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by Joan Busfield (editor)
Blackwell Publishers, 2001
Review by Christian Perring, Ph.D. on Aug 12th 2002

Rethinking the Sociology of Mental Health

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, I’ll 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 important—the basic idea being that how people diagnosed with mental illnesses are treated depends very much on the given diagnosis rather than the person’s 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).  What’s striking about this view is that it makes clear that there’s 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 person’s social position and status will determine the resources they have at their disposal in order to define and protect … 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.  It’s 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 doesn’t engage in the philosophical literature that has approached these issues with more rigor.

Julie Mulvany’s 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-Ponty’s phenomenological framework is capable of expressing and assisting such frightening aspects of agoraphobic existence.  (p. 110)

I’m 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, Davidson’s 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 Scheff’s labeling theory.  It’s 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.  Scheid’s 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.

Christian 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.