Julie Mulvany suggests at the start
of her contribution to this book sociologists appear to have abandoned the
study of serious mental illness. This
is an odd claim to include in a book that aims to take thinking about the
sociology of mental health forward, as Joan Busfield says in her introductory
chapter. The contributions to Rethinking
the Sociology of Mental Health are varied in their approaches but they are
strong enough that Mulvany is unduly pessimistic the field.
It seems to be a truism that
sociology takes a liberal, leftist, or radical approach to its subject matter,
and the papers here are certainly no exception. The underlying assumption of the authors is that the way that
society treats mental illness is deeply flawed, and the best solution is to
change our social practices. In this
review, Ill briefly discuss each paper.
Joan Busfield provides a very
useful survey of contemporary sociology of health; she starts with the concern
that the understanding of medicine is becoming dominated by genetics, and the
understanding of psychiatry is dominated by neuroscience. Busfield emphasizes that a sociological
approach to mental health and disorder is still essential. She refers to the work of Talcott Parsons,
Thomas Scheff, and Michel Foucault, as well as a host of lesser-known
sociologists. She argues that labeling
theory is still very importantthe basic idea being that how people diagnosed
with mental illnesses are treated depends very much on the given diagnosis
rather than the persons actual mental state.
She suggests that the areas for future research include the linkages
between the body and mind and the biological and the social, the sociology of
the emotions, the analysis of risk, the role of the pharmaceutical industry and
its relation to mental health practice, as well as the epistemological and
ontological assumptions on which sociological work on mental disorder is
grounded (p. 12). Whats striking
about this view is that it makes clear that theres little distinction in
content to be made between sociology and other academic disciplines such as
ethics, philosophy and social psychology.
The differences between the traditions lie far more in their
intellectual heritages, styles, and methodological assumptions.
Simon J. Williams gives us a
particularly philosophical paper with Reason, emotion and embodiment. He discusses the relation between emotions
and rationality, providing a short survey of western philosophy
unsurprisingly, he is critical of the Cartesian tradition. He instead favors the notion of embodied
agency and is clearly strongly influenced by the work of J. Barbalet. He refers to a great many theorists, but his
central claim seems to be that a persons social position and status will
determine the resources they have at their disposal in order to define and
the boundaries of the self (p. 26), which is plausible enough. Williams gives his claim more bite when
applying his approach to the current approach to depression; he makes the
striking suggestion that it is indeed quite normal if not healthy to feel
dissatisfied, disillusioned or even downright depressed at times; not simply
due to prevailing ideologies of happiness and personal fulfillment, but also
because of the embodiment dilemmas and existential predicaments we all, qua
humans, inevitably face (p. 29).
Whether this suggestion is striking because it gives us a powerful
insight or a banality dressed up in academic disguise may be a matter of
opinion, but it does seem to trade on an equivocation in the meaning of normal:
depression may well be normal in that is an expected reaction to life
circumstances, in the same way that it is normal to experience cuts and even
deeper wounds, but it does not follow from this that depression is
healthy. Its clear that Williams is
giving an argument for that staple of medical sociology, the claim that
medicine is co-opting normal conditions to expand its domain he even refers
to Brave New World.
Unfortunately, his argument is short on empirical grounding for its
central claim, and doesnt engage in the philosophical literature that has
approached these issues with more rigor.
Julie Mulvanys paper Disability,
impairment or illness (which previously appeared in Sociology of Health and
Illness, 22(5), 2000, contrary to the assertion on the back cover that all
the papers here are original) is one of the most interesting in the book. It compares the work of sociologists on
mental illness with the work of sociologists on disability. In disability studies, the medical model of
disability, in which the person with a disability is seen as having a deficit
and therefore being less able to participate in the world, is contrasted with
the social model of disability, in which a person with functional impairments
of mind or body is seen as disabled by the ways society has excluded people
with such differences from the practices of ordinary life. Mulvany argues that sociologists of mental
illness have a great deal to learn from the social theory of disability, and
her argument is a rich one. She faults
disability studies for paying little attention to psychiatric illness, and does
a great job at building bridges between the two areas of study. She writes without resorting to jargon and
gives a strong argument for her main claim.
Mick Carpenter analyses mental
health policy under welfare capitalism since 1945. He compares three approaches to understanding social policy:
social democratic, Marxist structuralist and poststructuralist, and applies
these to the USA and several European countries. He concludes that not fiscal crisis alone, but its combination
with neoliberal political control that accelerated the emergence of a downsized
psychiatric system in both the USA and Britain, and that the differences as
well as similarities between the two countries indicate that the institutional
inheritance of social democracy made a positive impact in Britain even in a
neoliberal era (p. 63). He builds on
the work of Esping-Anderson and his discussion may well become rather obscure
to those readers who, like myself, are unfamiliar with the theorists he discusses. His discussion of a very broad topic seems
to be rushed given the space limitations, and even without following the
details, readers may suspect that it is very difficult to make convincing
arguments about the explanation of major social trends in such a short paper.
Nick Manning grapples with a
slightly more manageable topic; the legitimacy of the diagnostic category of
personality disorder. He briefly
discusses the approach of the DSM and the grounding of psychiatry, compares DSM
with ICD, then goes into the history of the category of borderline personality
and antisocial personality disorders, and then comes to a conclusion. He does not think that the personality
disorders have a strong scientific basis and he outlines an argument showing the
problems in validating these categories.
But really his topic is too large to be susceptible of such brief
analysis, and it is best taken as a suggestion of an approach for a longer more
detailed examination of the issues concerning the personality disorders.
Joyce Davidson examines the phenomenology
of agoraphobia, inspired by the philosophy of Merleau-Ponty. She goes into one particular case history in
some detail, the story of a single mother living in a Scottish village. She concludes,
The contested lived spaces of others jar the senses,
and they can become overwhelmed and anxious to the extent that they suffer from
a full-blown panic attack. This chapter
has shown that Merleau-Pontys phenomenological framework is capable of
expressing and assisting such frightening aspects of agoraphobic
existence. (p. 110)
Im not convinced that we need to
bring in jargon-laden philosophy in order to understand and even partially
explain the lived experience of phobias; a well-written memoir can do a great
deal to convey what a mental illness is like.
Nevertheless, Davidsons project is an interesting one and her argument
is worth scrutiny.
Derrol Palmer provides one of the weakest chapters
with a discussion of who gets to decide who is delusional. Palmer argues that there is no objective
criterion of delusion, and that the real determination of who is delusional is
a matter of power. He makes the claim
that the psychiatrist and patient both have self-confirming epistemologies, but
the psychiatrist has more power than the patient, so when the psychiatrist does
not agree with the patient, he labels the patient as delusional. Clearly this work is very much in the
tradition of Scheffs labeling theory.
Its a tremendously crude approach, and does very little to examine the
considerable body of work within psychiatry that has attempted to define the
nature of delusion. Palmer goes into
considerable and unnecessary detail analyzing an exchange between a
psychiatrist and a delusional patient in an attempt to make his argument. Palmer wants sociology to challenge
psychiatry, but it is hard to imagine any psychiatrist being at all impressed
by his argument for the relativism of the epistemology of delusion.
Much more impressive is the paper of Bernadette
Dallaire, Michael McCubbin, Paul Morin and David Cohen on civil commitment due
to mental illness and dangerousness.
The authors ground their paper on impressive empirical studies,
comparing law and psychiatry in Britain, Canada and the USA. They take a highly critical stance toward
psychiatry, and marshal powerful arguments that psychiatry does not employ
objective criteria when labeling the mentally ill as dangerous. They warn in
their conclusion that The net result of a dangerousness criterion, then, may
be to manifest, reinforce, and reproduce stereotypes depicting as threats to
public safety persons who experience severe psychological distress or
disturbances (p. 146).
The final paper, by Teresa Scheid, focuses on the
role of managed care in the provision of services for the mentally ill. She builds on the work of many researchers,
especially that of David Mechanic in his important book Mental Health and
Social Policy. Scheids own
research is primarily based on interviews with clinicians in private practice
and their experience on how the business of managed care has changed the
quality of services they provide.
Overwhelmingly they report that they have been prevented from giving
people in distress the therapy they need to recover fully. While her sample size is small, her research
gives strong reason to be very concerned about the effect that managed care is
having on our society.
Overall, this is a valuable collection of
articles. Even though some of my
comments have been critical, I am encouraged that sociologists are expanding
their methods by turning to other academic disciplines such as philosophy in
examining mental health. Any
satisfactory study of mental illness must be interdisciplinary to some extent,
and it is important to include a sociological stance. Busfield is certainly correct about the dangers of an overly
reductionist theory of mental illness relying purely on genetics and
neuroscience. But these papers also
demonstrate the dangers of relying on overly simplistic sociological approaches
to mental illness, especially in the excesses of labeling theory when it
neglects the real differences between normality and pathology. This collection shows some of the latest
work in sociology with its strengths and weaknesses, and it also enables the
reader to learn about roots of current sociological thought. It will be valuable to any researchers
interested in the foundations of psychiatry and the ethical assessment of our
treatment of people with mental illnesses.
© 2002 Christian Perring. All rights reserved.
Perring, Ph.D., is Chair of the Philosophy Department at Dowling College,
Long Island. He is editor of Metapsychology Online Review. His main research
is on philosophical issues in psychiatry. He is especially interested in
exploring how philosophers can play a greater role in public life, and he is
keen to help foster communication between philosophers, mental health
professionals, and the general public.