Guest post. The manufacture of madness? Why social construction in psychiatry is not as simple as it seems

Huw Green

Mental health problems: Constructed or discovered?

Anyone who has spent time reading or listening to psychologists recently is likely to have encountered the idea that mental health problems are ‘social constructs’. What is meant by this is that entities such as depression or schizophrenia and personality disorder, which we might ordinarily think of as diseases; are actually descriptions that flow out of our culture and moment in history. There may be good reasons for thinking about mental health in this way. Anybody who claims that there is no social construction involved in the disorders outlined by the American Psychiatric Association (APA) is unaware of the way the manual is written. Prior to 1952 there was no DSM, and every 15 years or so since, a revision has appeared. These updatings are usually chock full of new diagnoses, many of which have been regretted by the very people who helped bring them into existence. Indisputable though this may be, it is a form of description which can stand in the way of understanding the true complexity of such problems. If they are just constructs then why do so many of the people who experience them find the experience so like a disorder; so real? In order to be clearer about this we need to ask exactly what we mean by social construction.

For some commentators, the implication seems to be that if we stopped talking about ‘schizophrenia’ or ‘personality disorder’, then they would more or less disappear. This is the argument which Mary Boyle appears to make in the final chapter of Schizophrenia: A Scientific Delusion? In this line of reasoning, there is much to be gained from demonstrating that life events, social inequality, abuse, and even the mental health system create ordinary, understandable distress, which then gets inaccurately and arbitrarily labelled. It is likely that this depiction is true in a good many cases.

 However, there are at least two meanings we might intend by saying that something is socially constructed and it is a distinction that is easy to fudge. In the first sense, we could be suggesting that social conventions are the only sense in which something exists (as with, for example, The Human Rights Act, The Premier League and The Church of England) and that a change in our verbal behaviour could eliminate it.

A second meaning would be to draw attention to the fact that certain parts of the natural world cannot easily be spoken about without recourse to elaborate, but potentially misleading, metaphors. Thus the space-time continuum gets referred to as a ‘ rubber sheet‘ ; strands of DNA get ‘ hijacked‘  and the hippocampus ‘ stores‘  memories. These are all constructs insofar as they are they are linguistically created mental images which help us imagine what is going on in reality. None of them is straightforwardly untrue, but if we take them too literally (DNA has never been held up at gunpoint by a primordial molecular criminal) they give us a misleading picture of complex processes.

This distinction between constructs that only exist through consensus and constructs that are created around real entities and processes, is drawn by the philosopher of science Ian Hacking who, in his book The Social Construction of What, explores the ways that childhood sexual abuse, mental illness and even rocks are ‘constructed’ in the latter sense of the word. Much of the debate about the reality of DSM constructs is tangled up in this distinction.

There exist, to paraphrase Wittgenstein, states of affairs in the world. Language meanwhile, is the system we have for trying to describe those states of affairs. Although the states of affairs can’t be changed by the words we speak, the way we furnish our world is no trivial matter, for what we call reality consists both of these states of affairs and the way we describe them.

So what of this second meaning of ‘socially constructed’? When we talk about the world we necessarily translate it into words, conjuring up mental images that move us away from the reality of the thing itself. Cancer is a ‘real’ physical event, but it remains true, as Susan Sontag points out in her beautiful Illness and it’s Metaphors that we speak about it in ways that are unhelpful. Take for example, the suggestion that people ought to ‘fight’ their cancer, implying that the sufferer can somehow do something tangible about their illness by sheer will alone, creating unnecessary misery for people with the disease.

What are the implications of this second form of social construction for our attempts to talk about, say, schizophrenia? One important difference is that although we can still say that schizophrenia is socially constructed, we remain nonetheless able to entertain the possibility that there is a distinct neurocognitive ‘disorder’ in the organism towards which this construct is legitimately trying to point. The definition given in the DSM, which has changed in various ways over the years, is very obviously constructed; a definition after all is just a verbal attempt to capture some state of affairs in the world. Meanwhile, the reality (the ‘state of affairs' itself) is something ‘out there’ beyond language and is not ‘constructed’ in the sense we are interested in here.

If this seems arcane, we should take it back to the level of the concrete. Psychiatric diagnosis is in a protracted state of disarray. There exist numerous accounts attesting to the fact that schizophrenia is frequently diagnosed in people who not only recover rapidly from their distress but feel the label itself does them more harm than good (the articulate Eleanor Longden and Peter Bullimore are prominent examples). Alongside these, there exist accounts (those of Elyn Saks or Peter Chadwick stand as good examples) suggesting that a Schizophrenia diagnosis can act in much the same way as the identification of any other disorder, accurately naming a real problem and flagging up a treatment more useful than any other that has been encountered. These two possibilities suggest a diagnosis that is overly inclusive rather than one which can simply be dissolved.

Under this description, the question is not one of rejecting psychiatric diagnoses but of improving them, both in terms of their design and in the rigidity with which they end up being applied in clinical practice. Part of the answer will lie in finding out the nature of different disabling neurocognitive states of affairs, how they manifest themselves, and how they are exacerbated by our social environment. Only when we have done this, can we stop using existing constructs (DSM diagnoses) and start using a system that resembles not so much labelling, but diagnosing proper.

Huw Green is a PhD student and trainee clinical psychologist based in New York. You can follow him on Twitter here. He blogs regularly at http://psychodiagnosticator.blogspot.co.uk/. 

Those keen for further discussion of the social construction and mental health may find this paper by Michael Walker of interest. (Ed).