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The manufacture of madness? Why social construction in psychiatry is not as simple as it seems

Anyone who has spent time reading or listening to psychologists recently is likely to have encountered the idea that mental health problems are ‘social constructs’. What is meant by this is that entities such as depression or schizophrenia and personality disorder, which we might ordinarily think of as diseases; are actually descriptions that flow out of our culture and moment in history. There may be good reasons for thinking about mental health in this way. Anybody who claims that there is no social construction involved in the disorders outlined by the American Psychiatric Association (APA) is unaware of the way the manual is written. Prior to 1952 there was no DSM, and every 15 years or so since, a revision has appeared. These updatings are usually chock full of new diagnoses, many of which have been regretted by the very people who helped bring them into existence. Indisputable though this may be, it is a form of description which can stand in the way of understanding the true complexity of such problems. If they are just constructs then why do so many of the people who experience them find the experience so like a disorder; so real? In order to be clearer about this we need to ask exactly what we mean by social construction.

For some commentators, the implication seems to be that if we stopped talking about ‘schizophrenia’ or ‘personality disorder’, then they would more or less disappear. This is the argument which Mary Boyle appears to make in the final chapter of Schizophrenia: A Scientific Delusion? In this line of reasoning, there is much to be gained from demonstrating that life events, social inequality, abuse, and even the mental health system create ordinary, understandable distress, which then gets inaccurately and arbitrarily labelled. It is likely that this depiction is true in a good many cases.

However, there are at least two meanings we might intend by saying that something is socially constructed and it is a distinction that is easy to fudge. In the first sense, we could be suggesting that social conventions are the only sense in which something exists (as with, for example, The Human Rights Act, The Premier League and The Church of England) and that a change in our verbal behaviour could eliminate it.

A second meaning would be to draw attention to the fact that certain parts of the natural world cannot easily be spoken about without recourse to elaborate, but potentially misleading, metaphors. Thus the space-time continuum gets referred to as a ‘ rubber sheet‘ ; strands of DNA get ‘ hijacked‘ and the hippocampus ‘ stores‘ memories. These are all constructs insofar as they are they are linguistically created mental images which help us imagine what is going on in reality. None of them is straightforwardly untrue, but if we take them too literally (DNA has never been held up at gunpoint by a primordial molecular criminal) they give us a misleading picture of complex processes.

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