As some of you may have guessed by now I am currently reading a book on “Social construction” or social constructivism or constructionism by Ian Hacking called the “Social Construction of What?”. At the risk of boring certain members of the audience even further (audience what audience?). I want to give a resume of Chapter 5 (pp 100 – 125) entitled “Madness: Biological or Constructed” and maybe draw a few conclusions of my own.
There are many controversial diagnosis in psychiatry (Intermittent explosive disorder, ADHD and conduct disorder in children, Sexual addiction and personality disorder in adults) where it is suspected the medical profession is medicalizing certain aspects of behaviour that until recently were considered deviant, naughty, normal or criminal but which are now seen as an illness in need of treatment. There are also cases of diagnoses that have gone the other way (homosexuality and moral imbecility) have all dropped out of current usage and are no longer considered illnesses.
Some mental illnesses are described as transient, they show up at a specific moments in time and place and then mysteriously disappear. Examples include hysteria in 19th century France, Multiple personality disorder in 20th century America and Anorexia which can according to Hacking can be quite local in its history and at the time of writing was particularly virulent in Argentina of all places.
But is there a sense in which mental illness is “constructed” or is it “real” and if mental illness is real what do we mean by real? Hilary Putnam had this to say about reality:
“ (there is a ) Common philosophical error of supposing that reality must refer to a single super thing, instead of looking at the ways we endlessly renegotiate – and are forced to renegotiate – our notions of reality as our language and our life develops”
So is there a sense in which reality is constructed and the dichotomy between what is considered real and constructed a false one in this case? “Socially constructed” and “real” do appear to be at odds with each other. Psychiatry is a part of medicine which views itself as a branch of the natural sciences dealing in “real” things not stuff which has been socially constructed or made up by social workers. Psychiatry sees schizophrenia at its heart as a biochemical/ neurological/ genetic disorder but a minority of critics think that the disorder itself has been socially constructed. Is there a way of reconciling these apparently incompatible views? Hacking thinks there is.
Hacking describes interactive, indifferent and natural classifications or kinds of things. He believes the idea of an indifferent kind of thing can be adapted to resolve the differences between the biological and constructionist camps. Hacking defines an indifferent kind as one that does not interact directly with its environment but is not entirely passive either. Electrons are indifferent to the idea of electrons and do not interact with the concept of what it is to be an electron and so remain unchanged by the concept. Electrons are there fore a natural kind of thing because they have no agency and act as a philosopher would say under description. Likewise the diagnosis of schizophrenia is indifferent to what it means to be a schizophrenic but a schizophrenic on the other hand is conscious of what it is to be schizophrenic and is changed by that diagnosis. Schizophrenics when allied with others who have the same diagnosis (Schizophrenia fellowships and interest groups) are able to influence the diagnosis which in turn changes how the diagnosis is viewed by those so diagnosed. There is in effect an active dialogue between the diagnosis and the diagnosed which evolves over time. A similar dialogue may be occurring between notions of what an electron is thought to be by scientists and how it is thought to behave in the laboratory but this has nothing to do with any independent thought or action carried out by electrons.
The word “kind” was first used in this context by JS Mill and William Whewell and was used to describe the way in which the thing or group being classified interacts with the classification and vice versa. The interaction between kinds and their classifications can be strong or weak in nature and occurs through a looping effect described above in relation to how a diagnosis of schizophrenia changes the individual and is turn changed by the individual. The social sciences (sociology, anthropology, psychology?, Psychiatry?) have for a long time tried to emulate the natural sciences (physics, chemistry, biology, medicine) to identify “true or natural kinds” that is kinds which are fixed and have an objective reality and nowhere is this more clearly demonstrated in Psychiatry than in the research to discover a neuro-chemical basis for schizophrenia.
Indifference does not necessarily imply a fixed and passive response. Schizophrenia may not interact with the idea of schizophrenia but schizophrenics interact with the business of psychiatry and with the psychiatrists who are attempting to treat the condition (or are they treating the individual?). When philosophers talk about natural kinds the indifferent nature of the kind in question is in a technical sense taken for granted, but natural also implies a fixed and passive quality that is not necessarily implied by indifferent. Things classified as natural are not aware of being so classified and do not interact with their classification but schizophrenics do react with their classification or diagnosis so schizophrenia, as it affects the individual, should according to Hacking, be seen as an indifferent rather than as a natural kind.
The targets for the natural sciences are relatively stationary; the targets for psychiatry (literally and figuratively) are, owing to the looping effect, not. The term Schizophrenia was first coined in 1908 by Eugen Bleuler but descriptions of schizophrenia like symptoms are to be found in the Egyprian Ebers Papyrus (BC 2000) and in ancient Greeks and Roman texts which describe symptoms of psychosis but not in a way that would satisfy a modern diagnosis of schizophrenia. However there is a widespread conviction in the psychiatric profession that like America, the condition was always there and waiting to be discovered and will continue to be with us as long as there are people around unluckily enough to be so afflicted. In the constructionist camp disorders like schizophrenia are interactive and essentially man made, in the biological camp they are fixed and timeless. Hacking thinks there is a middle ground by describing mental illnesses like schizophrenia as indifferent.
N.B. Hacking is describing the condition schizophrenia as it affects the individual as an indifferent kind he is not describing those diagnosed with schizophrenia as indifferent to their condition.
“Does mental illness exist”
Why yes, yes it does.
Wow, Shrink solved that debate pretty quick. I’ll e-mail Thomas Szasz and let him know.
Sorry E, Monkey Boy may have to precis this for me, this post is a light year over my head.
Psychiatry is a soft science. With bits of actual science running through it. Schizophrenia is a complex word / diagnosis with different meanings depending on if you are on the diagnosing or being diagnosed side of things. People are not electrons. Schizophrenia may in part be a self fulfilling dianosis (make up a label and they will come), it may also be something that actually exists.
None of which makes much difference to how nurses should nurse. Treat people as people first not as a walking talking illness. Help people improve the quality of their lives in partnership as much as possible. Base practice on best evidence and experience.
I did get a little confused near the beginning so may have lost track somewhere.
I’m glad I wasn’t the only one… a little complex for me – but in the context of ‘constructivism’, and in a medical vein rather than (or as well as) a social one:
Mental illness diagnosis is a complexity of subjectively observed/reported phenomena aligned to a diagnostic ‘checklist’.
Hence, and as an aside, I’ve always preferred the approach of treating each phenomena by specific psychological intervention – or problem solve the presenting issues – when they present as a problem, not just because they present.
(eg manic spending for Bill Gates would not perhaps present the same problem as it would for many).
Not sure if I read it right – but is ‘indifference’ inferring perhaps that there is a science and a nature to the issues that needs to come together?
oldschoolbaby – I’d paraphrase it as: Some people think schizophrenia is a disease like other diseases. Some people think it’s a social fiction. Hacking thinks it’s a bit of both. It’s not a disease like other diseases because schizophrenics can affect what gets called schizophrenia. From the description of his argument above he doesn’t really explain why he think this means it’s not a construct. Perhaps he does.
Anyway… I’m sure I had a point…
Isn’t this all just hand-waving though? We have no way to resolve this dilemma at present. So we can choose to see schizophrenia as constructed, indifferent or natural, but talking about it isn’t going to reveal which is right. And really, all this hand-waving about kinds and agency is just an attempt to have it both ways, to pretend that classing mental illnesses as constructed wouldn’t compromise their status as diseases (and the status conferred on people affected as ‘ill’ rather than ‘weird’, as ‘recluse’ rather than ‘pariah’).
At least I put pretty pictures on my posts
It’s a collection of symptoms that have been given a name, it’s funny how the number of diagnosable mental health problems just grows and grows though to accomodate what people are experiencing. You see misdiagnosis, difference of opinions between professionals and in some cases, symptoms but no underlying disorder. For some people diagnosis is a relief, they can seek specific treatment for a specific illness, there is a reason they experience what they do, for others, it could mark them for life.
If you recieve a mental health diagnosis, the likely hood is that it will appear on every referal letter or report your G.P. ever writes, reguardless of whether you have recovered.
Mr H’s model works particularly well with autistic spectrum disorders. It won’t, however, on an acute ward full of florid schizophrenics. And don’t say ‘societal construct’ to an autistic with decompansatory psychosis, caused by enviromental stressors. Bludgeoning to death with non-medical social models is the leading cause of work-place fatalities in Psychiatric Care.
Well if mental illness doesn’t exist: -
What on earth have they been doing with me for the past 18 months?
What would we do with all the Psychiatrists and Nurses and Social Workers?
Does it mean I get my real life back now pleae?
Well, all that’s a bit over my head, I’m over here in the science corner with my IT stuff. So let’s make this whole mental health model a bit simpler for the likes of me shall we:
IF RespondsToMedication == TRUE
THEN
CALL Duty Psychiatrist
TAKE Medication
GOTO Sleep
ELSE
CALL SocialWorker
GOTO CBT
END
Just kidding – no-one writes FORTRAN or uses GOTO statements much anymore
… actually, that’s not true. About the FORTRAN. But I don’t. Friends don’t let friends write FORTRAN. I’m FORTRAN free since 1993 
.
Dammit, Z, the blog software doesn’t indent properly. That makes it look like I don’t indent my code!!!
FORTRAN? I thought that disappeared in the 80s?
@Z > No, it’s still alive and well. There was a new, updated syntax released in 1990 called FORTRAN 90, even.
The real story: FORTRAN stopped being used by everyone except the scientific community a long time ago, as you point out. However, up until very recently, with the advent of C and C++, there really wasn’t anything remotely comparable available for scientific and mathematical processing.
In addition, when it comes to number crunching, it’s LIGHTNING fast. The compiler is very, very heavily optimised for the kind of things the likes of CERN get up to (million X million sparse matrix multiplication and the like). There are also blindingly fast mathematical libraries, such as the NAG libraries, available, that in some cases are justification enough to keep using FORTRAN. Academics don’t have tons of cash, so they can buy a faster machine or write it in F77. The compiler is also available for pretty much every super-high-spec supercomputer out there.
Finally, the scientists who write the code, for whom writing code is not their main occupation, know FORTRAN really really well and have no desire to learn C++ just because some upstart techie told them to. They don’t have the same requirements for their code that we do in corporate IT – maintainability is less of an issue for them, other than in a very small number of cases, raw speed is less so for us.
I ended up writing quite a bit of it in 1993 as a summer intern at the now defunct DEC. We used to get code in from customers who were thinking of spending $20 million on machines from us to run their oil exploration, galaxy scanning, or weather simulations. One of the things they would do is either give us some FORTRAN code of theirs and ask us to get it to run as fast as possible on the relevant hardware and report the numbers back, or write some demo code.
The speeding-up work is called ‘benchmarking’ in the industry, we referred it it as ‘giving this code some go-faster stripes’. This can be a lot of fun.
I also got to play around with it, albeit the F90 stuff, using it to do things like solve differential equations numerically, and the like, for demo applications.
And yes, according to various friends of mine in scientific jobs, FORTRAN is still alive and well. There’s just too much valuable investment in it to throw it away, and C++ and Java notwithstanding, it’s still up there with the best in terms of raw speed for maths stuff.
Everyone else wouldn’t touch it with a bargepole. I prefer Java and C#.NET myself.
Erm….my desktop wallpaper image is a pretty colour!
*knows nothing about computer codes*
oh dear… so I have spammed your comments page. Still you did ask…
another non-sequitor:
….just got a ticket to Leonard Cohen’s additional gig at the O2 in November… hurry folks, tickets are selling fast. He was amazing on Thursday.
*SIGH*, I could talk tech with you forever DeeDee…, Even 6502 assembly is still being used for embedded apps…
Z – this is where we refer to them ‘Code’ posters as “delusional” – because we don’t understand.