The Social Nature of Mental Illness

Dr. Leonard Bowers

• Publisher: Routledge
• Year: 2003
• Print ISBN: 9780415227773
• eBook ISBN: 9781134587261
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Psychiatrists assert that mental illness is a physiological brain disorder. The anti-psychiatry movement refutes this on grounds of lack of evidence claiming that mental illness is socially defined. Len Bowers offers a rational, objective and philosophical critique of the theories of mental illness as a social construct and concludes that, though sometimes misguided, they cannot be wholly rejected. This critical scrutiny of a controversial and keenly-debated issue will be of interest to psychologists, social workers, psychiatrists, sociologists and professionals in paramedical disciplines.

Chapter 1
Introduction

Psychiatry is a controversial institution. There may be many reasons for this, from regular scandals about its practice to its interlinking with the law. The reason that concerns us here is the nature of mental illness as a social phenomenon. Debate and criticism on this issue are to be found largely among academics from professional psychiatric backgrounds, and the academic disciplines of history, anthropology, sociology and philosophy. Controversy arises from a number of sources: from the polarisation between those arguing for a social or for a physiological aetiology; from efforts to define the essential nature of mental illness; from historical and anthropological data that appear to show variance in the nature of mental illness; and from arguments about the nature of minds and bodies.

The literature arising from these controversies has a lengthy history. In the 1970s it was characterised as ‘anti-psychiatry’, but many of the ideas and discussions appearing then had venerable academic histories and continue to be recycled in different forms to the present day. Nowadays these debates surface most frequently in transcultural or historical psychiatric studies and reflections. Some of the most common ideas received their clearest statement in the labelling and deviancy literature of sociology in the 1950s and 1960s, and discussion in this book therefore starts with this topic.

All these arguments circle like moths around one common flame: the nature of mental illness as a social phenomenon. Unlike physical illness, most mental illnesses have no physiological signs or symptoms, and psychiatrists have no recourse to blood tests, cytology or X-rays to determine their presence or severity. Mental illness is determined and defined by the social behaviour of the sufferer. From this deceptively simple beginning, the debate over the status of psychiatry has exploded in every direction. The questions raised continue to rumble and reverberate below the surface, influencing topics and methods of research, interdisciplinary relationships and the treatment offered to the users of psychiatric services.

It has been argued that mental illness is not really an illness at all, and that when we speak in these terms we are, unbeknown to ourselves, talking in metaphors. Thus when mental illness is treated by doctors in hospitals with drugs, the metaphor is being taken literally. Mental illness is really another way of talking about life problems or the effects of social problems. To treat it as a real illness only serves to cover up the true origins of the problems, whether these be in the life choices of the sufferers or in their political predicament. For example, depressed and battered housewives should not be regarded as suffering an illness which needs treating with drugs, but as people in a predicament which requires moral and political solutions. Some would go on to argue on the same grounds that the compulsory detention and treatment of those who are merely socially deviant is immoral and wrong. Such people, instead of being excused from their actions on the basis of some supposed illness, should be held as accountable for their actions as anyone else.

Unsurprisingly, these arguments have been strongly rejected by psychiatric professionals, whose first response has been to point to the very real nature of mental illness and the disastrous effects it has upon people’s lives. Two other responses are also to be found in the literature: first, that disordered social behaviour implies disordered brain function, and thus mental illness is really a physiological brain abnormality that merits the title disease; second, that all illness, mental and physical, is determined by social criteria and that mental illness is no less an illness because of this. In support of this argument it is pointed out that most illnesses were identified as such long before any physiological mechanism was known or identified. These defences of psychiatry cannot themselves be easily reconciled with each other, and each solution may be associated with differing ideologies about the purpose, organisation and methods of treatment to be used by psychiatric professionals. On the topic of the social nature of mental illness there is no uniform doctrinaire approach, and ideas elsewhere termed anti-psychiatric sometimes have wide currency within certain sections of the discipline itself.

Some of the more extreme critics of psychiatry from sociological backgrounds have argued that because mental illness is defined by social criteria, it is logically impossible for corresponding physiological entities to be identified. Efforts to do so would be like the attempt to find the specific neurophysiology of lying, burglary, bad manners and other such social phenomena. For the same reasons it is sometimes said that psychiatry will never therefore be a natural science, with the development of causal laws about mental illness. At this point all the arguments against a positivist sociology are brought to bear upon psychiatry on the grounds that it has comparable empirical status to that discipline.

Attempts have been made, largely from within sociology, to analyse and describe the social criteria of mental illness. In order to do this, sociologists have generally considered mental illness to be a smaller subset of what they call, in general terms, ‘deviance’. Commonalities between all forms of deviance, or social rule breaking, have then been sought and applied back to mental illness in order to illuminate possible social processes in the identification and treatment of the mentally ill. It is somewhat inevitable that sociologists would seek to understand mental illness in this way, as their major topic of interest is social order. The question that arises is whether mental illness can be analysed in these terms, whether it can be considered as a form of social disorder or social rule violation, in a way that promotes further understanding and does justice to the empirical nature of mental illness as a phenomenon. Furthermore, some sociologists have elevated their consideration of the influence of social processes upon mental illness to the level of a causal explanation. Thus they assert that not only is mental illness determined by social criteria, but that the social behaviour of which it is composed has a wholly social aetiology. If this could be firmly and clearly established, then at least one of the implications would be the discarding of psychiatry as a medical project.

If mental illness is wholly a matter of social processes, what then is its meaning and function? Some have argued that the stigmatisation of the mentally ill is one example of the common human tendency to reject disvalued subgroups and blame them for social troubles. Negative attitudes towards the mentally ill are thus seen as directly parallel to racism and anti-Semitism. For some interpreters these negative social attitudes towards the mentally ill influence the course and outcome of their disorders. Others assert that mental illness has no more reality than the witchcraft of those persecuted under the inquisition—it is socially created in order to provide a group that may act as scapegoat, or an opportunity for ventilation of social frustrations. Thus the argument about the social definition of mental illness ramifies into political interpretations of the institution of psychiatry.

These are not the only deductions which may be drawn from considering mental illness to be a social construction. When imported into social anthropology, it implies that because of social differences mental illness should show extreme variance between different cultures. Whether the variance which is found is to be explained in precisely this way is a matter of dispute. Some scholars take a strong position, asserting that mental illness is completely socially defined, and that its incidence, nature, form, and the efficacy of its treatment vary according to the culture under consideration. One of the implications often drawn from this conclusion is that mental illnesses cannot be properly compared across cultures. For instance, what is considered clinical depression in the West may not be so considered in another culture, may be evidenced in a very different way or may not be present at all. The idea that the aetiological weight of social or cultural factors in a mental illness can be determined by cross-cultural comparison is thus undermined before the attempt is made. Others have, of course, argued completely to the contrary, asserting that mental illness is universal, a position usually coupled with the assertion that mental illness is a physiological brain disorder whose cause has not yet been firmly identified.

Very similar arguments are to be found in the literature on the history of psychiatry. Significant numbers of authorities argue that mental illness is socially defined and has varied significantly from epoch to epoch. Some say, for example, that the huge rises in the numbers of incarcerated insane during the nineteenth century were due to changes in the concept and definition of insanity. If this and other similar arguments were to be accepted, they would imply that the problem of mental illness may be minimised or ameliorated by a change in definitions and their associated social policy.

Upon these common foundations a variety of critiques of psychiatric practice have been constructed. Some have boldly recommended the dismantling of the entire psychiatric enterprise, whereas others have argued for radical reformulations of the nature of mental illness with consequent changes in treatment and research priorities. Yet others have argued for the abandonment of some research methods and strategies in favour of alternative approaches, and some have stipulated limitations upon what can be discovered and known within the realm of psychiatry.

Although these ideas have influenced thinking within psychiatry, they have by and large been rejected by the most influential and powerful professional group in psychiatry: the psychiatrists themselves. Nevertheless, these critiques have influenced the thinking of other psychiatric professionals, and are widely read and absorbed by academic scholars outside the mainstream departments of psychiatry. They thus contribute to internal interprofessional differences and to external appreciations or studies of the institution of psychiatry.

The objective of this book is to uncover and demonstrate the common ground of these interpretations, exposing and tackling their internal logic and consistency, showing much of it to be confused, incoherent or erroneous. All these mainly faulty interpretations circle around the nature of mental illness as a social phenomenon. Some assert a social aetiology for mental illness, some a high degree of influence by social forces and others that mental illness is thoroughly and completely socially constructed. My purpose here is to examine the rationality of these claims, what they might actually mean and in which cases they are to be accepted or rejected. The prime focus will therefore be upon clarification and logical argument. Previous work on this issue has overly concentrated upon arguing from empirical data—all that has been generated from this are opposing interpretations of the data, rather than solutions. These issues cannot be resolved in this way. Clarification can be best achieved by reflection and arranging what we already know. Insofar as this is the case, this book could be characterised as being about the philosophy or theory of psychiatry.

In the course of achieving clarity on these issues, it has been impossible to move without bumping into the cultural furniture of dualism, the nature of evil, life as suffering, the nature of science, etc. The discussion in the following pages is therefore far more wide-ranging than a simple consideration of mental illness alone, and there are implications for a number of areas other than psychiatry. Throughout the following exploration of psychiatric concepts, my guiding light has been the later philosophy of Ludwig Wittgenstein. His technique of dissolving philosophical conundrums through analysis of ordinary language has proved to be of great value in sorting out the conceptual problems of psychiatry. He wrote:

Language is a labyrinth of paths. You approach from one side and know your way about: you approach the same place from another side and no longer know your way about.

(Wittgenstein 1958:I, para. 203)

Thus this book returns again and again to a consideration of the nature of language and of how we use words in order to show the roots and origins of the confusions that arise when considering mental illness as a social phenomenon.

Such is the breadth of territory that this book has had to cover in order to expose the commonality between a variety of traditions within different disciplines that I am very aware that sometimes scant attention has been paid to major figures. There is also, I am sure, much relevant and illustrative material that has been left out. However, to have concentrated any more on single academic thinkers or subject areas would have quickly lost the overview which I have struggled to achieve. One figure that does crop up regularly in the following pages is that of Thomas Szasz. I make no apology for repeatedly using him as an exemplar of certain arguments, as he has more often been rejected than effectively countered.

On the other hand, the work of Laing has not been discussed in great detail. Although a senior figure of that school of thought frequently referred to as ‘anti-psychiatry’, his thinking is of a significantly different nature to that of other scholars considered here. Laing is largely concerned with presenting an existential, psychological and family systems theory of schizophrenia. His thinking has more in common with psychotherapeutic theorising, and therefore his ideas have more overlap with psychotherapy and cognitive psychology, and less relevance to social constructionism.

Although over the following pages I will be arguing that many of the assertions made about the social nature of mental illness are misguided or wrong, this should not be taken to mean that they should be wholly rejected. Indeed, once clarity has been achieved it will be seen that in certain senses the claim that mental illness is socially constructed is eminently correct. This has implications for psychiatry as an institution which will be detailed in the final chapter.

Chapter 2
Deviance

Despite its antiquity, the dominant mode of thinking in the sociology of mental illness is still that of the labelling perspective. It continues to be a central plank in the teaching of sociology on nearly all basic courses, and it makes its appearance in the curricula of both social workers and mental health nurses. In the meantime, labelling theory, and the whole heated controversy over it that took place in the 1970s, has been mostly bypassed by psychiatrists and psychiatric researchers. There is a wealth of written material dating mostly from the 1970s, none of which can really be said to have comprehensively settled the question one way or the other. The theoretical and philosophical issues raised by the labelling debate were never resolved, and have therefore been simply left behind, only to re-emerge in different forms and terminologies in the present day.

This approach to mental illness has two major characteristics: first, mental illness is regarded as deviance from social norms and, second, the effect of the reactions of those surrounding the mentally ill person is greatly emphasised.

CLASSIC LABELLING THEORY

Perhaps the clearest statement of ‘labelling theory’ has been made by Lemert (1951), who made the following tripartite distinction:

1. Primary deviance, the initial deviant act or characteristic.
2. Social reaction, the response of other people to the primary deviance.
3. Secondary deviance, the response of the deviant to the social reaction.

To take then the paradigmal case, the primary deviance of the armed bank robber is the robbing of the bank, the societal reaction is his arrest, conviction and jailing, and his secondary deviance resides in him identifying with other bank robbers and prisoners, committing further crimes and fulfilling the expectations of his custodians and others.

Now the great strength of labelling theory can be seen: the concentration on and description of social process. Labelling theory thus gave birth to a heterogeneous family of sociological studies on marginal and deviant groups and individuals. These studies were able to describe how deviant individuals view themselves, others and their world. Indeed, many of their actions were shown to be guided or constrained by the social reaction to their initial deviance. By carrying out these studies with sympathy, sensitivity and eloquence the sociologists were able to show that sometimes, and in some ways, society’s institutions for the management of deviance and deviant individuals had paradoxical effects. Prisons produced criminal recidivists, mental hospitals encouraged crazy behaviour. By a process of selective attention to some aspects of the deviant behaviour combined with exaggeration, descriptions of social process were used to lend support to political cries for reform, revolution or abolition of some of society’s institutions. So enamoured with irony did sociologists become that it was made to appear that the criminal justice system produced crime, and that psychiatry produced mental illness. Thus the motivations and intentions of those professional and occupational groups who believed that they had devoted their lives to meaningful and worthwhile work were ignored.

This kind of social critique was afforded further strength by Becker’s variation of Lemert’s statement of the theory. Becker (1963) made the whole matter of social norms relative by making out a strong case for deviance not being in fact a characteristic of individuals at all. Instead, he argued, it is the making of social rules that creates deviance, and as social rules vary considerably from place to place, culture to culture and epoch to epoch they have no objective, culture-free, ahistorical status. Deviant individuals are, Becker tells us, those who have been labelled as such and treated in accordance with that label. Whether one is to be considered deviant or not therefore becomes a matter of social contingency, rather than a personal characteristic of oneself or one’s acts.

APPLICATIONS TO MENTAL ILLNESS:
SCHEFF AND GOVE

Scheff (1966) elevated labelling theory into a comprehensive, systematic aetiological theory of mental illness. Mental illness is, to Scheff, publicly labelled residual rule breaking. The picture he has in mind is as follows. Society has a number of residual rules for whose infraction there is no label. These rules are being broken all the time by a variety of people for a number of different reasons and causes. In a small proportion of these cases the residual rule violator is called mentally ill. The psychiatrist is called in, the label confirmed, and under the pressure of the expectations of those around him, the person begins to fulfil the social role of ‘being mentally ill’. The publication of Scheff’s book, Being Mentally Ill: A Sociological Theory, led to a veritable storm of controversy in both psychiatric and sociological circles. Scheff’s main critic, Walter Gove, conducted an open battle with him, mainly through papers and letters in the American Sociological Review (Scheff 1974, 1975, 1976; Chauncey 1975; Gove 1975, 1976; Imershein and Simons 1976). Gove’s main method of argument was to quote empirical studies that countered the tenets of labelling theory. For example, he would describe evidence that there was a tendency for behaviour to be normalised rather than identified as mental illness, that mental illness was partly genetically determined, or t...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• CHAPTER 1: INTRODUCTION
• CHAPTER 2: DEVIANCE
• CHAPTER 3: RULES
• CHAPTER 4: CULTURE
• CHAPTER 5: DIAGNOSIS
• CHAPTER 6: HISTORY
• CHAPTER 7: POLITICS
• CHAPTER 8: ILLNESS
• CHAPTER 9: PHYSIOLOGY
• CHAPTER 10: SOCIAL CONSTRUCT
• BIBLIOGRAPHY