Throughout history, there have been differing views of how mental illness was thought to occur, and how it should be subsequently treated. For example Greek and Roman philosophers such as Hippocrates and Plato advocated that abnormal behaviour resulted from an internal disease, with Hippocrates believing it was an imbalance of the four humours that were thought to flow through the body (Comer, 2005). As such, physicians of the time treated it accordingly, using a mixture of methods such as “bleeding and restraining” (Comer, 2005: 8) to more supportive techniques such as calming atmospheres and music. However with the decline of the Roman Empire from roughly 500 A.D., a change in perceptions of abnormal behaviour occurred with religion dominating thought over science. As such, mental illness became viewed as arising through possession of the Devil, with the only “cure” being an exorcism by clergymen, or beating and starving the individual (Comer, 2005). However it was only around the 1400’s that mental illness became viewed as a sickness within the mind (Comer, 2005: 10), and as such the asylum was created as an institution to care for the mentally ill, and while often a cruel place, it was seen as the establishment charged with caring for those deemed mentally ill (Scull, 2006).
Yet the main so called change in reform of the mentally ill was attributed to the work of Tuke and Pinel (Comer, 2005: 11) where instead of promoting treatment involving beatings and restraint, they used methods where the mentally ill were allowed to be unrestrained and encouraged to monitor their own behaviour, in methods known as “moral treatment” (Scull, 2006: 115). These methods transformed the way mental illness was handled, however, into the 20th century; many of the mentally ill were still being confined to long term stays in asylums (Comer, 2005).
While this is a very brief history of mental illness, the changing perceptions of the causes and subsequent treatment of the mentally ill throughout history raises several important issues. Firstly, the definition of mental illness has not remained constant and indeed “mental illness” itself has been called “madness”, “insanity” (Comer, 2005: 10) and in the field of psychology, is studied as “abnormal psychology”. This raises the second issue, in that “mental illness” is still defined as something which could be considered deviant or not normal, and as such requires the individual to receive treatment. The field that has been associated and subsequently dominated diagnosis and treatment of mental illness in the 20th century (Summerfield, 2001) is psychiatry. Psychiatry typically draws upon positivist thinking, in that a mental illness is a real and observable phenomenon (Eisenberg, 1988: 2) that must be diagnosed and subsequently treated, with the usual assumption that the illness has manifested due to some biological abnormality (Fisher, 2003).
However while this view continues to dominate thinking within psychiatry, it can be argued that these concepts of mental illness have been heavily criticised and indeed, the institution of psychiatry itself has also been criticised. Therefore the aims of this essay are to firstly examine the problems of the psychiatric approach and how social theory has provided a useful evaluation of how mental illness, rather than existing as real and observable illnesses which psychiatrists must find and treat, could actually be seen as socially constructed. This will then lead into a discussion of the debates around how useful a social constructionist perspective is, before evaluating the institution of psychiatry as a whole, drawing on the work of Foucault and associated theorists, arguing that the psychiatric institution, instead of being a liberating force for the mentally ill, actually exercises methods of social control. Finally this will allow for an assessment of whether these evaluations are more useful to consider than continuing adopting the dominant positivist methods forwarded by psychiatry.
The Problem of Psychiatric Approaches to Mental Illness
The current system which psychiatry utilizes in order to define and diagnose mental illness is the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual, currently in its fourth edition lists what it has defined as mental illness onto 5 axes. For example Axis 1 contains all disorders considered to be related to mental health, from mood disorders to sexual disorders with the exception of personality disorders and what is termed “mental retardation”, which is placed on Axis 2 (Comer, 2005). In addition to this, certain criteria are listed, in order to determine if an individual can be diagnosed with a specific mental illness. For example, depression would be classified as a mood disorder and in order to be diagnosed as having a major depressive episode, an individual would need to exhibit five out of eight symptoms listed persistently for at least two weeks, with one symptom being either “depressed mood” or “loss of interest or pleasure” (Davidson and Neale, 2001: 242)
While this is a useful approach, should a positivist stance be taken in that mental illness is an observable fact, waiting to be uncovered in an individual (Eisenberg, 1988), it becomes problematic when considering two issues. Firstly what has been defined as “mental illness” has not remained constant within psychiatry and has also faced criticism over how it is diagnosed, and secondly, the categorisation of an individual as mentally ill can have serious social consequences such as producing stigma (Thornicroft, 2006).
In addressing the first issue, at the inception of the DSM in 1952, sixty categories were listed as being mental illnesses, and this number increased to one hundred and forty five illnesses in the second edition in 1968 (Balon, 2008), however it was perhaps in the third edition, published in 1980, where the biggest change occurred. Not only has 230 illnesses been identified and classified as illnesses, but a change occurred in which homosexuality was removed as being a mental disorder after campaigning from Gay activist groups (Silverstein, 2008). However the DSM in its current form continues to cause controversy over classifications, especially with those surrounding sexuality, for example it has been questioned as to whether issues such as female orgasmic disorder or certain fetishes should actually be classified as “disorders” (Ussher, 1997: 5). Similarly, classifications for diagnosis have also been somewhat vague. For example, while diagnoses for depression typically include a timeframe in which the symptoms must be present, there is no such temporal criterion for sexual disorders, meaning that diagnosis could be somewhat ambiguous (Balon, 2008: 190).
This idea of the DSMs’ criteria making diagnosis somewhat vague was highlighted in the classic study by Rosenhan (1973) in which eight participants were each sent to twelve different psychiatric hospitals and instructed, at admissions, to say they had been hearing voices, and had heard the words “empty”, “hollow and “thud” (Rosenhan, 1973: 251). Each participant was subsequently admitted to the respective hospital, and upon admission, apart from general nervousness of their situation, continued to behave normally and told staff they were no longer experiencing any symptoms. Despite this, participants were admitted to the hospitals for periods ranging between 7 and 52 days, and all but one was discharged with the diagnosis “Schizophrenia – in remission” (Rosenhan, 1973: 252). While this study is flawed due to its deception and would not have been ethically allowed in modern times, it did raise some serious issues about psychiatric evaluation and diagnosis, with perhaps one of the most troubling aspects being that perfectly sane individuals were labelled as schizophrenic, and likely would have been “stuck with that label” (Rosenhan, 1973: 252).
This leads onto the second problem of psychiatric definitions of mental illness, in that individuals become labelled as having an illness, meaning they are more readily seen as deviating from social norms and as such, reactions to the individual with the mental illness change radically (Bowers, 1998:7). This can often produce a stigma of mental illness meaning once individuals are classified as being mentally ill, they may suffer problems with their family and friends or discrimination at work and this can often be fuelled by media interpretations of mental illness (Thornicroft, 2006).
For example because a mental illness such as schizophrenia is classified by the DSM as having at least 2 symptoms including hallucinations, delusions disorganised speech etc, for a significant proportion of time for a least a month (Comer, 2005: 360), it becomes simplified by the media as meaning a person with a mental illness will be “mad and dangerous” (Thornicroft, 2006: 113). Similarly this transfers into the public who are found to have a “profound ignorance” (Thornicroft, 2006: 231) over what it means to be mentally ill and also problems for mentally ill individuals who are often targets for discrimination and, as such, find their lives change as a result of the label of mentally ill that is imposed upon them.
Alternative Methods of Defining Mental Illness
Given the problems that appear to arise from the dominant psychiatric methods of defining and diagnosing mental illness, it would seem that alternative methods should be considered as to how mental illness should be viewed. One method is to take the definitions of mental illnesses themselves and determine how they have arisen through discourse and how they can be subsequently viewed as socially constructed (Ussher, 1997, 4). For example, the psychiatric viewpoint of mental illness is framed as objectively diagnosing an individual with a mental illness, which is seen to be real and identifiable. However if a postmodern approach was adopted, which asserts that there are no absolute truths, e.g. a mental illness doesn’t just exist, but instead is “different interpretations are formed through language” (Walker, 2006: 71). This would imply that instead of psychiatry objectively discovering a mental illness within an individual, they have actually created a perspective whereby someone who has a mental illness is ill and deviating form the norm, and as such needs to be diagnosed and treated (Walker, 2006: 72).
This social construction of mental illness is done so through the utilization of discourse. In the case of the psychiatric perspective, the view that mental illness is identifiable and diagnosable is taken as truth, with the psychiatrist – patient relationship dominated by the psychiatrist who diagnoses the illness and proceeds to medicate the individual (Armstrong, 1994: 19; Walker, 2006: 74). However while the feelings that an individual presents to a psychiatrist may be very real, the associated labels such as “schizophrenia” or “depression” only exist as they have been agreed upon as taking a certain meaning through language. This can also be the case in viewing mental illness as a whole; the psychiatric discourse has created these categories of mental illness, which become associated with wholly negative connotations, producing severe consequences for the individual. For example, if Foucauldian discourse perspective is taken, this categorisation would provide a definition of how the individual understands their identity, and perhaps more importantly how others view their identity (Roberts, 2005: 38). However this can also end up becoming their identity. For example, instead of being an individual with “schizophrenia”, they become “schizophrenic” and that is their identity.
However if the postmodernist perspective of mental illness is followed through, it suggests that mental illness does not actually exist, nor do the labels that follow it, such as schizophrenia or depression. Instead these are just constructions formed by psychiatry to allow them to categorise people as they feel necessary (Walker, 2006: 75). However this also suggests that individuals who experience these symptoms should not merely be categorised as psychiatry dictates, because, as has been discussed previously, this often produces stigma. Instead, by adopting a postmodernist perspective, subjective accounts of individuals’ experiences should be used to determine how they construct their “illness”, rather than viewing them as ill patients who are deviating from the norm.
For example by allowing individuals who have been “diagnosed” with, say, depression to construct their own discourse around their experiences, more useful information may be sought about how they feel in relation to this diagnosis and may also help to reduce stigma that is associated by the categorisation process employed by psychiatry. For example a study by LaFrance, (2007) utilized the discourse of women, to examine how they constructed their experiences of depression having received a medical diagnosis of depression. The findings from adopting a discourse analytic approach found that the women, upon receiving a “diagnosis” of depression often felt relieved as they could then interpret it as “it’s not my fault” (LaFrance, 2007: 134), however in relation to more physical illnesses, they felt it was difficult to gain a legitimacy for their pain as the actual “illness” was not readily observable “what I wish we could do is like stick a thermometer in your ear and check your serotonin level” (LaFrance, 2007: 134).
By allowing individuals who are “diagnosed” with depression to discuss more openly their experiences of having being labelled as such, it can allow for a reinterpretation of what these illnesses are. Rather than being objectively defined as a pathological entity within the body, using a postmodernist perspective utilizing discourse, mental illness can be viewed from the perspective of the individuals’ experiences of the “pain, illness and distress” (LaFrance, 2007: 137) they encounter. This allows for a removal of mere categorisation and may also help to minimize stigma.
However it should also be noted that while taking a postmodern perspective by deconstructing the labels of mental illness could be useful in providing more insight into individuals’ experiences and as such, minimise stigma, it can have limitations. For example as Ussher (1997) notes, if you take an extreme deconstructionist perspective, a situation is created whereby “nothing is real, everything is just a social label; an invention of those in power” (Ussher, 1997: 5). This could have consequences, in that there are no longer categories which define a “sexual problem” or a “crime”, as they merely become constructions of language. If this argument was followed through, it would mean that issues such as paedophilia would be justified as there would no longer be any reason to warrant criminalising sexual acts with children (Ussher, 1997: 6) and this is clearly wrong. However if a certain level of deconstruction is acknowledged, as mentioned above, it could be useful in creating a shift away from the dominant psychiatric view of an objective diagnosis and labelling system of mental illness.
The Continuing Dominance of Psychiatry
Social Control of Psychiatry
It has been outlined above that drawing on a postmodern perspective of utilizing discourse to deconstruct categories of mental illness forwarded by psychiatry could be useful, particularly in gaining insight into those who experience mental illness and also using that to help reduce the stigma which evolves from labelling and categorising. However, despite the clear faults the psychiatric methods have in defining and diagnosing mental illness, these alternative approaches have not been introduced. It could be said that this is due to the power that psychiatry yields over the mentally ill.
For example, Scull (2006) notes, in the early 19th century, reform of how mental illness was treated occurred by which it became a “condition which could only be authoritatively diagnosed, certified and treated by a group of legally recognised experts” (Scull, 2006: 111). While this change occurred as to who could legitimately deal with the mentally ill, a change, as mentioned above, also occurred into how the mentally ill should be treated, with Pinel and Tuke advocating the notion of treating the mentally ill “rationally and humanely” (Scull, 2006: 114). This may therefore suggest that the 19th century revolutionised how mental illness was viewed and treated, with the idea of the mentally ill being liberated. However, in drawing on the works of Foucault, it could be said that this view is quite misguided.
While Foucault’s’ work is complex and wide ranging, his concepts of power/knowledge and the body have been central to providing an alternative account of the domination of psychiatry and how society views mental illness. For example in Foucault’s (1967 ) work “Madness and Civilization”, a detailed history is provided on how madness has been changed and redefined throughout history. In brief, it is argued that a transformation occurred in that there was a change from the sane person being able to communicate effectively with the madman, to a state whereby the madman is segregated and not to be communicated with (Matthews, 1995: 24). This occurred, as from the Middle Ages to the Renaissance period, madness was seen as moving from an entity which was beyond human life, to something that was inherent within the self. As such, it was seen as something that required individuals with the affliction of madness to be confined, and indeed by the 17th century those who were considered deviant were to be segregated, including the mad, the unemployed, prisoners etc (Matthews, 1995: 25). However, it was seen that they were not confined for their own wellbeing or safety, but instead because they were not contributing effectively to society as normal citizens. Towards the 18th century, it is argued that even with the introduction of more humane methods of treating the mentally ill, such as those forwarded by Pinel and Tuke, this was still seen as a method of control, attempting to transform the mad individual into someone deemed socially normal (Matthews, 1995: 25).
For example, Foucault (1967 [2001: 255-256]) notes that:
“the asylum of the age of positivism, which is Pinel’s glory to have founded, is not a free realm of observation, diagnosis and therapeutics; it is a juridical space where one is accused, judged and condemned, and from which one is never released except by the version of this trial in psychological depth -that is, by remorse”
This implies that the methods considered as being the liberation of the mentally ill in the 19th century, which pre-empted modern psychiatry, were actually methods of controlling the mentally ill. They are labelled as having an illness such as “depression” or “schizophrenia”, which is a deviation from normal functioning, reasonable individuals, and as such, require treatment in order to attempt to return to them to normative state. With this view of modern psychiatry, it could be said that as it is the dominiant institution responsible for mental illness, it acts as a method of social control by having the power to identify “deviant” individuals and attempt to treat them, subsequently cure them of their illness and return them to normality.
Social Control through Surveillance
However, crucial to understanding this method of social control, is to also understand the power that the psychiatric institution holds over the mentally ill, and it could be argued that it is through Foucaults’ (Rabinow, 1991) ideas of disciplinary power. For example, Foucault argued that instead of old methods of control of deviant bodies being used, such as physical punishment (Armstrong, 1994: 21), new methods were created which allowed for bodies to be “observed and analysed” (Armstrong, 1994: 21) through methods of surveillance. To illustrate this idea, Foucault uses the idea of Bentham’s design for an ideal prison, known as the panopticon, where a central watchtower looks over cells distributed in a circular fashion (Roberts, 2005: 34). The method of the panopticon was to be able to continuously observe inmates, however from the inmates’ point of view, they would never know when they were being watched, or if they were being watched at all. This allows for a dynamic in which a power relation is created and maintained, whereby the individual is made a subject, never free from knowing when they are being observed and thus having to correct and monitor their behaviour accordingly (Roberts, 2005: 34).
For example as Foucault notes, “it must be possible to hold the prisoner under permanent observation, every report that can be made about him must be recorded and computed” (Foucault, cited in Rabinow, 1994: 217). While this was referring to prisoners being held as criminals, the concept can also be identified and analysed in relation to psychiatric institutions. For example after a diagnosis of a mental illness has been made, individuals become analysed and evaluations for treatment made, and this becomes documented within medical records. While, as Roberts (2005) notes, that this is standard procedures for care, from a Foucauldian perspective, it could be seen as a panoptic method of ensuring the individual is continually watched and assessed, and should any deviations occur, interventions may used, to correct the deviancy (Roberts, 2005: 36).
However this does not merely occur within an institution, but the levels of panoptic surveillance may occur within an individual’s community. For example if someone is given the identity of “schizophrenic”, they will be monitored by many different professional staff that will assess their treatment and symptoms but they will also be subject to surveillance from family members or friends (Roberts, 2005: 36). This would imply that the methods of psychiatric social control extend beyond simply having the authority to correct deviancy, but instead psychiatric disciplinary power infiltrates many aspects of an individual’s life, meaning they may never be “free” from surveillance of their illness or having an identity of being mentally ill.
This Foucauldian perspective is rather critical of the psychiatric institution, however when considering the stigma that those with a mental illness encounter, it could be a useful theoretical approach to take when considering the dominance of psychiatry. For example, as mentioned previously and highlighted by the Rosenhan (1973) study, a diagnosis and labelling of being mentally ill can become a lifelong issue and often, while being subject to surveillance by psychiatric and medical institutions, individuals are also subject to surveillance by their friends, family and peers, however if what is viewed is negatively perceived, or if the individual does not “correct” their behaviour this can have consequences. For example as Thornicroft (2006: 25) states from an individual with mental illness, “I have lost all my friends since the onset of my illnessaˆ¦I lost my career, my own flat, my car. Mental illness has destroyed my life”. This suggests that again, the dominance of psychiatry, even in modern times, if taken from a Foucauldian perspective, can have drastic consequences for those who are diagnosed with mental illness.
Other Power Relations as Explanations for Psychiatric Dominance
Foucauldian perspectives clearly illustrate that psychiatry can be considered the dominant institution for monitoring those with mental illness, as they are able to “correct” them by means of social control and also the very manner in which psychiatry functions, allows them to survey those with a mental illness indefinitely, through the ideas of disciplinary power. However one other aspect that should be considered as to why psychiatry has continued to be the dominant institution for identifying those who are mentally ill, is their intrinsic affiliations to the pharmaceutical companies (Scull, 2006: 127). For example, in returning to the methods of the psychiatric institution, they take a positivist view that mental illness is real and observable and requiring treatment and they usually identify it as underlying a biological abnormality of brain functioning, such as serotonin deficencies in depression (Comer, 2005).
However it could be argued that it is pharmaceutical industry that continues to allow this approach to be taken. For example, if classifying a mental illness as real and observable with an underlying biological cause, this allows for the assumption that it can be treated, and the pharmaceutical industry fuels this, by providing the medication (Fisher, 2003: 66). However this view is also advocated by psychiatry, because as Scull (2006) and Fisher (2003) argue, the profits that pharmaceutical companies make contribute towards funding “research, the journals and the departments of psychiatry” (Fisher, 2003: 66). As such, the psychiatric profession have an invested interest in maintaining their positivist standpoint, and as this happens to conform to the positivist natural model of scientific research, it has asserted itself as the only reality, due to holding this power (LaFrance, 2007: 128).
Usefulness of the Critical Evaluation of Psychiatry
As can be seen in the discussions above, the evaluations of psychiatry drawing on social theory perspectives have been quite critical, both in terms of how psychiatry defines and diagnoses mental illness, but also how the institution of psychiatry as a whole functions. For example it has drawn from post modern perspectives to suggest that the very notion of mental illness is socially constructed through discourse (Walker, 2006) and from a Foucauldian perspective, the psychiatric institution serves to control the deviant population by attempting to normalise them again through the use of disciplinary power (Roberts, 2005). However, while these evaluations are certainly useful and provide a perspective into how psychiatry and mental illness can be viewed, to take this wholly negative view may be just as problematic as adopting the purely positivist assumptions forwarded by psychiatry.
For example, in addressing the first evaluation that mental illness can be considered to be socially constructed through discourse, as explained by Ussher (1997), if this is taken to the point of an extreme social constructionist perspective, then nothing will actually be considered “real”, just multiple realities created through discourse. This could be problematic for those who do suffer from mental illness. For example interpreting mental illness as something that doesn’t actually exist, or is not definable but merely a social construction is not very helpful for an individual with real symptoms which they experience. For example as Bowers (1998) mentions, to take a view that mental illness is something that could be considered beneficial or non existent is “a failing to accept the reality of their suffering and disability” (Bowers, 1998: 104). As such, theoretically it may be useful to consider mental illness as socially constructed, and indeed given the study by Rosenhan (1973), diagnosis can often be difficult or misinterpreted, for those who actually suffer from mental illness, a “diagnosis” may actually be comforting. For example, in an excerpt from an individual with mental illness, it can be seen that often a diagnosis means that it feels something can then be done. The individual, when discussing her initial diagnosis of schizophrenia recalls “it was so enormously helpful to think; (a) this was something diagnosable, and (b) there are self help groups” (Thornicroft, 2006: 48).
As such, while the psychiatric methods of defining and diagnosing mental illness could be seen as theoretically problematic, as they are known, individuals who are diagnosed may feel comforted to know that the symptoms they experience are not simple constructions, but an actual treatable illness.
In addressing the second criticism social theory has levelled at psychiatry, in that from a Foucauldian perspective, it can be seen as an institution of continual surveillance and social control (Roberts, 2005). This implies that psychiatry exists with a unidirectional form of power, selecting deviant individuals and attempting to normalise them through treatment and surveillance. However it could be said that this power/knowledge approach to psychiatry is somewhat simplistic, implying only psychiatric “experts” are involved in addressing the diagnosis and treatment of “lay peoples’” mental illness, however this may not be the case. As mentioned in the LaFrance (2007) study, sufferers of mental illness have been invited to express their views on their experiences of mental illness and how they viewed their treatment and this can often be used to inform and re-evaluate how these with mental illness should be treated by “experts”.
For example Pilgrim and Rogers (1997) highlight that often those who had experienced mental illness could not contribute the onset to a singular cause but, identified numerous causes such as a loss of a child, previous abuse, having a broken engagement etc (Pilgrim and Rogers, 1997: 42). However psychiatrists typically noted onset as originating from something which was termed “biomedical” (Pilgrim and Rogers, 1997: 43) and as such, by identifying how sufferers view their illness, this can help further inform the “experts”. Similarly, Pilgrim and Rogers (1997) also highlight that there is not “expert” knowledge of mental illness and “lay” knowledge of mental illness but often the two are often intertwined, with expert knowledge becoming subject to “layification” (Pilgrim and Rogers, 39). Therefore to simply assert that psychiatry exerts social control and surveillance over mental illness suffers appears to be ignoring the notion that individuals may not be passive patients and may have their own interpretations and views on their illness.
It is somewhat difficult to determine whether the critical evaluation social theory provides in reaction to the methods psychiatry uses to define and treat mental illness are more useful. For example, while the positivist methodology currently adopted by psychiatry has been problematic given their changing of what constitutes as mental illness (Balon, 2008) and also the reported difficulties in diagnosis (Rosenhan, 1973), it is unclear whether adopting a social constructionist approach would be useful in practice. While it certainly has highlighted the faults of positivist notions of “schizophrenia” and “depression” simply existing (Walker, 2006) and this may help to reduce stigma, given that it is such a widely accepted approach, people in some cases may find comfort in being given a diagnosis (Thornicroft, 2006).
Similarly, while the works of Foucault are certainly insightful in suggesting that the liberation of the insane was merely a different form of confinement through social control, it does provide an assumption that psychiatry is merely an institution whose aims are to normalise individuals through medication and view them as simple, passive recipients of care. However as Pilgrim and Rogers (1997) highlighted, often knowledge which lay and experts hold of mental illness can become intertwined and, indeed, psychiatrists have utilized research into patients’ experiences in order to provide a better standard of care for them.
Therefore this essay would advocate, in a similar manner to Ussher (1997) that neither the psychiatric positivist methods are completely flawless and neither are social theory approaches, such as post modernism or a Foucauldian analysis. However a combination of the two may not provide a better system either, therefore while it is acknowledged that social theory has provided a useful critical evaluation of psychiatry, it is not necessarily a correct one. As such, it may be more useful to consider the individuals who suffer from mental illness as the ones who should advocate h