Social Constructions of Mental Illness
Abstract and Keywords
This article rejects the idea that the sociology of mental illness classification and organizational embeddedness shows that mental illness is a pure social construct. The three styles of social construction include pure constructionism, interactive social construction, and harmful dysfunction (HD) conception. Because mental illnesses are social artifacts, they cannot be universal. Interactive conceptions of mental disorder illustrate the effects of social classification through situating them within institutional practices, social meanings, and interactions. The HD view offers the grounds for critiquing mental health practices. The HD analysis shows that the current Diagnostic and Statistical Manual of Mental Disorders definitions pervasively confuse problematic but natural human emotions which develop as responses to stress with mental disorders. The profound social influences on constructions of mental disorder reveal the value of sociological approaches for the study of phenomena that are typically viewed as aspects of individual personalities and brains.
Both professionals and laypeople view mental illnesses as qualities of individual minds, personalities, and brains. This assumption provides the basis for the official classification of psychiatric disorders—the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association (2000). This manual assumes that its various diagnostic entities both have a natural underlying reality and are universal so that the symptoms defining each diagnosis are comparable wherever and whenever they appear. These individualistic and naturalistic conceptions are entrenched in the major mental health professions that define, study, and treat mental illness as well as in common sense. Sociologists who study conceptions of mental disorder thus confront deeply rooted and socially legitimated asociological models.
In contrast to commonsensical and psychiatric views of mental illness, the sociology of knowledge studies the social meanings attached to mental symptoms and categories. The sociology of knowledge focuses on collective, intersubjective social worlds that are distinct from both the subjective inner worlds of individuals and the objective, universal worlds of natural objects (Zerubavel 1997). This perspective traces these meanings to their roots in cultural assumptions and interest group practices (Mannheim 1936). It grounds all knowledge, including scientific knowledge, in its historical and social settings. Social processes influence classifications of knowledge as well as the institutions, practices, and behaviors in which this knowledge is embedded.
(p. 560) A critical, but unresolved, question in the sociology of psychiatric knowledge is the sorts of articulations that exist between culturally embedded assumptions about mental illnesses and any natural reality that underlies these illnesses. The pure, interactive, and harmful dysfunction views provide three different perspectives about how cultural and natural factors shape conceptions of mental illnesses.
23.2. Three Styles of Social Construction
23.2.1. Pure Constructionism
One branch of social construction, which I call “pure” social construction, assumes that mental illnesses are culturally constituted. This perspective views concepts of mental illness as reflections of social values; people who are considered to be mentally ill have violated particular kinds of norms (Scheff 1966). These norms are not part of the natural world but arise from social rules that power structures reinforce. Because norms are social products, mental illnesses have no universal foundation and display substantial variation across different times and places.
Pure constructionism in the study of mental illness grew out of attempts to show how current Western categories of disorder are actually culturally relative. Philosopher Michel Foucault (1965) famously viewed mental illness as a social and historical rather than as a medical problem. He asserted that Western notions of reason and rationality, which claim to have universal validity, actually reflect historically contingent processes of understanding. Madness, for Foucault, is a disorder of modernity. Psychiatry embodied a new code of knowledge that used medical discourse to classify, contain, and control those who it called “mad.” Before the seventeenth century the mad were viewed as possessing special insight into fundamental aspects of existence. After that time, however, the psychiatric profession emerged to manage and discipline the mad—who were not economically productive citizens—and to segregate them from normals. Its diagnostic systems demonstrated the fundamental irrationality of mental illness and provided experts with the power to define fundamental aspects of the identities of those that it categorized. Psychiatric classification schemes used seemingly objective scientific language to stigmatize and exclude the mentally ill.
A long anthropological tradition preceding Foucault also focused on how the presumably natural phenomenon of mental illness in fact reflected cultural values and practices. In her classic essay “Anthropology and the Abnormal,” Ruth Benedict (1934) questioned the universal nature of Western definitions of normality and pathology. Using a variety of examples such as paranoia, seizures, and trances, she asserted that virtually every behavior that Western psychiatry defined as abnormal was seen as normal in some other culture. For example, the native peoples of Siberia viewed seizures as signs of special connections to supernatural powers rather than (p. 561) as dreaded illnesses. Likewise, the Dobuans of Melanesia typically have paranoid personality styles marked by constant suspicions and fears. Modern Americans, in contrast, would view comparable styles as indicators of paranoid disorders. For Benedict (1934, 79), “all our local conventions of moral behavior and of immoral are without absolute validity.” Normality resides in culturally approved conventions, not in universal standards of appropriate psychological functioning.
Many contemporary anthropologists follow the pure constructionist tradition that Benedict established. For them, emotions are not natural kinds that refer to the biological things that are being classified but to culturally determined classification schemes that humans use to interpret their own and others’ experiences (Barrett 2006). The huge variety of emotional expressions across cultures and history is a particularly important indicator of the thoroughly psychosocial nature of emotional norms and deviations from these norms (Gross 2006). Cultures provide norms that indicate what emotions people should show in given situations, the idioms through which they are supposed to show them, and the feelings connected to the emotion that they ought to experience. For example, anthropologists and historians suggest that there are as many types of sadness as there are cultures (Barr-Zisowitz 2000). Likewise, anger stems from inequitable social relationships, not from any biological grounding (Gross 2006).
Because mental illnesses—no less than customs, values, and norms—are social artifacts, they cannot be universal. Instead, definitions of mental disorder stem from culturally specific learning. “These cultural schemas,” notes anthropologist Richard Castillo, “can cognitively construct a particular behavior as an episode of mental illness, whereas a different set of cultural schemas can cognitively construct a similar behavior as something normal and normative” (1997, 16). Conceptions of mental disorder are—in all important respects—social constructions.
Psychologist and philosopher Derek Bolton provides a variant of the pure constructionist view. Like it, he regards definitions of mental disorder as aspects of social norms. Psychiatric symptoms are not intrinsically pathological but are deviations from evaluative norms of appropriate behavior: “‘Normal’ carries the implication like us, and ‘abnormal’ not like us” (2008, xiv). For Bolton, the boundaries between normality and disorder are inherently fluid and subject to negotiation, rendering the quest to define “real” mental disorder as meaningless. No objective standards can indicate when the concept of mental disorder is used legitimately or illegitimately: Success in this enterprise is simply a matter of who has the power to negotiate a broader definition. What makes conditions “disorders” are their harmful social and psychological consequences, which stem from value-laden decisions.
Bolton, however, deviates from most pure constructionists who typically critique the expansion of psychiatric control. Unlike them, he believes that the current DSM classifications pragmatically capture the harmful conditions that the mental health professions ought to be treating. He urges psychiatry and allied professions to give up fruitless attempts to define genuine disorders but instead to treat all conditions that lead to suffering, impairment, and adverse outcomes. “What matters is,” according to Bolton, “consequences in terms of distress, disability and risk” (2008, 200).
(p. 562) Pure constructionist views have several inherent deficiencies, which have more or less importance depending on the particular variant of this perspective that is in question. The first lies in equating mental disorder with violations of social norms. The claim that “mental disorder” is solely an evaluative concept fails to distinguish what is distinctive about mental illness vis-à-vis many disvalued conditions, ranging from ignorance and ugliness to adultery and crime, which also violate social norms (Wakefield 1992). A pure constructionist perspective has no factual criterion it can use to distinguish mental disorders from other negatively evaluated states that are not considered to be disordered.
A second problem of pure constructionist views lies in their conflation of the expression of symptoms, which culture profoundly influences, with the underlying conditions themselves, which can have biological foundations. Emotional displays can be overt, culturally influenced, manifestations of covert, brain-based processes (Turner 1999). For example, constructionists often contrast physiological displays of depression in non-Western cultures with its psychological manifestations in the West, arguing that the two distinct idioms have little in common (Kleinman 1988). Yet some underlying condition must be present to even allow for a comparison of different forms of the same state. Comparison is only possible if something constant serves as a point of reference to observe meaningful variation. Contrasting different symptomatic presentations simply makes no sense if they are not variants of a more basic phenomenon.
A third problem of pure social constructionism lies in its inability to consider any natural effects of diseases that arise independently of their social classifications. The distorted thought processes of schizophrenia, massive and continual use of alcohol, or extravagant behaviors of bipolar disorders can have real consequences regardless of the social definitions placed upon them. These effects are not comparable to phenomena such as money that are pure social constructions and that would lose significance if people stopped believing in their value. While social classifications of mental illness have undoubted importance, they do not exhaust or constitute the phenomena of mental disorders.
Fourth, pure constructionist views inherently lack any objective concept that can serve as the basis to critique particular views of mental disorder. Only some standard of judgment that stands outside of particular cultural categories can show that one model is more or less adequate than any other model. Paradoxically, because constructionists (Bolton notwithstanding) are often among the most strident critics of the psychiatric profession, their premise that mental illness is whatever is defined as such in a particular cultural context provides no logical grounds for claiming that any view of mental illness is either better or worse than any other. For example, psychiatrists in the Victorian era generally considered masturbation to be a serious mental disorder: A pure constructionist has no grounds for saying that their views were simply wrong. Because they lack any standards that can transcend particular cultures, pure constructionism cannot provide coherent critiques of concepts of mental disorder.
Finally, perhaps the major failing of pure constructionist views is that they consider nature and culture to be two opposing forces. For them, social values and (p. 563) cultural processes are distinct from, not complementary to, natural phenomena. To the extent that mental disorder is socially constructed, it ceases to be grounded in biological forces. Natural and cultural processes, however, are often complementary: Humans are hard-wired to respond to collective cultural symbols and social dynamics (Horwitz 2007). The question should not be whether nature or culture influences pathology; instead, we want to know the particular ways that natural and cultural forces interact to produce mental illnesses.
23.2.2. Interactive Social Construction
A second style of social construction does not take as its target the existence of a universal conception of mental disorder. Instead, it brackets the question of whether mental illnesses have a natural reality, focusing instead on how cultural categories and individual responses to these categories interact to produce historically specific biographies of mental disorder. The interactive view emphasizes how cultural conceptions of mental disorder shape the behaviors of people to whom these notions are applied and how their reactions to being categorized in turn change the original stereotypes. Interactive social construction sets aside the extent to which fluctuations in types of mental illness reflect or deviate from any natural kind as irrelevant to its intellectual project.
The philosopher Ian Hacking provides the most prominent and incisive interactive social constructionist view (Hacking 1995, 1998, 1999). Hacking assumes a fundamental difference, albeit more in degree than in kind, between mental and physical illnesses. Physical diseases are indifferent to their classifications: Cultural assumptions about bodies have little or no impact in changing the underlying nature of disease. In contrast, classification of mental illnesses can profoundly change how people think about themselves and respond to the way they are classified. Both interactive and indifferent forms of classification are important: “We need to make room, especially in the case of our most serious psychopathologies, for both the constructionist and the biologist” (Hacking 1999, 109).
Hacking uses case studies of particular mental illnesses to illustrate how people are aware of the ways they are classified and how they actively modify their behavior to conform to—as well as struggle against—the ways that others categorize them. He describes a looping effect whereby labeling people in one way rather than another causes them to change their behavior in light of professional classifications. For example, multiple personality disorder (MPD) is a condition in which patients see themselves as having many mutually exclusive personalities that presumably develop as a result of repressed memories of abuse in early childhood (Hacking 1995). Once professionals developed this stereotype they applied it to patients, who themselves came to view their past childhood experiences differently and genuinely came to believe that they had been abused. Their acceptance, in turn, confirmed the validity of the initial stereotype.
Psychiatry forged, rather than discovered, the connection between early child abuse and the later development of multiple personalities. It provided a culturally (p. 564) acceptable mode of expressing distress that became widely adopted (and then quickly repudiated). For Hacking, the truth or falsity of conceptions of MPD and other mental disorders is beside the point: The importance of social constructions lies in the ways in which categorizations change the way that people think about themselves, describe their behavior, and act according to the assumptions embodied in them. People construct their pasts based on which cultural narratives provide them with coherent and satisfying accounts of their distressing conditions, not those that conform more or less closely to some presumably objective disease condition. Mental illnesses thus are likely to develop when ecological niches that exist in specific times and places provide them with fertile grounds in which to grow and flourish (Hacking 1998).
Hacking’s notion of the interactive nature of conceptions of mental illness heightens the complexity of distinguishing what is natural from what is social. For example, we might ask if some natural reality underlies social conceptions of attention deficit hyperactivity disorder (Hacking 1999, 102–103). Yet pure forms of attention deficit hyperactivity disorder (ADHD) cannot be isolated from the ways in which this construction is institutionalized and used, and changes the behaviors, explanations, and experiences of those who are classified. Not just children themselves but also their parents, teachers, and physicians use classifications of ADHD to interpret behaviors and their interpretations shape the resulting behaviors and experiences of the diagnosed people. Moreover, as the term “interactive” suggests, the influences between classifications and individual behaviors goes in both directions. Social classifications profoundly affect individual behaviors but the interpretations and responses of the subjects of classification also can change the initial labels.
The works of philosopher Mikkel Borch-Jacobsen also illustrate the interactive social constructionist perspective. Like Hacking, Borch-Jacobsen considers the question of whether any mental illness is “real” or “constructed” a false one. Instead, he asks: “How is it made? Out of what elements? How does it work? What purpose does it serve?” (2009, 71). Borch-Jacobsen’s studies illuminate the social biographies of mental illnesses such as hysteria, depression, and PTSD. For him, the fact that mental illnesses have particular histories and cultures that are constructed, negotiated, and renegotiated through the efforts of professionals, drug companies, and patients has no bearing on the question of whether they are also natural facts.
Other interactive constructionists emphasize that—although mental illnesses are social constructions—they have genuine effects. Lennard Davis (2008), for example, analogizes mental illness to money, which is a totally human-made invention that lacks any grounding in the natural world but nonetheless has tremendously important consequences. Mental disorders, like money, only exist to the extent that people recognize them. Once they are embodied through social processes of categorization, however, labels take on a genuinely causal power that influence the behavior of those who are classified (Davis, 2008, 7).
Interactive conceptions of mental disorder show the influences of social classification through situating them within institutional practices, social meanings, and (p. 565) interactions. They avoid the problems of the pure constructionist perspective because they do not set relativistic social conceptions against universalistic natural conceptions. Instead, they usefully circumvent the dichotomy of nature and culture by bracketing the reality of the former. One of their shortcomings is that they don’t differentiate the extent to which different sorts of conditions are more or less interactive: Schizophrenia, for example, might be less responsive to social labeling than anorexia or MPD. Another drawback is that—lacking a conception of what is natural—they cannot evaluate and critique the adequacy or inadequacy of various concepts of mental illness. The harmful dysfunction perspective seeks to fill this gap.
23.2.3. Harmful Dysfunction
The harmful dysfunction (HD) conception developed in the prolific writings of Jerome Wakefield (1992, 1999, 2007) is the major conception of mental disorder that joins social to natural considerations. Its use of an evolutionarily grounded concept of mental disorder, which serves as a universalistic base for analyzing social variation, distinguishes it from both the pure and interactive versions of social construction. It diverges from these two perspectives because it assumes that the natural biological functioning of psychological mechanisms, as well as social values, must be incorporated into adequate explanations of mental disorders. Only psychological conditions that are caused by dysfunctions—failures of psychological mechanisms to perform the functions that evolution designed them to serve—are mental disorders. The HD conception uses this universalistic standard as a basis to show how much cultural deviation exists around biologically grounded psychological dysfunctions (Wakefield 2002).
The HD analysis views psychological dysfunctions as conceptually equivalent to physical dysfunctions. Just as the heart is designed to pump blood, the lungs to breath, or the kidneys to process waste, evolution designed psychological processes of cognition, motivation, emotion, and the like to operate in certain ways: Fear emerges in response to danger, sadness to loss, anger to inequity, and so forth. A mental disorder exists when some psychological mechanism is unable to perform its natural function, that is, the function that evolution designed it to do. Dysfunctions, which can lie in the hardware of the brain or the software of the mind, exist when psychological processes either arise in contexts they are not designed for (e.g., fear in the absence of danger or sadness without loss) or fail to emerge in contexts when they ought to arise (serious danger or loss).
There is a major difference, however, between mental and physical dysfunctions. Mental dysfunctions are inherently contextual. In contrast to physical organs, which do not turn off and on but which operate continuously, psychological mechanisms are designed to be triggered in certain contexts and not to emerge in the absence of appropriate triggers. Both cultural and subjective systems of meaning influence what contexts are and therefore what normal responses to them should be. This means that the determination of what an appropriate or inappropriate context for the emergence of an emotion is much more difficult to detect for psychological (p. 566) than for physical functioning. For example, witches and ghosts might be appropriate sources of fear in cultures with meaning systems that emphasize the reality of these phenomena but are inappropriate in the absence of such meaning systems.
Several bodies of evidence indicate the universality of some psychological dysfunctions. Horwitz and Wakefield (2007) use loss response mechanisms as an example. Even though the evolutionary functions of loss response mechanisms are not fully known, findings from studies of primates, infants, and a wide range of cultures indicate that humans are biologically designed to become sad in situations that involve losses of valued close attachments, social statuses, and meaning systems. Nonhuman primates show a clear resemblance to humans in observable features of expression, behavior, and brain functioning in the ways they respond to loss. Loss responses thus appear to be an inherited aspect of the human genome. Moreover, human tendencies to become sad in response to loss appear very early in life before infants have learned culturally appropriate ways of expressing sadness. Further, cross-cultural and historical studies show distinct continuities in the expression of loss across widely different cultural contexts, presumably because these stem from the evolution of humans as a species. The biological roots of normal sadness in no way preclude important social influences in the particular types of situations that trigger loss responses, the sorts of symptoms that arise in response to loss, and the norms regarding the appropriate expression of sadness. While cultural and individual meanings play essential roles in shaping the final expression of emotions, what they shape is biologically embedded.
The harmful component of the HD analysis stipulates that only conditions that are harmful can be mental disorders. When dysfunctions are also socially disvalued, and therefore harmful, they are mental disorders. Because social values always at least partially determine what conditions are harmful, concepts of mental disorders are to some degree intrinsically relative to particular times and places. For example, dyslexia is a disorder in literate societies where it is seriously handicapping but is not harmful, and therefore not disordered, in preliterate ones that neither teach nor value reading (Wakefield 2007). Likewise, social phobias only emerge in groups where anxiety over interacting with strangers leads to social disabilities. Identical conditions can thus be disordered in one group but not in another.
The HD analysis, however, differs from the pure constructionist view because negative social evaluations are never sufficient conditions for the presence of disorders. Many conditions, whether ignorance, ugliness, lack of willpower, or criminality, are also socially disapproved and impairing, but are not disordered because they do not result from psychological dysfunctions. An adequate concept of mental disorder thus requires a factual component that distinguishes disorders from other negative conditions. Only harmful conditions that also stem from psychological dysfunctions are mental disorders.
The HD concept has a number of strong points. Its central notion of dysfunction is compatible with commonsense intuitions that have underlain conceptions of disorder for millennia. Aristotle, for example, associated depressive disorders with internal dysfunctions when he defined them as “groundless despondency” and “beyond due (p. 567) measure” (in Jackson 1986, 32). He thus distinguished disorders from natural emotions that are grounded in and proportionate to external circumstances. It also usefully distinguishes mental disorders, which arise when some internal psychological mechanism is not performing its naturally selected function, from other sorts of deviations such as ignorance, nonconformity, and normal—but socially disvalued—emotions. Only violations of social norms that stem from an inability of a psychological mechanism to perform its natural function are mental disorders.
The HD perspective is also useful because it distinguishes underlying mental dysfunctions, which are universal, from idiomatic expressions of symptoms, which are culturally influenced. It recognizes that phenotypical expressions of mental illnesses can be social expressions of an underlying natural genotype. For example, panic attacks in the United States, ataques de nervios in Puerto Rico, or koro in Melanesia might be differing cultural expressions of a similar core anxiety condition. The HD conception is compatible with the critical role of social factors in shaping the variety of expressions of mental disorders as well as with differing definitions of what behaviors are defined as disordered in particular times and places.
In addition, the HD view provides the grounds for critiquing mental health practices. The failure to perform an evolutionarily designed function is a necessary condition that sets limits on the legitimate use of the concept of mental disorder. A condition that is not a dysfunction is not a disorder. For example, the current DSM definition of major depression conflates normal sadness that arises after loss and that naturally dissipates over time with true depressive disorders that are not proportionately grounded in social contexts (Horwitz and Wakefield 2007). This definition not only medicalizes normal emotions but hampers the search for the causes, prognoses, and treatments of true disorders that are dysfunctions.
Finally, the HD concept usefully distinguishes clear poles of disordered and nondisordered conditions but at the same time is compatible with vague, fuzzy, and ambiguous boundaries between disordered and nondisordered states. Cultural values and social interests, not nature, set the borders between definitions of normality and pathology that are found in any particular time and place. The HD perspective accepts the underlying reality of natural mental disorders while at the same time recognizes that culture has profound influences on the expressions, definitions, and responses to mental illness. Nature and culture do not provide opposing explanations but are complementary parts of a single conception of mental disorder.
The HD conception, however, remains underdeveloped. Knowledge about the natural functions of most emotions, and thus of their dysfunctions, often relies on speculation and awaits further development. The “harm” element, in particular, has not been adequately specified. When wide social variation exists in definitions of harm, designations of mental disorder correspondingly become highly varied across cultures. This feature seemingly invalidates the HD claim to universality. A more coherent natural concept of mental disorder might solely rely on the “dysfunction” component of the HD definition. Harm would then become one of a number of social dimensions that indicate social variation around a universal conception of psychological dysfunction.
(p. 568) 23.3. Social Constructions of Contemporary Psychiatric Knowledge
This section illustrates how social constructionist views can shed light on several issues surrounding current psychiatric classifications. The many psychiatric diagnostic entities in the current official manual, the fourth edition of the Diagnostic and Statistical Manual (APA 2000) are now taken-for-granted reflections of genuine natural pathologies. The origin of this manual lies in the DSM-III, which the profession established in 1980. The DSM-III is viewed as a turning point in psychiatric history because it provided a better and more objective portrayal of natural reality than the psychodynamically oriented DSM-II that it replaced. A president of the American Psychiatric Association, Melvin Sabshin (1990, 1272), called it a triumph of “science over ideology.” Another prominent psychiatrist explained that “the old psychiatry derives from theory, the new psychiatry from fact” (Maxmen 1985, 31). An eminent psychiatric researcher, Kenneth Kendler (1990), proclaimed that “scientific evidence” rather than the charismatic authority of “great professors” stands behind the classificatory systems of the recent DSMs. The DSM diagnostic entities presumably provide evidence-based categories that are based upon underlying natural entities.
The various psychiatric classificatory manuals since the DSM-III enumerate precise definitions of each of several hundred conditions that rely on the presence of given numbers of presenting symptoms. These symptoms can be isolated from the personal histories and social contexts in which they arise and thus can be compared across different individuals who display the same symptoms. Such disorders as major depression, bipolar disorder, posttraumatic stress disorder, attention deficit disorder, and many others are now widely recognized both within the mental health community and the culture at large. How do the various social constructionist perspectives illuminate the development and institutionalization of the DSMs since 1980?
23.3.1. Pure Constructionism
Before the DSM-III was published in 1980, specific diagnoses had a limited role in psychiatry. The earlier manuals, the DSM-I (APA 1952) and DSM-II (APA 1968), used a psychodynamic framework that viewed overt symptoms as disguising a far more complex underlying reality. Unconscious mechanisms could produce a variety of outward manifestations such as anxiety, hysteria, sexual perversions, and character disorders. The same symptoms might stem from different causal mechanisms or distinct symptoms might develop from the same underlying mechanism. For example, depending on complex developmental dynamics, the repression of deviant sexual urges might lead to hysterical symptoms in one person but to obsessive-compulsive disorder in another. Therefore, the manuals that preceded (p. 569) the DSM-III did not place much stake in particular diagnoses because manifest symptoms were no more than clues that often hid the fundamental causes of various disorders.
The DSM-III revolutionized psychiatric diagnosis by providing the profession with numerous conditions that were sharply differentiated from each other, easy to measure, and thought to reflect underlying diseases. The entities of the DSM are so widely accepted that it is difficult to realize how arbitrary many of them initially were. Depression provides an example. In 1976, the prominent British psychiatric diagnostician R. E. Kendell published an article whose subtitle accurately conveyed the classificatory situation at the time: “The Classification of Depressions: A Review of Contemporary Confusion.” Kendell reviewed twelve different systems of classification of depression, none of which had priority over the others. No consensus existed regarding many issues including whether psychotic and neurotic depressions were distinct or variants on a continuum; whether endogenous and exogenous depressions were similar or different; how many variants of depression existed; whether depressive symptoms were continuous or discrete; the relationship of depressive illness to depressive temperament; and how depressive disease was related to normal sadness. In 1979, just a year before the publication of the DSM-III, prominent psychiatrists Nancy Andreasen and George Winokur (1979) concluded that research on depression consisted of “a hodgepodge of competing and overlapping systems.”
Yet the DSM-III definitions almost immediately gained virtually unchallenged acceptance. It is now the authoritative manual used in all settings that require diagnoses, including general medical and specialty mental health practices, research studies, epidemiological investigations, and clinical trials of all forms of treatment. How did a confused hodgepodge of distinct classifications become transformed into such a widely acknowledged, scientific reflection of natural reality in such a brief period of time?
A pure constructionist view emphasizes how the DSM-III arose to help psychiatry resolve the legitimacy crisis it underwent in the 1970s, raise professional prestige, and protect the financial interests of the profession. By the 1970s, the classification system of dynamic psychiatry that was embodied in the DSM-I and DSM-II created serious credibility problems for the profession. In particular, the field lacked discrete disease entities that were foundational for any respectable medical specialty (Rosenberg 2008). The emphasis on understanding underlying unconscious mechanisms and resulting neglect of overt symptoms meant that psychiatrists had trouble defining and measuring the disease conditions that purportedly gave legitimacy to the profession. Psychiatry was mocked within the broader culture for not even being able to recognize what mental illness was (Rosenhan 1973, Szasz 1974). Other medical specialists also looked down on psychiatrists for practicing what they regarded as more of an art than a science. Moreover, competing mental health professionals, including clinical psychologists and psychiatric social workers, could assert that they possessed comparable expertise in treating psychosocial problems. In addition, the growth of third-party funding of payment meant that (p. 570) psychiatrists feared they would have trouble getting reimbursed for treating the often unmeasurable entities of psychodynamic thought. The growing importance and regulation of psychoactive drugs also required a model that assumed that specific disease conditions were the targets of treatment.
The diagnostic paradigm embodied in the DSM-III helped solve many aspects of the crisis of psychiatric legitimacy. It divided the many developmental difficulties, life problems, and distressing conditions in the psychodynamic model into suitable disease entities, in the process providing the psychiatric categories that a medical paradigm demanded. These categories not only justified psychiatry’s place as a legitimate medical specialty but also warded off competition from nonmedical psychotherapeutic professionals who could legitimately claim to provide therapy to people with psychosocial problems in living but had no warrant to treat diseases. Its system of disease categories also fit the demands of third-party payers, which required greater accountability in the results of treatment, and of pharmaceutical researchers and manufacturers, which required specific illnesses as targets for drug treatments. Although the manual rejected etiology as a basis for its definitions of disorders, their formulation as “diseases” could easily elide into the brain-based conditions that biologically oriented psychiatrists and, later, family advocacy groups promoted.
The DSM-III categories gained their acceptance and became “real” through the political, professional, and institutional advantages they had, not from an accumulation of new scientific knowledge. No empirical research had shown that they were superior to alternative diagnostic systems. Their “scientific” nature consisted solely of the fact that they were easy to measure, not that they helped elucidate the etiology, prognoses, or treatments for the various entities they classified. Their adaptation and acceptance had little to do with science but resulted from their usefulness, convenience, and rhetorical value to powerful interest groups. In this sense, they were purely social constructions.
23.3.2. Interactive Constructionism
The pure constructionist view elucidates many aspects of the development and institutionalization of the DSM-III. It also has several limitations. One is that it provides a strictly top-down view of mental illness categories. It neglects the study of how official diagnostic classifications influence the self-conceptions and behaviors of people to whom they are applied and how patients in turn shape these labels to achieve their own ends. In contrast, an interactive constructionist view shows how patients often aggressively seek out and apply disease labels to themselves for such purposes as obtaining drugs to relieve suffering or to enhance performance (Borch-Jacobsen 2009, chapter 13; Conrad 2007). Disease labels also sometimes help to explain otherwise inexplicable symptoms or even to provide valued identities (Hadler 1996, Grinker 2008). In other cases, lay resistance to the DSM categories led to alterations in the diagnostic criteria (Hacking 1995).
The interactive view shows how transformations in psychiatric knowledge can also have wide-ranging consequences that extend beyond the DSM to influence theories of (p. 571) motivation and interpersonal behavior in the broader culture. For example, “chemical imbalance” is the most popular current explanation of mental disorders in the population at large (Carlat 2010). This notion is relentlessly promoted through drug advertisements that emphasize how correctable chemical imbalances cause mental disorders, public service messages that stress how these disorders stem from flaws in brain chemistry rather than in character, and mental health advocacy groups that advance the message that mental disorders are physical, brain-based illnesses, just like diabetes or asthma.
Paradoxically, the growing public acceptance of neurochemical theories of behavior has been accompanied by growing scientific skepticism that chemical imbalances can account for the development of mental disorders (Lacasse and Leo 2005). It is difficult to isolate levels of neurochemicals and, to the extent that this is possible, there is little evidence that, for example, depressed patients have lower serotonin levels than others. Similarly evidence is weak that the most popular class of drugs, the selective serotonin reuptake inhibitors (SSRIs), which elevate serotonin levels, produce better results than treatments that work through other mechanisms. The wide range of conditions that the SSRIs affect, including anxiety, eating, attention deficit, substance abuse, personality, and a host of other conditions, suggests that the drugs are not correcting a specific neurochemical abnormality but are instead acting on very general brain functions that influence many emotional and behavioral systems.
Nevertheless, the notion that levels of various neurochemicals affect a variety of behaviors has permeated into not just popular discourse about mental disorders but also into lay theories of the foundations of self-conceptions and social behavior. For example, some dating sites match couples on the basis of their presumed levels of various neurochemicals. Helen Fisher (2008), the developer of one such site, explains the basic philosophy behind it: “I think we fall in love with someone who has a different chemical profile for dopamine, serotonin, estrogen and testosterone that complements our own. This is the basic premise behind my work with Chemistry.com.”
People also have come to attribute their own behaviors to their levels of these neurochemicals. For example, Paul and Patricia Churchland are two prominent philosophers of neuroscience. A New Yorker profile describes a typical interaction between them:
One afternoon recently, Paul says, he was home making dinner when Pat burst in the door, having come straight from a frustrating faculty meeting. She said: “Paul, don’t speak to me, my serotonin levels have hit bottom, my brain is awash in glutocortocoids, my blood vessels are full of adrenalin, and if it weren’t for my endogenous opiates, I’d have driven the car into a tree on the way home. My dopamine levels need lifting. Pour me a Chardonnay and I’ll be down in a minute.” Paul and Pat have noticed that it is not just they who talk this way—their students now talk of psychopharmacology as comfortably as they talk of food. (MacFarquhar 2007, 69)
The growing public acceptance of neurochemical theories illustrates the interactive nature of explanations of human conduct. A stereotype emerges that chemical (p. 572) deficiencies are responsible for behavior and is relentlessly promoted through ubiquitous advertisements, news stories, Internet sites, and public service messages. People come to use it to explain their own experiences, despite the fact that there is no way that they could know what levels of neurochemicals actually accompany their own behaviors. The increasing penetration of neurochemical theories of behavior into personal and cultural explanations reinforces the power of the original conception.
Interactive social constructionist perspectives illustrate the dynamic relationship between systems of categorization and resulting behaviors. Explanations that attribute mental illnesses to levels of neurochemicals do not stem from the actual locus of symptoms in the brain but from the high degree of credence that the current culture places on brain-based accounts of behavior. Attributing symptoms to depleted levels of serotonin has no more inherent validity as a cultural explanation than attributing them to witchcraft, phrenology, or the unconscious. Once such reasons are given credence, they become grounds to contest notions of responsibility, liability, and stigma. Whether or not they succeed or fail lies less in their correspondence to a presumed reality than in their power as cultural accounts and rationales for particular interest groups.
Neither the pure nor the interactive perspectives can address the relationship between socially created classification schemes and the underlying reality that is presumably being classified. Strict constructionist views deny that such a reality exists because any classificatory system is inherently culturally constituted. Likewise, the interactive view brackets but does not address this issue. Therefore, neither view has a place to stand that would provide a principled critique that can suggest how the DSM and biologically oriented theories of mental disorder could provide a more accurate portrayal of the entities that they classify and study.
23.3.3. Harmful Dysfunction
The grounding of mental disorders in dysfunctional psychological mechanisms provides a basis for distinguishing mental disorders from other sorts of socially disvalued experiences and thus to suggest revisions when the DSM fails to apply this distinction. Two current controversies illustrate the value of the HD perspective for critiquing the current DSM diagnoses.
The first controversy is over whether or not bereavement should be considered a mental disorder. Voluminous evidence indicates that people naturally grieve after the death of an intimate (Archer 1999; Horwitz and Wakefield 2007, 30–33). For example, the earliest known literary portrayals of human experience such as Gilgamesh and The Iliad focus on grief as a basic human emotion. Likewise, while different cultures have varying expressions of grief, sadness and accompanying psychological and somatic symptoms after the loss of a loved one is a universal experience. Even many primates show demonstrable signs of depression-like symptoms after the death of a close relation. In most cases, the universal symptoms of grief dissipate with the passage of time and only a minority of the bereaved remains highly symptomatic after several months (Bonanno 2009).
(p. 573) Current DSM criteria recognize the normality of intense sadness among bereaved people. Criteria for major depressive disorder (MDD) require five or more out of nine symptoms that include sadness or lack of interest or pleasure, last for at least two weeks, and create clinically significant impairment or distress. However, MDD criteria also contain an exclusion criterion for people who meet these criteria as a result of bereavement: “The symptoms are not better accounted for by Bereavement” (APA 2000, 356). That is, people who develop enough symptoms to meet the MDD criteria after the death of an intimate are nevertheless not defined as disordered but instead as suffering from a natural, nondisordered response to loss unless their symptoms are especially severe or long-lasting. Yet many losses in addition to bereavement—the sudden ending of a romantic relationship, the loss of a valued job, the discovery of a life-threatening illness in a loved one—can also trigger symptoms of MDD. The DSM, however, makes no comparable exception for any kind of loss other than bereavement.
Wakefield and colleagues (2007) use the HD conception to demonstrate that bereavement and other kinds of losses have virtually identical consequences in terms of such factors as the number, severity, and persistence of symptoms and the degree of interference with life. There are, therefore, good reasons to believe that bereavement is a model for other types of loss responses rather than a categorically unique stressor. They conclude that intense sadness is a biologically designed response to a broad range of losses, from separation from a love-object to a decline in social status. They thus recommend that, parallel to the bereavement exclusion, depressive symptoms that appear as a response to major losses should not be classified as disorders even when they satisfy DSM symptom criteria.
Despite the great similarities between bereavement and depressive conditions that emerge after other losses, it is unlikely that the DSM-5 will expand the bereavement exclusion. Indeed, the initial recommendation of the DSM-5 task force on mood disorders is to eliminate the bereavement exclusion on the grounds that “evidence does not support separation of loss of loved one from other stressors” (APA 2010). Given the two-week required duration of a major depressive episode, abandoning the bereavement exclusion could result in the massive pathologization of a normal, ubiquitous behavior. Almost everyone experiences the loss of an intimate at some point in their lives. Many, possibly even most, of these grief reactions meet MDD criteria after a two-week period. The proposed change could, at a stroke, define a majority of the population as suffering from a mental disorder. The HD perspective provides powerful criteria that, at minimum, justify maintaining the current bereavement exclusion and perhaps the grounds for extending it to cover other major losses.
While the controversy over the bereavement exclusion shows the value of the HD perspective to critique psychiatric criteria, it also indicates that who is “right” about the nature of the reality underlying psychiatric classifications will not determine the status of the bereavement exclusion or any other controversy over DSM criteria. Instead, factors such as the persuasiveness of arguments for treating as wide a range of people as possible for impairing conditions, the composition of the membership of (p. 574) diagnoses-defining committees, and the interests of pharmaceutical companies and mental health professionals in having the largest potential markets will determine if the bereavement exclusion disappears, remains, or broadens. While the concept of a natural distinction between normal sadness and depressive disorder provides a powerful rhetorical tool, cultural values and social power rather than the accurate portrayal of nature will determine the outcome of this debate.
A second example of the HD critique of the application of psychiatric knowledge lies in debates over the value of screening for depression and other mental disorders. Although mental health practice is far less coercive than in the past, new forms of control continue to arise. One is the establishment of screening programs that attempt to identify people who are not in mental health treatment but who have or who are at risk for developing mental illnesses (Horwitz and Wakefield 2007, chapter 7). For example, New Jersey now requires health care providers to screen all new mothers for signs of postpartum depression. Likewise, many programs have emerged that encourage primary care physicians to screen all their patients for conditions such as depression, anxiety, and PTSD. Adolescents attending schools are an especially common target of screening programs. A presidential commission has proposed that “every child should be screened for mental illness once in their youth in order to identify mental illness and prevent suicide among youth” (New Freedom Commission 2003).
Screening efforts among adolescents arose after studies identified large proportions of adolescents—sometimes the majority—as suffering from depression, anxiety, substance abuse, and other mental disorders. Moreover, these studies found that most of these conditions went unidentified and untreated. Screening advocates view the early identification of such conditions as a means of facilitating appropriate treatments and preventing the subsequent onset of more serious conditions. In addition, they see programs that screen for and subsequently identify mental health problems as a way of thwarting the development of associated impairments such as poor school performance, interpersonal problems, and teenage pregnancies.
Typical screening instruments ask students questions such as the following: Have you often felt sad or depressed? Have you slept more during the day than you usually do? Do you feel tense and nervous when you’re around other people? Youth who affirm a number of these questions—usually a third or more of all students who take these tests—are then given a more intensive, second-stage interview using DSM diagnostic criteria. Those who are confirmed as disordered in these interviews are then referred to mental health treatment. Depending on the instrument used, around 5 to 10 percent of school populations are identified as requiring treatment at any particular time.
The HD perspective provides the grounds for showing how screening programs that aim to detect untreated mental illness are instead more likely to mislabel normal and widespread adolescent distress and emotional angst as mental disorders (Horwitz and Wakefield 2009). It shows how screening instruments pervasively confuse ubiquitous feelings of sadness, irritability, oversleeping, nervousness, embarrassment, restlessness, and the like with mental disorders. These so-called symptoms are (p. 575) common results of normal responses to life stressors, family and school problems, and the natural intensity and lability of adolescent emotions. Most such distressing states will be short-lived and highly situational and so are not signs of mental disorders.
The use of second-stage instruments based on DSM diagnostic categories is presumed to insure that only true cases of disorder are identified. Yet many DSM diagnoses—especially major depressive disorder (MDD)—themselves do not separate normal sadness and other distressing emotions from mental disorders. Because they do not require clinicians to place symptoms in the context of events in adolescents’ lives, they do not distinguish symptoms that are signs of underlying disorders from those that arise from the turmoil and stressfulness of adolescence. Moreover, the two-week required duration requirement for MDD symptoms insures that diagnostic interviews fail to separate the transitory nature of normal emotions from the enduring and often chronic nature of most mental disorders. Yet once adolescents are wrongly identified as disordered they often become the object of surveillance and subsequent drug and psychotherapeutic treatment.
The HD analysis indicates that current DSM definitions pervasively confuse problematic but natural human emotions that develop as responses to stress with mental disorders. It thus provides the grounds for critiquing control efforts such as screening because they misidentify large proportions of adolescents who display normal levels of negative affect in response to stressful events as suffering from disorders that warrant professional treatment. As with efforts to change the bereavement exclusion, conceptual tools can only provide the intellectual foundation for critiquing mental health practice. Interest group politics and the relative success of rhetorical claims that mental health screening programs help identify and treat needy populations vis-à-vis that they mislabel normal distress as mental disorders will determine whether these programs will succeed or fail.
This chapter has focused on one aspect of the social nature of mental disorder: the different ways that cultural and natural aspects of mental illnesses are formulated. It outlined three ways of examining the relationship between psychiatric knowledge and social reality: the pure constructionist, interactive, and harmful dysfunction approaches. These styles provide useful accounts of such issues as the emergence of general systems of psychiatric classification, the adaptation of brain-based idioms for explaining behavior, and controversies over the application of psychiatric knowledge.
The profound social influences on constructions of mental disorder suggest the value of sociological approaches for the study of phenomena that are typically viewed as aspects of individual personalities and brains. Social perspectives can also (p. 576) provide valuable insight on other aspects of psychiatric knowledge such as the structuring of the symptoms of mental illness into culturally appropriate idioms, social influences on the development of mental disorders, the political economy of mental illness, and the contextual reasons for how people come to define themselves and others as having a mental illness and to seek various forms of treatment once these definitions are made, among many others.
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