Book Review

The Cloak of Competence

N Engl J Med 1994; 331:621September 1, 1994

Article

The Cloak of Competence
Revised and updated edition. By Robert B. Edgerton. 247 pp. Berkeley, Calif., University of California Press, 1993. $35 (cloth); $15 (paper). ISBN: 0-520-08225-7 (cloth)

Edgerton's revised edition of his 1967 book, The Cloak of Competence: Stigma in the Lives of the Mentally Retarded (Berkeley: University of California Press), retains its relevancy even though patients who are mildly cognitively impaired, the subjects of his books, are no longer admitted to state facilities for the mentally retarded. The new edition includes the original text along with 25-year follow-up data on selected cases and two new chapters that address conceptual criticisms of the original book and a review of how thinking about people with mild mental retardation has changed over the years.

In field research begun in 1959, Edgerton, an anthropologist, used the participant-observer method to investigate the lives of 48 mildly mentally retarded young adults whom he studied after their discharge from Pacific State Hospital in California; deprivation and behavioral disturbance had been primary factors in their original hospital admissions. His work was pioneering in its investigation of how mentally retarded persons adapted in the community at a time before deinstitutionalization was commonplace and before the concept of normalization was introduced. He emphasized the stigma of the disability and the need mentally retarded persons felt to deny their cognitive handicap and attempt to pass as normal in society; he refers to this phenomenon as the “cloak of competence.” Edgerton presented a series of detailed portraits in which he addressed life before the hospital; life in the hospital; life after discharge; neighborhood, home, and possessions; making a living; relations with others; sex, marriage, and children; use of spare time; self-perception; and predictions of outcome. These observations have been updated to 1992.

At the time of the first edition, IQ tests were considered to be highly prognostic of long-term adaptation, and improvement in the status of people with mild mental retardation was thought to be unlikely. Edgerton found that their social adaptation was substantially better than originally predicted, especially when there was a benefactor available in times of crisis. Social adaptation continued to improve even though the degree of cognitive impairment did not change. The case of one person discussed in the concluding chapter is particularly instructive. This person is able to work effectively in an inner city and finds others to assist him to compensate for his inability to read and to count. In many ways he is successful despite the fact that his cognitive abilities have not improved.

Edgerton's findings are in keeping with the functional definition of mental retardation introduced in 1992 by the American Association on Mental Retardation, which places greater emphasis on adaptation and less emphasis on cognitive level. His observations are also in keeping with an approach that stresses developmental adaptation and deemphasizes the label “mental retardation.”

Edgerton effectively discusses critiques of the earlier edition of his book, particularly those based on social-constructionist views. However, he does not discuss the theory of multiple intelligences presented by Howard Gardner. People with mild cognitive impairment who have good interpersonal intelligence may adapt the best, because of their ability to find others to assist them. The number of patients evaluated in 1992 is substantially smaller than the original sample; therefore, Edgerton challenges others to confirm his findings in new population groups through extended follow-up.

In conclusion, The Cloak of Competence is as relevant today as it was in 1967. It continues to raise issues about how far mildly mentally retarded people can progress in matters of social adaptation despite their lifelong cognitive impairment. Edgerton suggests that with appropriate programs, social abilities can be enhanced when adequate supports are in place, thus diminishing the stigma of mental retardation and perhaps eliminating the need for a cloak of competence.

This book is recommended not only for specialists working with people who have developmental disabilities, but also for the general physician who wants to understand better the life experiences of people with mild mental retardation. The book is clearly written, the bibliography is comprehensive, and it contains several informative tables. We can look forward to the more extensive biographies of individual patients promised by the author.

James C. Harris, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205