Abstract
In this paper, I provide an overview of social constructionist research on psychiatric diagnosis and classification and discuss its contribution to the ongoing criticism of dominant practices in the field of mental health and of the medical model upon which they are based. The basic premise of the social constructionist perspective is that experience, knowledge and practice are constituted through historically specific interpersonal, institutional and social processes. Research within the social constructionist paradigm attempts to denaturalize phenomena that have come to acquire a taken-for-granted character by highlighting the processes through which these are socially constituted. In the field of mental health social constructionist research focuses on highlighting the contingent, socially produced character of categories of mental distress and of associated professional practices. Within this paradigm, thus, classification, the dominant system of knowledge regarding mental distress, and diagnosis, the practice of assigning a psychopathological category to a person, are not taken as given or as resources, but rather are treated as topics of investigation in their own right. The aim is to examine how these systems of knowledge and practice have come to take their current form, how they are accomplished in practice and finally the consequences for mental health institutions and for individuals in distress.
I will not deal here with the growing literature that examines the historical development of psychopathological categories, deconstructs these categories and discusses the role of commercial and professional interests in psychiatric classification. I focus on empirical studies that analyze texts either of or about psychiatric knowledge and practice. The studies I review belong to the discourse analytic tradition in psychology, as well as to ethnomethodological and ethnographic research in sociology and anthropology.
Investigating the diagnostic process
From a social constructionist perspective, diagnosis is not an act of discovery of a pre-existing entity lying inside the sufferer and manifesting itself in symptoms but a process of actively formulating a case, transforming the client’s experiences to symptoms of a disorder and attributing a disorder to a person as an explanation of the experiences reported. The diagnostic practice itself, then, is worth investigating in order to highlight the processes through which the transformation of a person’s experiences and complaints to symptoms of a mental disorder is accomplished.
Hak (1989, 1992) and Barrett (1996), working in sociology and anthropology respectively, provide genealogical accounts of the transformations through which intake clinical interviews between mental health professionals, prospective clients and their relatives culminate in psychiatric reports. Hak (1989) convincingly argues that psychiatric reports combine statements from the interviews, which are treated as ‘findings’, and statements from the stock of psychiatric knowledge, which are used to formulate the case. Clinical interviews are transformed into psychiatric reports through selecting only information that fits the psychiatric formulation, reformulating that information in psychiatric terms, objectifying clients through systematic deletion of their perspectives, obscuring the professional’s participation and fragmenting the client’s experience in order to fit into the standardized sections of a psychiatric report (Barrett, 1996; Hak, 1989). In this way, the report produced appears to be an objective and disinterested documentation of the client’s symptoms that supports the diagnosis given and the course of action recommended. These studies document clearly the processes of reformulation through which a psychiatric case is constructed out of information regarding a person’s distressing experiences. Moreover, they show how this active process is systematically deleted from the written record, so that the diagnosis appears as a self-evident decision based on observed evidence.
The selective attention to information by mental health professionals is also evident in a conversation analytic study of consultations between psychiatrists and clients with a diagnosis of psychosis (McCabe et al., 2002). This study showed that psychiatrists systematically pursued their agenda of checking the frequency and severity of symptoms in relation to the medication taken. Not only did they fail to engage with clients’ frequent attempts to talk about the content of their symptoms, but their reactions indicated the interactional difficulty that such attempts caused them. This reaction is consistent with the biomedical understanding of psychotic experiences as meaningless symptoms of an underlying mental illness, with which neither professionals nor patients should engage. Once a diagnosis is given and a person’s troubles are reformulated in psychiatric terms, professionals’ interactions with clients actively encourage them to adopt this perspective when describing their experiences. This finding has been replicated in other studies. Clients seem to learn, for example, through repeated interviews with mental health staff, to self-select and volunteer from the range of their experiences only those that are relevant to a psychiatric examination (Barrett, 1996). In her ethnographic study of a psychiatric unit, Terkelsen (2009) described the various strategies through which staff members coach patients into adopting a biomedical explanation for their experiences, taking on the patient identity and assuming responsibility for looking after themselves through constant self-monitoring of their condition and compliance with medication.
Documenting the uses of diagnosis and classification in professional practice
In this section I move from research into the diagnostic process and client-professional interactions to studies of the way in which diagnosis and classification inform professional discourses and practices. Here the focus is on the construction of cases in routine mental health practice through professional meetings and written records as well as on the ways in which professionals draw upon medical discourses when accounting for their practice.
A central site where patient cases are formulated is regular team meetings of mental health professionals, in which patients are reviewed and decisions are taken regarding their treatment. Studies of professional team meetings (Barrett, 1996; Crepeau, 2000; Griffiths, 1998, 2001; Soyland, 1994) reach surprisingly similar conclusions. The meetings appear to be sites of struggle between different mental health professionals, more specifically between psychiatrists on the one hand and non-medical professionals, i.e. psychologists, social workers and psychiatric nurses, on the other. This struggle is reflected in competing conceptualizations of cases using on the one hand a biomedical account, which portrays the patient in question as a passive sufferer of a biochemical imbalance, uses a diagnostic label and culminates in proposals for medical interventions, or on the other hand a social account, which portrays the patient as an active agent with beliefs and desires, locates the patient’s problems in the context of his or her personal and social circumstances and is linked to supportive, practical and welfare interventions. The negotiation of competing versions in the course of team meetings serves a variety of functions regarding organizational requirements, staff workloads and allocation of resources. What these studies clearly show is that diagnosis and classification, or more generally the application of a medical understanding to people’s experience of distress, is not a straightforward and uncontested matter, but that it is actively negotiated against other possible understandings. Moreover, competing conceptualizations are tied up with power struggles between mental health professions, lead to different courses of action regarding intervention and, finally, serve a variety of institutional functions.
Studies of written documents, on the contrary, reveal a more uniform way of conceptualizing patients’ problems within the medical paradigm, possibly because written records are permanent, more highly institutionally regulated and constitute sites of demonstration of professional expertise, competence and accountability. Written records, more than verbal exchanges, determine the way a person’s distress is understood and treated within mental health institutions, as the person’s transformation to a psychiatric patient is effected through a successive series of records that constitute interpretations of previous interpretations of the patient’s condition (Barrett, 1996; Hak, 1992). Clinical records are effectively selective reformulations of verbal accounts and previous records and their function is to construct a unified story of the patient in question over and above the various stories told by the different parties concerned, by prioritizing those elements that combine together neatly to paint a picture of a mentally ill person. Clinical records are represented as factual, neutral and objective descriptions and explanations of the patient’s history and condition. This is achieved through systematically removing from the record elements that indicate the professionals’ active role in formulating it and privileging clinical observation over patient perspectives. The main functions of clinical records are to render patient histories understandable, patients treatable and clinicians knowledgeable and effective (Swartz, 1996).
The use of the medical discourse of diagnosis and classification by mental health professionals is also apparent in studies which seek professional views on various aspects of clinical practice. Starting with the process of diagnosis itself, it seems that psychiatrists alternate between two modes of explanation for their diagnostic decisions, an empiricist account, which presents diagnosis as an objective process of identifying symptoms in a way that is consistent with scientific-medical understanding, and a contingent account, which acknowledges the implication of the subjectivity of the diagnoser and professional inclinations in the diagnostic process (Harper, 1994, 1995). The psychiatrists interviewed in Harper’s study shifted between the two kinds of accounts depending on the context of the argument; the use of each account served a variety of functions. On the whole, it seems that the production of empiricist accounts enables professionals to retain their scientific credentials while the use of contingent accounts allows an appeal to personal and contextual factors in order to explain elements of uncertainty and variability in diagnostic decisions. Similarly, when talking about depression in the context of research interviews physicians were found to oscillate between a medical understanding of depression as a biological condition and a more social understanding of the role of context in depression (Thomas-McLean and Stoppard, 2004). However, studies of the ways in which professionals account for controversial issues, such as the use of ECT (Johnstone and Frith, 2005; Stevens and Harper, 2007), medication failure (Harper, 1999), adverse effects of medication (Liebert and Gavey, 2009) and violent episodes in psychiatric wards (Benson et al., 2003) have consistently highlighted the central role of medical discourse. Professionals justify practices such as administering ECT or prescribing medication despite their controversial character through on the one hand positioning their recipients as severely mentally ill, stressing the biological basis as well as the chronicity and severity of the patients’ symptoms, and on the other hand portraying themselves as expert medical practitioners, who apply medical procedures while rationally weighing risks and benefits.
The studies presented in this section highlight two central aspects of the role that classification and diagnosis play in professional discourses and practices. On the one hand, they demonstrate the flexible, contextually bound and functional character of the use of diagnosis and classification. Professionals draw upon a variety of conceptual frames and lines of argumentation depending on the context and the functions their actions are called upon to serve. On the other hand, these studies highlight the dominance of medical discourse, which seems to serve as the backdrop for the employment of other discourses and the fallback discourse when the expert status of professionals is challenged. It is not accidental, I think, that professionals will negotiate competing versions of client problems in team meetings and will flexibly draw upon biological and social understandings when discussing mental health issues in a neutral setting, but they will fully adhere to a medical account in written records and when their practice is challenged. In professional discourse openness and flexibility seem to be predicated upon the unquestionable acceptance of the value of the medical model as the foundation of clinical practice.
Examining the consequences of diagnosis and classification for persons in distress
Individuals in distress are positioned within the medical model as patients, sufferers of a biological condition. The use of the medical discourse of mental disorders is not restricted to the medical profession and mental health services but permeates contemporary culture and is prevalent in the way people talk about their experience, even if they have never been in contact with mental health services. Discourse analytic studies have shown that individuals with a diagnosis of depression (Lafrance, 2007; Lewis, 1995) and premenstrual syndrome (Swann and Ussher, 1995) readily reproduce a medicalized version of their problems. Through the appeal to medical discourse, participants’ troubles are separated from their self and their life stresses and located within their body, and this gave their condition legitimacy and enabled them to disavow responsibility for their distress. The participants in these studies tended to draw upon other discourses as well, either in a way that was complementary to medical discourse or as alternative understandings of their distress, and this potentially allowed them to develop ways of understanding their experience outside the dominance of the medical paradigm.
On the other hand, the positioning of a person as a patient in the medical discourse, especially with regard to severe mental health problems, has serious repercussions regarding the person’s agency and credibility. Individuals positioned as patients find that the accounts of their experiences are undermined as products of their disturbed mental condition and they often have to negotiate and actively dispute their positioning as a patient and the meaning of that positioning in order to regain credibility and self-determination (Benson et al., 2003) or to legitimate their version of reality (Georgaca, 2000, 2004; Harper, 1995).
The studies presented above develop a critique of the concept of mental illness through examining the consequences of the biomedical understanding of distress for individuals experiencing it. Another fruitful line of investigation would be to highlight alternative non-medical understandings of distress, as a way of publicizing and disseminating more empowering perspectives. Social constructionist research has not gone very far in this direction, and this is arguably one of its limitations.
Conclusion
Social constructionist research on psychiatric classification and diagnosis has investigated the processes through which the dominant medical understanding of mental distress is enacted in mental health practice and drawn upon to account for experiences of distress both by mental health professionals and by people with experience of distress. More importantly, it has highlighted the contextual and functional character of the medical discourse and of other discourses, as well as the consequences of these discourses for mental health theory and practice and for people in distress. The contribution of social constructionist studies to the developing critiques of psychiatric classification and diagnosis, I would argue, is in the direction of denaturalizing and destabilizing psychiatric knowledge and practice, thus opening the way to alternative, more empowering understandings of and practices dealing with distress. As to what these understandings and practices might look like, social constructionist research has not had much to contribute to date, and possibly this lies beyond its remit, to be pursued by other forms of research and even beyond scientific investigation, in the realm of mental health activism.