David Mechanic, in his pioneering textbook, Medical Sociology,⁽¹⁾ views human activity within an adaptive framework—as a struggle of human beings to control their environment and life situation. While this view informs the research to be outlined, there are a number of ways it differs in emphasis from much medical sociology. First, by its concern with particular disorders defined in medical terms. Second, by its use of the investigator rather than respondent to characterize phenomena—to decide, for example, whether an incident should be classified as a life event. Third, by the importance placed on context. In order, for example, for an investigator to make a judgement about the likely meaning of an event such as a loss of a job it is essential to know whether it cast the person in a bad light; its impact on the person’s family; her chance of getting another job, and so on. It is such circumstances surrounding an event that usually give it meaning via the emotion they create. Finally, by recognizing that where appropriate such emotion should be taken into account: ‘A world experienced without any affect would be a pallid, meaningless world, and it is what gives us feedback about what is what is good or bad about our lives’.⁽²⁾

Concern with context in the social sciences was central to the problem of meaning discussed widely in Germany in the late nineteenth century; and the ideas were introduced into sociology by Max Weber⁽³⁾ and into psychiatry by Karl Jaspers,⁽⁴⁾ although no one showed how to apply the methods systematically to concrete examples.⁽⁵⁾ Jaspers, in his Allegemeine Psychopathologie, emphasized the way in which Verstehen, or understanding, on the part of an investigator ‘depends primarily on the tangible facts’ (i.e. verbal contents, cultural factors, people’s acts, ways of life, and expressive gestures) in terms of which the connection is understood, and which provides the objective data.⁽⁴⁾ While this view influenced the approach to meaning in what follows, there is a critical difference. No attempt has been made to make a judgement about the presence of a causal link between a set of circumstances and a psychiatric episode. The investigator has to judge only the likely meaning of a set of circumstances in the light of ‘tangible facts’ about a person’s past and present. Any link with disorder is explored using established scientific procedures.

As noted by Jaspers, it is possible to take note of cultural factors; for example, when rating the likely implications of a birth, as part of research among women in a black township in Zimbabwe, investigators took into account the cultural importance on a wife producing a male child for her husband and his family.⁽⁶⁾

A second, more limited, use of context deals with the actual observation of emotion. For example, the Camberwell Family Interview, by taking account of vocal (in contrast to verbal) aspects of speech, for example, establishes how far a parent’s talk about a child conveys ‘criticism’ rather than ‘dissatisfaction’.⁽⁷⁾ The approach can be extended to deal with core sociological concepts such as role commitment. For example, mothers in North London have been shown to differ substantially in commitment to roles such as ‘mother’ or ‘wife’ judged by how enthusiastically associated activities are discussed.⁽⁸⁾ The relevant context is limited to the interview itself and what this conveys about a person’s emotional style. In everyday life we automatically make allowances for the fact, for example, that some people show warmth in a more open way and, by taking this into account, makes it is possible for different expressive styles to be treated as equivalent.

These developments have enabled ‘soft’ variables to be quantified. It has also been possible to make a reasonably persuasive case that significant bias has not followed the use of the investigator as the measuring instrument. For example, Creed⁽⁹⁾ in a study of appendectomy found a relationship between severely threatening events rated contextually and the onset of non-inflamed but not inflamed conditions. This result was persuasive for two reasons. First, on the basis of a detailed description of the event and surrounding circumstances a consensus rating team reached agreement about the likely degree of threat, blind to what the person conveyed she felt and to whether she was a patient. Second, Creed, who provided the team with this edited account, was blind to clinical details. (He consulted medical records after the ratings had been made.) Such flexibility is difficult, if not impossible, with a questionnairebased instrument which hands over the task of measurement to the respondent.

There are now a number of investigator-based instruments developed to deal with psychiatric issues covering areas ranging from ‘expressed emotion’ (e.g. critical comments, warmth, etc.), attitudes to self (e.g. self-esteem), plans and concerns (e.g. commitment to various roles), behavioural systems (e.g. styles of attachment), experience of adversity in childhood (e.g. sexual and physical abuse), and characteristics of non-family groups (e.g. restrictiveness of a psychiatric ward regimen). Around each a fair amount of replicable and theoretically relevant findings have emerged. Particularly important was the development in the 1960s of the clinically informed interview-based Present State Examination (PSE) by Wing et al.⁽¹⁰⁾ later amended to deal with a 12-month period,⁽¹¹⁾ and psychosocial measures such as that of ‘expressed emotion’⁽¹²⁾ and the Life Events and Difficulties Schedule.⁽¹³⁾ Part of the strength of the resulting research has been due to the levels of inter-rater reliability achieved and the ability of the approach to deal with time order. It is often overlooked that even with longitudinal designs it can be important to be able to establish what has happened between interviews.

The characteristic features of the aetiological studies that have emerged can be illustrated by those dealing with life events. The significance of findings concerning depression is enhanced by the fact that most studies have produced broadly consistent findings about the role of events.^{(14, 15 and 16)} Indeed, for some years the challenge has been not so much to establish the presence of an effect, but to learn more about the nature of the events involved and to integrate findings into a more comprehensive aetiological model.⁽¹⁷⁾