which had served
as a key variable in the Menninger Foundation's Psychotherapy
Research Project.18 For each scale, a score of 0 indicated the poor¬
est or least healthy rating, 100 represented the healthiest rating.
Intraclass reliabilities of summed staff judgments ranged from
.67 to .82. A principal-component factor analysis and a normal
varimax rotation was performed on the five staff ratings at each
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of the three patient-related times of date collection. All factors
with an eigenvalue of 1.00 or greater were rotated to the normal
varimax criterion. "Contact with reality and responsibility for
self" emerged at each of the three time periods; it accounted for
about 70% of the variance and was chosen as our marker variable
for examining relative stability or change in staff ratings over
time. Note that self-labeling data and staff-rating data were not
collected at precisely congruent times, except at T-3, the fourth
week of hospitalization. For ease of exposition, however, the same
notation denoting time will be used for both sets of data.
Patient behavioral involvement in ward activities was mea¬
sured by whether a patient was elected to a position of responsi¬
bility in the patient government or whether he avoided such in¬
volvement.
Other measures included: (1) biographical variables (age, sex,
education, marital status, and financial status); (2) previous psy¬
chiatric treatment experiences (prior psychotherapy or inpatient
hospitalization that may connote previous problems-in-living or
coping; moreover, having previously been in the role of patient
may bear on current acceptance or rejection of the role and the la¬
bel); and (3) current hospital experience variables such as diag¬
nosis, length of current hospitalization, and type of recommenda¬
tion made for additional treatment.
Statistical Analyses
For the 43 patients, Ward's Hierarchical Grouping Analysis18
was used to delineate patterns of stability or change in self-label¬
ing at the three points in time. A three-group solution was chosen
and three groups of patients demonstrating three different pat¬
terns of self-labeling over time were delineated. That is, the hier¬
archical grouping analysis procedure clustered together patients
with relatively similar change patterns regarding self-labeling
over the three points in time. The means of the three groups delin¬
eated from the cluster anlaysis are seen in the Figure. Multiva-
riate analysis of variance (MANOVA) was computed to compare
mean staff-rated pathology scored at T-l, T-2, and T-3 for patients
in each of the three groups identified by the cluster analysis. The
MANOVA and univariate analyses of variance tested mean dif¬
ferences between the three groups on the MMPI scales. Chi-
square analysis was used to examine differences by groups for pa¬
tients classified on involvement in patient activities (election to
patient government or not), length of hospitalization (less than
seven weeks or seven weeks or longer), and posthospital treat¬
ment recommendation (inpatient or outpatient referral) and bio¬
graphical variables or where analysis of variance was not appro¬
priate.
RESULTS
Unit staff (N 27), as a group, believed that the ideal
=
patient should moderately agree with the statement that
he is mentally ill, as a prerequisite for treatment
(X 5.96). By contrast, patients, as a total group, were ini¬
=
tially undecided about whether or not they themselves
were "mentally ill" at T-l (X 4.19). The two means were
=
significantly different beyond the .001 level (£ 3.96) and
=
suggest differences in the way in which patients as a
group perceived themselves and the way in which staff be¬
lieved patients ought to perceive themselves.
Among the 43 patients, Ward's Hierarchical Grouping
Cluster Analysis provided three self-labeling patterns
over time (see Figure): group 1 (N ll) slightly agreed
=
that they were mentally ill at T-l (X 5.3), but moderately
=
disagreed that they were mentally ill by T-3 (X 2.4). We=
call group 1 the "label rejectors." Group 2 (N 21) changed
=
from slightly agreeing that they were mentally ill at T-l
 Group 1 (N ll) =

( =
5.1) to viewing themsdves as moderately mentally ill Label Rejectors
at the end of four weeks (X 6.0). We call group 2 the "la¬
=

bel acceptors." Initially, group 3 (N ll) strongly dis¬

=

agreed that they were mentally ill (X=_1.3) and at T-3 T-l T-2 T-3
they still disagreed, but slightly less (X 2.7). We call
=
Strongly Agree
group 3 the "label deniers."
On the MMPI, those who denied that they were men¬ Moderately Agree
tally ill throughout provided a mean profile within normal
limits, no TC (corrected) scale being over 70. By contrast, Slightly Agree
those who initially accepted the mental illness label
(groups 1 and 2) provided elevated scores (over 70) on five Undecided
scales (depression [D], hysteria [Hy], psychopathic deviate
[Pd], psychasthenia [Pt], and schizophrenia [Sc]). Within Slightly Disagree
this group of initial acceptors, those patients (group 2)
who continued to accept the label had significantly higher Moderately Disagree
scores in contrast to the "deniers" (group 3) on D, Hy, Pa,
Pt, Sc, Si, and the general factor A. On most scales, the la¬ Strongly Disagree
bel "rejectors" (group 1) provided scores intermediate be¬ X 5.3 3.5 2.4
tween the extremely elevated scores of the label "accep¬
tors" and the unremarkable scores of the label "deniers."
In general, high scores on these scales are indicative of
Group (N 21)
2 =

more severe self-reported psychopathological disorder.16 Label Acceptors

These data are summarized in Table 1. It should be noted
that no assumption is made that the MMPI data consti¬ T-l T-2 T-3
tutes "an uncontaminated indicator of overall pathology," Strongly Agree
rather, the assumption is made that it provides a system¬
atic patient self-report of a variety of symptoms that he Moderately Agree
may be experiencing. As such, it may not be particularly
surprising that the "deniers" report fewer symptoms, Slightly Agree
while the "acceptors" reported relatively more severe symp¬
toms. The MMPI data serve to validate the self-labeling Undecided
reports; and, the specific elevated scores among the groups
demonstrate differences in self-report of specific kinds of Slightly Disagree
symptoms by the different groups.
The means of the MMPI "validity scales" (L, F, and K) Moderately Disagree
disclosed no significant differences between the three pa¬
tient groups, suggesting that the obtained scores were Strongly Disagree 1
equally valid across samples. X 5.1 5.8 6.0
The mean staff behaviorally rooted global pathology
ratings obtained by the three patient groups at the three Group 3 (N ll)
=

points in time are seen in Table 2. The three groups did Label Deniers
not differ on the T-l mean ratings of global psychopath-
ologic disorder; indeed, the means were nearly identical.
In the eyes of the staff, all three groups apparently had T-l T-2 T-3
started out on relatively equal footing. Strongly Agree
Over time, the total patient sample was rated by staff as
having made a significant mean improvement in global Moderately Agree
psychological functioning from T-l to T-3 (F 11.05, =

d/=40, P<.002). However, MANOVA analysis indicated Slightly Agree 5_

a significant group-by-time interaction. The Newman
Keuls tests of individual mean difference disclosed that Undecided 4
the label "rejectors," (group 1) were rated by the staff as
having significantly improved in global mental health Slightly Disagree
from T-l to T-2 and from T-l to T-3, in contrast to both
group 2 (P < .01) and group 3 (P < .10). No significant dif¬ Moderately Disagree
ferences were obtained across time for groups 2 and 3.
Thus, patient group 1, the "rejectors," who first accepted Strongly Disagree 1
and then rejected the "mental patient label," were rated X 1.3 2.6 2.7
by staff as having made the most significant mean im¬ Cluster analysis of patient self-labeling 36 hours after admis¬
provement toward psychological health. Group 2, the label sion (T-l); and on the eighth day (T-2) and 29th day (T-3) of hospi¬
"acceptors," were not seen as having made significant talization.

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 gains toward psychological functioning. The label "de¬ Table 2.—Mean Staff Ratings of Global Functioning
niers" also were not rated by staff as having made much From Cluster Analysis of Self-Labeling
improvement on the average.
The three groups also differed significantly in the fre¬ Staff Ratings of Global Mental Health*
_A_
quency with which members were elected by their peers to Group Means
positions of responsibility in patient government. The T-l T-2 T-3 Across Time
group of label "acceptors" (group 2) were elected as lead¬ Group 1 (N = 11)
label "rejectors" 56.36 62.73 67.46 62.18
ers significantly more often, followed by the label "rejec¬
Group 2 (N = 21)
tors," then the "deniers," who were elected least often. label "acceptors" 57.71 55.67 58.71 57.37
That is, elected to patient government were 16 out of 21 Group 3 (N = 11)
label "acceptors," seven out of 11 "rejectors," and two out label "deniers" 57.18 58.55 61.00 58.91
of 11 "deniers" ( 2 8.99, df=2; P<.025).
=
Total means
at three times 57.23 58.21 61.53 58.99
Label "acceptors" tended to be hospitalized longer than
were either "rejectors" or "deniers," who were hospi¬
* Administration of questionnaire was 36 hours after admission

talized for about the same length of time. Hospitalized
longer than the mean of seven weeks were two of 11 "re¬
jectors," 12 of 21 "acceptors," and three of 11 "deniers"
(X2 5.52;d/=2;P<.10).
=
However, type of recommendation (inpatient vs out¬
patient)for additional treatment did not distinguish
among the three clustered groups. Rather, there was a
tendency for patients who could financially afford addi¬
tional hospitalization to receive such a recommendation.
No statistically significant differences existed among
the three groups with regard to sex, age, education, mari¬
tal status, diagnosis, or frequency or length of previous
hospitalizations or psychotherapy.
SUMMARY AND CONCLUSIONS
Rosenhan, among others, has described the mental hos¬
pital, perhaps overgeneralizing, as a potentially counter¬
therapeutic institution.10 Not only have such investigators
believed that the hospital environment is dehumanizing
and alienating, but also that it provides a label—prescribes
a self-definition—that may work so as to freeze a deviant
identity in the eyes of self, staff, and others. However, the
present data, based on true patients, suggests that the
matter is considerably more complex than either of the
two predominant perspectives held currently on the self-
labeling phenomena.
In this study, unit staff indicated, on average, that the
"ideal" patient should feel that he is "mentally ill"; that
he should accept the deviancy of his behavior, and the la¬
bel. This was expected.
Among the patients, three self-labeling patterns were
delineated. On admission, on average, both groups 1 and 2
agreed that they were mentally ill; they accepted the la¬
bel. By and large, both of these groups described them¬
selves as relatively less healthy on the MMPI than did
group 3, and both groups 1 and 2 received several scores el¬
evated above 70. Group 3, on average, denied that they
were mentally ill and described themselves as relatively
"healthy" on the MMPI, receiving no scale mean elevated
above 70. But, neither group differed in severity of overt
(T-l); on the eighth day (T-2); and on the 29th day of hospitaliza¬
tion (T-3).
might continue to even more strongly.
accept it, perhaps
Concomitantly, if
labeling and its acceptance "freezes"
deviant behavior, we might expect those who initially ac¬
cepted the label to continue their disturbed behavior in the
eyes of the staff. But, if labeling is benign and if the ac¬
knowledgment of one's "mental illness" is a prerequisite
for "successful" patient role behavior, recovery, or re¬
lease,2" then we might expect that label rejection would be
associated with indications of more severe psychopatho-
logical disorder like diagnosis, and less staff-rated im¬
provement. None of these expectations were supported
here uniformly.
The group of T-l label "deniers" (group 3) remained in
the hospital and continued to deny that they were "men¬
tally ill," although not as strongly at the end of a month.
Discharged with medical advice, the "deniers," as a group,
were not rated by staff as having significantly improved
or deteriorated, participated little in patient government,
and were hospitalized as long as group 1, but less than
group 2. They provided unremarkable MMPI scores, and
received diagnoses and recommendations for additional
treatment that did not significantly differentiate them
from the other two patient groups. One might infer that
the "deniers" chose not to play the role of mental patient
as normatively prescribed. The "deniers" accounted for
about 25% of the sample.
The situation was somewhat different with groups 1 and
2 who on the average came into the hospital already ac¬
cepting the mental illness label. Two diverging career
routes were delineated within the hospital for these initial
acceptors.
On the average, group 1 (the "rejectors") came to give
up or reject the label over time, and in contrast to groups 2
and 3, provided moderately elevated MMPI scale scores,
were moderately involved in patient government, were
hospitalized as long as the "deniers" but less than the "ac¬
ceptors," received diagnoses and recommendations that
were not significantly different from group 2 or 3, but over

psychopathological disorder as judged by the team staff
after a week of observation.
Now, if the mental hospital reinforces a self-label of
mental illness, we might expect that patients who had ini¬
tially denied the mental illness label would come to accept
it and agree that they are mentally ill over time. We could
also expect that patients who initially accepted the label
time were rated by staff as becoming significantly more
healthy. In a certain sense, they might be considered the
"successful" patients. Initial acceptance of the deviant la¬
bel had no long-lasting effect even with the hospital. No
or pathological behavior
"freezing" of deviant self-label
occurred. For this 25% of our sample, hospitalization
served apparently to "unfreeze" self-application of a

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 deviant label.
Another group of initial acceptors, group 2, continued
and increased their acceptance of the label over time. The
"acceptors" were seen by staff on the average as almost
equally disturbed after four weeks as after one week; as a
group, they were most involved in patient government,
provided the most highly elevated MMPI scores, were hos¬
pitalized the longest, but received neither diagnoses nor
recommendations that differentiated them from the other
two groups. At first glance, the "acceptors" would appear
to be the primary group to which the expectations of the
malevolent view of labeling would apply: about 50% of this
small sample.
There may exist, of course, several possible alternative
explanations for the phenomena exhibited by the three
patient groups. That is, neither the "labeling-as-benign,"
nor the "labeling-as-malevolent" approach may exclu¬
sively provide satisfactory explanations for these results.
It is important to indicate that Scheff14<p9' has pointed out
that "just as the individual systems models under-stress
social processes, [the societal reaction] model... probably
exaggerates their importance. The social system model
'holds constant' individual differences, in order to articu¬
late the relationship between society and mental dis¬
order."
This becomes an important theoretical consideration
when examining the career pathways of the three groups
of patients, which perhaps suggest complex transactions
between these patients and the staff.
For example, from the societal reaction perspective, a
priori, it might have been expected that group 1, who had
initially accepted the label of mentally ill, might have in¬
creased their acceptance of the label with concomitantly
less favorable ratings by staff, and thereby follow a sim¬
ilar career pathway as did group 2, the eventual label "ac¬
ceptors." However, perhaps in the flux of an intensive
treatment unit, staff expectations of patient behavior
change; ie, ideally, patients should come to the unit feel¬
ing that they are mentally ill and in need of treatment,
but then should be prepared to give up this view of self as
"mentally ill" in the process of learning how to cope with
problems-in-living, with the help of staff. Lacking data on
staff expectations over time, the above formulation is sug¬
gested only as a normative expectation in keeping with
the ideology of intensive treatment settings.
While both groups 1 and 2 initially accepted the label,
both groups provided somewhat different self-reports of
symptomology on the MMPI. The label "rejectors" (group
1), who had been rated by staff as having demonstrated
significant improvement over time, had provided a self-
description on their moderately elevated MMPI profiles
indicating a "2-, 3-, 4-" configuration, suggesting feelings
of anxiety and depression, perhaps congruent with neu¬
rotic problems.16 By contrast, the "acceptors" (group 2),
who were rated by staff as demonstrating little psycho¬
logical improvement, provided the most highly elevated
MMPI profiles, especially on those scales (paranoia [Pa],
Pt, and Sc) that may be indicative of schizophrenic-like
problems: excessive inhibition and withdrawal.16
Both groups (1 and 2) tended to describe their symp¬
toms in somewhat different ways. But, throughout their
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first four weeks of their hospitalization, the "acceptors"
continued to agree that they were mentally ill (perhaps
showing "insight" into their problems; or perhaps reflect¬
ing the appraisal of them by staff based on their self-re¬
ported symptoms). And, at the same time, the "acceptors"
may have been considered by staff as less amenable to
therapeutic community treatment methods, with their
premium on participation, openness, communalism, and so
on.21 It could be surmised that, while adhering to norma¬
tive expectations that they define themselves as mentally
ill, the "acceptors" reported such severe symptoms that, in
reality, psychological improvement would have been diffi¬
cult to detect over the first four weeks. In this fashion, the
"acceptors" may have created some discomfort within the
staff; ie, staff may have experienced strain and unreward¬
ing difficulty22 in engaging with such patients, which may
have been reflected in their less favorable ratings of these
patients.
By contrast, the label "rejectors," who initially accepted
the label and reported moderate symptoms, may have
been somewhat more socially adept (than "acceptors") and
may have elicited relatively more favorable staff atti¬
tudes and behaviors. By conforming to staff expectations
and by being intermediate in their self-reported symp¬
toms, they may have been or were seen as more responsive
patients, thereby allowing a reciprocally and mutually re¬
warding form of interpersonal interaction with the staff,
their raters.
The data provided by and for the "deniers" require a
slightly different explanation theoretically. First, it should
be recalled that the unit's staff held the expectation that,
ideally, patients ought to agree that they were mentally
ill. The "deniers" throughout hospitalization disagreed
with this notion about themselves. This was also sup¬
ported by their MMPI profiles; they conveyed the impres¬
sion on this self-descriptive instrument that they were
suffering few, if any, symptoms. And, their scores on the
validity scales suggested that they were not significantly
different from the other two groups: little evidence was
available they had distorted their self-description. At the
same time, they received diagnoses and referral recom¬
mendations that were not different from the other two
groups. Now, either of two hypotheses may be offered. One
is that they really did have intrapsychic or interper¬
sonal problems that they did not choose to acknowledge
(thereby lacking "insight") and thus received unfavorable
staff ratings that did not differentiate them from the "ac¬
ceptors." Or, they really were not particularly unhealthy,
but in the process, violated staff expectations that they
ought to perceive themselves as in need of treatment by
agreeing that they were "mentally ill," thereby engender¬
ing within the staff the notion that little progress was
made by these patients. For the "deniers," the staff ratings
may be indicative of a lack of staff approval of the unwil¬
lingness of these patients to allow staff to perform their
therapeutic function. The "deniers," reporting few symp¬
toms by MMPI standards, and disavowing mental illness,
were perhaps less willing to respond to staff therapeutic
overtures and expectations, thereby providing a frustra¬
ting, cantankerous, or unmotivated quality of interaction
for all concerned, and thus leading to their shorter length
 of hospitalization compared with the "acceptors," even
though staff ratings were similar.
In a sense, these data suggest the possibility of complex
transactions between these patients and staff. When pa¬
tients report different symptoms, or none, then staff re¬
spond differentially in their behavioral ratings of such dif¬
ferent groups of patients. Because the MMPI was not
considered as an "uncontaminated" or as a pure measure
of "severity of psychopathology," only the ways in which
the three groups differed in their self-reports of symptoms
were noted.
In examining the differential careers of these three pa¬
tient groups (if such be generic, replicable, classes of pa¬
tients), future research might profitably explore the fre¬
quency, quality, and reciprocal nature of patient-staff
interaction patterns, along the lines suggested above.
In sum, the data presented here have delineated three
groups of patients who differentially accepted the label of
"mental illness" over time. Related to label acceptance or
rejection were different correlates or consequences. These
diverging career pathways were discussed in terms of dif¬
ferential application of two competing models initially,
and then hypotheses were advanced pertaining to the
quality of transaction between patients in the three
groups and the unit staff.
The results of this investigation should be interpreted,
naturally, with appropriate caution. First, the sample of
patients was small, and by their characteristics may not
be representative of hospitalized psychiatric patients gen¬
erally. They were highly educated and were treated in a
private hospital setting. Moreover, this sample had been
voluntarily hospitalized, in a legal sense, and few had en¬
countered prior legal difficulty.
In addition, an interpretation of what exactly patients
mean when they agreed or disagreed to the question "In
your opinion, are you mentally ill?" may be problematic.
Different patients may well have had in mind different
meanings attached to the term "mentally ill" as applied to
themselves. In order to more fully understand what pa¬
tients may subjectively mean when they agree or disagree
with such an item would require more complete investiga¬
tion with interviewing techniques. In this report, it is
broadly assumed that the MMPI self-descriptive data re¬
garding internal feeling states provided some, perhaps in¬
direct, clues concerning what the patients meant by their
self-assessment on the labeling question. Group 1, the "re¬
jectors," reported milder symptoms in comparison with
group 2, the "acceptors"; the "deniers" as a group reported
no score over 70. Initially, group 1 may have felt "men¬
tally ill" in accordance with their self-reported MMPI pro¬
file; group 2 may have felt that they were mentally ill ini¬
tially, but for somewhat different reasons, as indicated in
their mean MMPI profiles.
While recognizing the importance of examining pre-and
post- patient careers as they might be releated to self-la¬
beling and inpatient careers, the intent of this report was
solely to explore label acceptance/rejection patterns and
their correlates within a hospital setting. Finally, it
should be recognized that there are a variety of other
methodological approaches to the study of self-labeling
and its correlates; the method used here represents just
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one kind of approach to an examination of this much dis¬
cussed, little researched, topic.
In sum, it seems almost trivial to suggest the impor¬
tance for future research of the little studied individual-
setting interaction effects in producing certain kinds of
staff or patient behavior, process, or outcome. Future re¬
search, if it is to make a contribution to an understanding
of the real and complex patient and institutional problems
of mental health care, must recognize and deal with real
life complexities among real patients and real staff mem¬
bers, using a variety of theoretical and methodological ap¬
proaches. The useful, and complex, but rarely addressed
question: "What sorts of patients do relatively better or
worse, over time; under what kinds of admission, treat¬
ment, and discharge conditions; and with what sorts of
short-term and long-term results?" begs more systematic,
quantitative, and longitudinal study.
This research was supported in part by funding from the Menninger
Foundation, Topeka, Kans.
James B. Taylor, PhD, contributed comments on an earlier version and
provided the example-anchored scale construction; and Lolafaye Coyne,
PhD, provided statistical analysis.
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