The social construction of mental illness

To what extent are mental disorders things-in-themselves; that is, entities determined by their intrinsic nature? How far are those disorders shaped by the very concepts physicians employ to define and classify them? To some, such questioning will seem madness itself, a recursive doubt about the validity of clinical observation, one that can only undermine the pragmatics of practice. To others, recognizing how far the data of observation are determined by what patient and doctor believe to be true is fundamental to understanding the mutability of the clinical phenomena we encounter. In taking the position that mental disorders are socially constructed, I have deliberately set out to challenge the conventional wisdom that medicine is simply an empirical discipline registering objectively what is 'out there' in nature. By so doing, I do not in the least imply that diseases would not exist as phenomena in the world if men did not recognize them. Indeed, it is precisely their existence that provides the necessity for trying to make sense of them if we are to diminish human suffering. However, the concepts we invent to account for disease come to shape not only the observations we make and the remedies we prescribe, but the very manifestations of disease itself. Concepts of pathophysiology are 'constrained fictions'-'constrained' in that they must at least approximately match events in the world 'fictions' in that their ability to make sense of those events, or even to predict them, does not establish that they correspond to the connecting principles of nature. My argument will consist of four theses. First, that all scientific concepts are inventions of the imagination. Second, that the human sciences are beset by a paradox: what is believed to be true about behaviour affects the very behaviour which it purports to explain. Third, that the trajectory of illness is influenced by the beliefs patients and doctors hold about course and prognosis. Finally, that physicians, no less than their patients, are constrained by socially constructed roles.