For International Journal of Social Psychiatry (pre-proof uncorrected version)
THE TROUBLED RELATIONSHIP BETWEEN PSYCHIATRY AND SOCIOLOGY
David Pilgrim* and Anne Rogers**
* Department of Primary Care, University of Liverpool & Teaching Primary Care
Trust for East Lancashire.
** National Primary Care Research and Development Centre, University of
Manchester
* Correspondence: Professor David Pilgrim, Blackburn with Darwen PCT, Guide
Business Centre, School Lane, Blackburn, Lancashire, BB1 2QH ,UK.
1
THE TROUBLED RELATIONSHIP BETWEEN PSYCHIATRY AND
SOCIOLOGY
Abstract
The alienated relationship between psychiatry and sociology is explored. The two
disciplines largely took divergent paths after 1970. On the one side, psychiatry
manifested a pre-occupation with methodological questions and sought greater
medical respectability, with a bio-medical approach returning to the fore. Social
psychiatry and its underpinning biopsychosocial model became increasingly
marginalised and weakened. On the other side, many sociologists turned away
from psychiatry and the epidemiological study of mental health problems and
increasingly restricted their interest to social theory and qualitative research. An
interdisciplinary void ensued, to the detriment of the investigation of social
aspects of mental health.
Introduction
This paper has three aims. First, an indicative description will be given of the current
alienation between psychiatry and sociology. Second, a brief historical account will be
given about the emergence of the distance and distrust existing between the disciplines.
Third, some negative consequences of the interdisciplinary void will be explored and
some positive suggestions made about its repair.
Space does not permit a full content analysis of psychiatric texts and their recent position
about sociology. Nor is there space to explore the ongoing fruitful dialogue between
psychiatry and anthropology, where some overlapping interests with sociology can be
found (e.g. Kleinman, 1988; Littlewood and Lipsedge, 1997). With these constraints of
space in mind, our focus will be on psychiatry’s relationship with sociology, not the
whole field of social science. Since 1970, the relationship between psychiatry and
2
sociology has been distant and often hostile. Prior to that, as we will explore later,
practitioners in the two disciplines were often active collaborators.
The position offered in a recent prestigious textbook of psychiatry will be taken as
indicative of the inter-disciplinary alienation we wish to explore in the paper. Gelder,
Mayou and Cowen (2001), in the Shorter Oxford Textbook of Psychiatry, allocate over 23
pages to discussing ‘the contribution of scientific disciplines to psychiatric aetiology’. Of
these, 17 pages are allotted to discussing aspects of bio-determinism (covered under
headings of genetics, neuropsychology, neuropathology, physiology, endocrinology,
pharmacology and biochemical studies). Sociology is mentioned in just two paragraphs
of the 23 pages, with an accompanying table of topics describing five areas of potential
mutual interest (social class; stigma; institutionalisation; social deviance; and abnormal
illness behaviour). Moreover, half of the text’s small space allocation is given over to this
statement:
Many of the concepts used by sociologists are relevant to psychiatry [allusion to
table of five topics]. Unfortunately, some of these potentially fruitful ideas have
been used uncritically, for example in the suggestion that mental illness is no
more than a label for socially deviant people, the ‘myth of mental illness’. This
development points to the obvious need for sociological theories to be tested in
the same way as other theories by collecting appropriate data. (Gelder, Mayou and
Cowen, 2001:120/1, emphasis added)
This passage is from an eclectic and comprehensive textbook, not one dedicated narrowly
to biological psychiatry. Its authors are not, in principle, opposed to sociology making a
contribution to psychiatry, as they make clear in the first sentence.. However, the barely
veiled sub-text, given the fraction of space allocated and its’ content, is this: ‘for the time
being, sociology is of little use to psychiatry’. We now trace some historical reasons for
this disappointment. This will begin to open up a scrutiny of each discipline and the
difficulties created for and within the older bridging multi-disciplinary arena of social
psychiatry.
3
The immediate past
During the past thirty years, psychiatric epidemiology and medical sociology have
become, what Fenton and Charsley (2000) have called, ‘incommensurate games’. That is,
the theoretical and methodological preferences of the two approaches to mental health
problems in society have become discrepant. Moreover, the epidemiological wing of the
profession only reflects a more widespread divide from sociology. Rogers and Pilgrim
(2003) provide two examples that point up this divide.
The first is in relation to differences between the disciplines over the nature of mental
health and illness. Criticisms of psychiatric theory and practice from sociologists have
focussed on: the poor construct validity of diagnostic categories; the relative absence of
longitudinal studies in psychiatric epidemiology; the dominance of empiricism at the
expense of theoretical development; a lack of explicit reflection on the ideological nature
of psychiatric theory and practice; and the interest work of the drug companies in the
mental health industry.
The second major difference between the disciplines is in relation to service contact.
Sociological analysis is more inclined to problematise this, whereas psychiatrists
emphasise the inherently beneficent role of services. As a consequence, the emphasis of
psychiatric epidemiology has been on mapping the need for early intervention or on
equitable service access. Services are viewed as sites of an uneven right to treatment,
rather than as a threat to well being and citizenship
This leads to the epidemiological study of ‘need’ (i.e. numbers of identified diagnosed
cases) in order to plan ‘appropriate’ services, inviting socio-political questions such as:
‘“appropriate” for whom?’; ‘whose “needs” are being met by mental health services?’;
and ‘are notions of “access” or “service” meaningful, when coercion is involved?’
Sociological interest in the new social movement of disaffected patients ensures that
4
these questions are raised (Rogers and Pilgrim, 1991). In response, psychiatry limits its
social policy interest to stigma, and only considers itself as part of the solution, not as
part of the problem (Sayce, 2000).
Psychiatry, with good reason, has lost its trust in sociology. During the 1970s,
sociologists from the Marxian and Weberian traditions began to use medicine as an
object of sociological understanding or to illustrate a social theory (Reid, 1976). By the
1970s, medical sociologists had promoted themselves from handmaiden to ‘observer
status’ (Illsley, 1975). Sociologists, after 1970, increasingly saw themselves as providing
a sociology of medicine. Prior to that, they had largely been content to make a
sociological contribution to medicine.
Post-1970, sociology increasingly turned away from medical positivism and manifested a
broad openness to other orientations. The tradition of symbolic interactionism and
subsequent trends, like ethnomethodology and social constructivism, brought distance
into the common ideological project of social engineering, which had previously acted to
cement the enterprises of medical sociology and social psychiatry.
These theoretical shifts within sociology disrupted a prior inter-disciplinary
compatibility, by focusing on social phenomena being concept and context specific and
by emphasising subjectivity and inter-subjectivity in their field of inquiry. Meanings not
just causes were now considered to be important- the task for sociology was increasingly
descriptive and interpretive (verstehen) rather than explanatory (erklaren). The most
extreme rejection was to come from post-structuralism (especially the work of Michel
Foucault), with its abandonment of causal reasoning, truth claims and any confidence in
an independent reality, culminating in a focused exploration of ideas, language and
‘discursive practices’. With it came a concomitant abandonment of faith in quantitative
methods, such as the survey techniques of epidemiology and the randomised controlled
trial approach to testing treatment methods (including psycho-social interventions).
5
Prior to this trend, symbolic interactionism, a Weberian derivative from the Chicago
School of sociology, was to make its mark in the study of people with mental health
problems (e.g. Goffman, 1961). Lemert (1967) made a distinction between primary
deviance (multi-factorially caused) and secondary deviance (socially amplified by the
reactions of others). From this point on, psychiatric illness was treated with suspicion by
sociologists and their interest turned to the social processes, which led to labelling and
diagnosis, and the social consequences of psychiatric practice.
Whereas the previous relationship between psychiatry and sociology had been built on
co-operation, these newer studies were explicitly critical not only of the social control
role of psychiatry but also of its knowledge base (Pilgrim and Rogers 1994). Moreover,
the co-operation had worked previously, largely because sociology was co-opted by
medicine to help solve its problems; a convenient advantage of the empiricist legacy of
Durkheim after the Second World War.
By the 1980s, the sociological attack on
psychiatry, and the defensive reaction it provoked, led not to a prolonged and creative
debate but instead to a breakdown in interest on both sides.
Some organisational
pressures then amplified this divergence. For example, the rules of the research
assessment exercise in British higher education meant that sociological scholarship was
less valued in medical schools, where empirical papers, not books, especially ones
preoccupied with social theory, were privileged. In this context, sociology rather than
psychiatry departments may have been more desirable work sites in the academy for
sociologists.
The general trend of sociological criticism of psychiatry after 1970, understandably, was
met with defensive counter-argument. Tetchy reactions from psychiatrists depicted
sociological critics, with some justification, as being part of an international oppositional
movement, which aimed to denigrate and discredit their profession (‘anti-psychiatry’)
(Hamilton, 1973; Roth, 1973). This resentment against sociology was particularly evident
from some who had previously gained much from collaboration between the disciplines
(Wing 1978).
6
The complex field of ‘anti-psychiatry’ was not inhabited solely, or even mainly, by
professional sociologists. The key high-profile ‘anti-psychiatric’ critics, such as Ronald
Laing, David Cooper, Thomas Szasz and Franco Basaglia, were dissident members of the
psychiatric profession, though their critical products were largely sociological or
philosophical in character. Moreover, a more recent generation of dissidents have become
evident in the growth of ‘critical’ or ‘post’ psychiatry (Thomas, 1997; Bracken, 2003).
Also anti-racist critiques within the profession continued to problematise psychiatric
knowledge (Fernando, 1988; Sashidaran, 1993). Moreover, the technocratic approach of
bio-medical psychiatry was challenged by some psychiatrists, who emphasised the overdetermining role of social factors in both aetiology and recovery (Warner, 1985; Ross and
Pam, 1995) and the distorting effects of drug company interests on clinical practice
(Breggin, 1993; Healy, 1997; Kramer, 1993).
This unbroken pattern of internal dissent suggests that many substantive problems about
psychiatric theory and practice are both inherent and unresolved. These problems were
not invented by mischievous sociological critics. Nonetheless, the sociological character
of ‘anti-psychiatry’ meant that even internal critics of the psychiatric profession were
tarred with the sociological brush. (Note the allusion in the passage quoted at the outset
from Gelder et al to the ‘myth of mental illness’, as if this notion constitutes an external
attack from sociology. Thomas Szasz is a professor of psychiatry.)
Having characterised the last thirty years, which included the turbulence of ‘antipsychiatry’ and intimations of a break down in inter-disciplinary collaboration (enjoyed
by social psychiatry) in its wake, we now turn to the longer historical story of the
alienation between the two disciplines.
Victorian origins
In the Victorian period, under the influence of, and as a constituent of, eugenics,
psychiatrists and Lunacy Commissioners used epidemiological methods. This first
7
version of psychiatric epidemiology began with a preoccupation with counting cases of
mental disease, not with mapping definitively known aetiological sources of
psychopathology.
Whereas
infectious
agents
were
the
concern
of
medical
epidemiologists, psychiatrists wanted to count and regulate mad bodies. In the eugenic
view of Victorian psychiatry, the latter were both the victims of mental disease and its
aetiological source. The sequestration of patients from society and their subsequent
sexual segregation, in asylums, logically followed from this assumption.
Psychiatric epidemiology was bound up with a broad eugenic social policy of segregating
an assumed ‘tainted’ gene pool, in what Marx called the ‘lumpenproletariat’. This gene
pool was depicted as the source of various forms of deviance, including, but not limited
to, madness (Scull 1979; Porter 1989; Marshall 1990; Forsythe 1990). This eugenic
period was medically dominated and not inviting to sociologists, even though more
widely, in mainstream 19th century medical epidemiology (social medicine), sociology
was finding a significant practical role. Indeed, the roots of medical sociology can be
traced to social medicine (Rosen, 1979; Kleinman, 1986).
Dohrenwend (1998) points out a shift in the eugenically-driven consensus by the 1930s:
… belief in the paramount role of genetic inheritance began to change especially
in the United States, under the impact of two major events: the stock market crash
of 1929 followed by the Great Depression, and the US entrance into World War II
in 1941. The great depression made it clear that a person could become poor for
reasons other than inherited disabilities and research conducted during World War
II showed that situations of extreme environmental stress arising out of combat
and imprisonment could produce serious psychopathology in previously normal
persons, some of it long lasting. (Dohrenwend, 1998: 224)
Economic and war conditions were undoubtedly influential in shaping the production of
psychiatric knowledge. One clear example, earlier in Britain, was the environmentalist
challenge to the eugenic, asylum-derived, bio-deterministic legacy, which came from the
8
shellshock doctors returning from the First World War (Stone, 1985). Another was the
impact of observing concentration camp inmates, which inspired the development of the
concept of ‘institutional neurosis’, in the British asylums of the 1950s (Barton, 1958).
These examples highlight the post-Victorian emergence of mutual sympathy between
environmentally-orientated social psychiatrists and sociologists.
The salad days of collaboration
Around the Second World War then, an environmentalist period was ushered in. A strong
alliance with sociology became evident in pursuing a common agenda and social
scientists, including sociologists were active members of academic departments of
psychiatry (Klerman, 1989). In its Durkheimian form, sociology presented itself as an
objective project, whose purpose was to study social problems and produce knowledge to
further social policy objectives. This chimed with the goals of socially-orientated
psychiatrists.
Eventually an inter-disciplinary collaboration was to emerge and ‘social psychiatry’ was
formalised. This was characterised by notable collaborations of psychiatrists with both
clinical psychologists (Falloon and Fadden, 1993) and psychiatric social workers
(Goldberg and Huxley, 1992). Some of its methodological leaders were even sociologists
(Brown and Harris, 1978). Social psychiatry has been closely associated with a
biopsychosocial model of mental illness; an inclusive anti-reductionist approach, with a
wide potential appeal to both patients and to mental health workers (Engel, 1980;
Pilgrim, 2002).
The collaborative period was particularly influenced by the development of human
ecology, a theoretical trend within the Chicago School of sociology (Pilgrim and Rogers
1994). A seminal study based on this human ecology approach (Mental Disorders in
Urban Areas) was published by members of the Chicago School (Faris and Dunham,
1939). In exploring the influence of poverty and deprivation, the authors contrasted the
9
prevalence of ‘manic-depressive psychosis’, which appeared to be randomly distributed
across the city of Chicago, with the numbers of people diagnosed with ‘schizophrenia’,
found predominantly in poorer areas. Whereas Faris and Dunham focussed on social
isolation as a possible aetiological factor, Hollingshead and Redlich (1958) reflected the
popular appeal of Freudian ideas, which were prevalent in the USA at that time, in their
subsequent study.
This environmentalist phase of psychiatric research on inequalities in mental health
began to follow those evident in mainstream public health, with a focus on social
conditions and the quality of inter-personal relationships in different parts of society. A
spate of influential studies identified the relationship between mental health and social
class and demonstrated a consistent social patterning of mental disorders. These studies
showed that rates of mental health problems were more prevalent amongst those in the
‘lower’ classes (Hollingshead and Redlich 1958; Srole and Langer 1962).
Consistently reported findings were that the diagnoses of ‘schizophrenia’ and ‘personality
disorder’ were inversely related to social class. For so called ‘common mental health
problems’ (anxiety and depression), a link between social disadvantage and mental health
was also established, although this appeared to be less consistent than the finding for
‘schizophrenia’. The trend for ‘affective psychoses’ was towards greater prevalence in
‘middle’ and ‘upper class’ populations. Social class also predicted treatment type
deployed by the psychiatric profession. Lower class people received drugs and ECT
whereas richer clients received versions of psychotherapy.
Mutual disillusionment
Given the obvious common concern for ‘the social’, in both medical sociology and
psychiatric epidemiology after the Second World War, a trajectory was set for long term
inter-disciplinary collaboration. But this did not happen. The reasons for the breakdown
in the relationship are complex but, for the purpose of this article, can be grouped into
10
three. First, there were shifts of emphasis and theoretical preference inside sociology.
Second, there were also shifts inside psychiatry. Third, some of the alterations within
each discipline were a function of the negative interaction of these shifts.
Mutual
suspicion and disdain occurred, which lead to a vicious circle of shrivelling positive
interest in the other party’s concerns. These three groups of points will be unpicked here.
Theoretical shifts in sociology
Some of these have been noted already earlier, when setting the scene for the paper. Two
bonds between the disciplines had been evident in the collaborative phase- one from
Freud and the other from Durkheim. With the growth in legitimacy of psychoanalysis in
the 1930s and 1940s came an acceptance of ‘continuum’ models of psychopathology (we
are all ill to some degree according to psychoanalysts). This made the lack of precise
classification acceptable to those psychiatrists, who shared an over-riding commitment
with their collaborating sociologists to the investigation of social conditions. The
ambiguity created in Anglo-American psychiatry of psychoanalysis, and the consequent
role of continuum models, defused potential tensions and cleared the way for a shared
focus on the social antecedents of mental health problems (however they were codified).
Tolerant mutuality characterised the relationship between sociology and psychiatry, as
indicated here by Lawson (1989), a sociological contributor to social psychiatry:
…Psychiatry accepted that, as its disease categories were so tenuous and not
generally marked by physical signs, the sociologist’s concepts of impairment or
disability marked by social dysfunctions could be the key to unravelling the rates
of mental illness. (Lawson, 1989: 38)
Note how the notion of ‘mental illness’ remained in tact but psychiatrists were able to
accept alternative views than an illness model. Moreover, in relation to secondary and
tertiary prevention, strong alliances were made with sociologists. For example, this
included research into the role of adverse and alienating conditions within mental
11
hospitals, which demonstrably maintained and amplified pre-existing psychiatric
disability- ‘institutionalism’ (Brown and Wing, 1963).
After 1970, this reliance on a Durkheimian view in sociology and the Freudian influence
on continuum models in psychiatry was changed radically. Sociologists (and
psychologists) increasingly attacked the growth of neo-Kraepelian psychiatry, with its
rigid pre-occupation with categories, for confusing the map with the territory. For
example, psychiatrists assume that ‘schizophrenia’ is a non-problematic fact, when it is
simply a codification of ordinary judgments about madness and provides little or no
additional scientific value to these lay ascriptions (Coulter, 1973; Bentall et al, 1988; cf
Wing, 1978). Moreover, what psychiatrists now call ‘schizophrenia’ is not what was
originally described by Kraepelin and Bleuler (Boyle, 1990). With psychiatric categories
being such easy targets for criticism, scepticism about the reality of mental illness,
sometimes reached nihilistic proportions. Radical constructivists rejected mental illness
as a total error of reasoning (a ‘myth’ or a ‘metaphor’ not a fact (Szasz, 1961)).
After Szasz, the radical internal critic of psychiatry, and under the sway of Foucauldian
critiques of psychiatry, more and more sociologists depicted mental illnesses as social
representations or epiphenomena produced by psychiatric activity utilising preferred
reified categories (Miller and Rose, 1984; Parker et al, 1997; Prior, 1991). By 1980, most
sociologists had neither the theoretical inclination, nor the practical competence, to
support social psychiatric research. They became deskilled as social psychiatric
collaborators.
Shifts (and continuities) in psychiatry
By the end of the 20th century, far less consideration was being given to social psychiatry,
which was contained increasingly on the margins of the profession (Moncrieff and
Crawford 2001). The biopsychosocial model (Engel, 1980), favoured by many academic
psychiatrists, was being displaced by the ‘decade of the brain’, which inspired
12
expressions of biological triumphalism in its advocates (Shorter, 1997; Guze, 1998; cf.
Clare, 2000).
Despite the environmentalist phase in epidemiology and the growing confidence of social
psychiatry after the Second World War, the biological aetiology of madness was deemed
to be confirmed in the core of the profession by the apparently dramatic impact of the
phenothiazine group of drugs. These were now connoted by their producers and
prescribers as ‘anti-psychotic’ agents, implying curative capability, rather than them
being crude symptom-control adjuncts for some patients, some of the time (Moncrieff,
2002). With hindsight, critical psychiatric historians have demonstrated that the
‘pharmacological revolution’ was, if not a total myth, a considerable uncertainty (Scull,
1979). The policy of de-institutionalisation was the product of a variety of fiscal and
ideological forces; these drugs had little or no impact on this policy trend (Warner, 1985;
Rogers and Pilgrim, 2005).
However, more conservative accounts continued to depict madness as a biochemical
brain disturbance, pre-determined by a genetic fault but increasingly amenable to
medicinal remediation (from first the ‘old’ and now the ‘new’ ‘anti-psychotics’). For
example, Csernansky and Grace (1998) remained committed to the ‘pharmacological
revolution’ view and claimed that subsequent neuroscientific research provides us now
with unequivocal evidence of ‘schizophrenia’ as a genetically pre-programmed brain
disease (cf. Boyle, 1990).
The negative impact of the interaction
The impact of the shifts in the two disciplines was very clear.
Mutual hostility
developed, with sociological critics turning away from psychiatry. Eventually there was
even a diminishing interest in mental health as a sociological topic of inquiry. Many
promising beginnings, for example in labelling theory and in the ethnographic study of
psychiatric patients, petered out and were displaced by other more pressing concerns in
13
the sociology of health and illness (Cook and Wright, 1995). After 1980, sociologists still
researched mental health. For example, some new work appeared on modified labelling
theory (Link et al 1989), users’ views of psychiatric services (Rogers et al, 1993),
problems with psychiatric nosology (Kutchins and Kirk, 1997) and race and mental
disorder (Nazroo, 1998) but the extent of this interest was notably less than in the 1970s.
Moreover, this work rarely attempted to re-build broken bridges with psychiatry; usually
the opposite applied or was implied.
As for psychiatry, it retreated into ‘methodologism’ and ‘quantitativism’, after 1980,
unchecked by critical reflection about its reified diagnostic categories. It did not deal
comprehensively with the philosophical attacks on its knowledge base, let alone abandon
categorical reasoning as a lost cause. Instead, psychiatrists aspired, to attain better
construct validity, akin to improving the measurement of other epidemiological variables,
such as hypertension (Fryers, et al 2000).
At the very time when many sociologists were retreating into philosophical forms of antirealism, within a wider trend of post-modern social science, psychiatry retrenched and
became pre-occupied with defending its methods and its claims to medical respectability
and objectivity- what Hoff (1995) calls ‘medical naturalism’. There was a ‘return to
medicine’, with an increasing interest in linking epidemiology to neuroscience and
genetics (Wittchen, 1999). In clinical psychiatry, discredited pharmacological solutions
did not lead to therapeutic pessimism and a return to the social. Instead, faith was restated in a bio-medical approach, supported by the pharmaceutical industry producing
and profiting from new agents.. Many in one discipline naively took the reality of mental
illness for granted and looked forward to the next breakthrough in biological treatments
(the pharmacological revolution became permanent). Many in the other readily
abandoned reality as unknowable. A breakdown of trust and comprehension between the
disciplines inevitably ensued.
Even when social psychiatry shifted (partially) from a categorical to a dimensional view
of mental illness, this cleavage was sustained. For example, a number of prominent social
14
psychiatric researchers advocated a dimensional view, in which there are gradations of
psychological distress (Goldberg and Huxley 1992). This filtered down into tools such as
the General Health Questionnaire (GHQ), commonly used in primary care and
community population surveys. However, this dimensional view did not fully displace
categorical reasoning in psychiatry. In the American Psychiatric Associations’ Diagnostic
and Statistical Manual categories and dimensions are preserved together and are not
viewed as being incompatible.
Thus, this most recent phase in psychiatric epidemiology, since 1970, has been
characterised by greater diagnostic specificity and case identification, which accord with
the ‘medical necessity’ for intervention. This can be contrasted with the collaborative
phase of research, which was more concerned with the identification of the social causes
of, or dominant influences on, mental health problems.
Currently, policy and practice imperatives remain firmly rooted in a concern with
identifying rates of diagnosed mental illness in populations in order to provide sufficient
specialist services. This has largely displaced the community and environmental focus of
studies during the phase of collaboration, although in some recent studies both strands of
interest can be found (e.g. Ostler et al, 2001). Overall though, it is fair to say, in
summary, that psychiatry seems to have gone full circle over a century, from eugenics to
environmentalism and then back to genetic determinism and the service need it implies.
This pattern can be seen in the theoretical changes in psychiatric nosology.
The categories of DSM-1 were heavily influenced by both psychoanalytic theory and
war-time social psychiatry (Carpenter 2000). Later shifts in DSM and the section on
mental disorders in the International Classification of Diseases brought about major
changes in case identification and classification. DSM-II, whilst not adhering to what
may be viewed as explicit social aetiology, nevertheless incorporated psychoanalytically
influenced ideas about causal antecedents. By contrast, the specific aim of moving to
DSM-III was to expunge causality from diagnosis in favour of behavioural description:
15
Because DSM III is generally a-theoretical with regard to aetiology, it attempts to
describe comprehensively what the manifestations of the mental disorder are, and
only rarely attempts to account for how the disturbances came about, unless the
mechanism is included in the definition of the disorder. This approach can be said
to be descriptive in that the definitions of the disorder generally consist of
descriptions of the clinical features of the disorders. These patterns are described at
the lowest order of inference necessary to describe the characteristic features of the
disorder. (American Psychiatric Association, 1980:7)
The ‘a-theoretical’ position about aetiology, far from signifying non-committal
eclecticism, had the effect (if not the intention) of eliminating confidence in social
causation. Subsequent changes from DSM-III to DSM-IV represented a further
elimination of patient subjectivity and their biographical and social context, in favour of
an anti-holistic model of mental illness, compatible now with biological psychiatry
(Wallace 1994; Mishara, 1994). This emphasis on behavioural criteria and the silencing
of social causation hypotheses may signal a normative North American ideology.
Carpenter (2000) views the trend of promoting standardised categories of normality and
disorder in DSM as part of a US-inspired ‘MacDonaldisation’ of social and economic
life. For Carpenter, DSM-IV represents ‘the psychiatric equivalent of the World Trade
Organisation (WTO), promoting the principles of American Universalism as objective
standards that are beyond reproach’ (Carpenter 2000: 615). Certainly one of the
consequences of this focus on measurement and ‘objective’ criteria has been a negation
of the consideration of social context and personal experience (the routine concern of
medical sociology), as a core part of the psychiatric research endeavour.
Whilst more robust methods and credible diagnostic constructs have been the product of
recent activity in psychiatric epidemiology, they have been at the expense of a more
sophisticated understanding of the social nature of mental health inequalities. For
example, a recent study found that the subjective rating of quality of life, for individuals
in a residential population was associated with lower levels of distress, which would not
16
normally be counted as constituting either a major or minor mental illness (Thomas et al,
2001). This important reminder of low-grade unhappiness and demoralisation, as part of a
continuum of distress and dysfunction, can be contrasted with an emerging rigid
categorical world of psychiatric epidemiology after 1980.
The problem stated re-visited
Now that an historical account has been given of the breakdown of trust and cooperation
between psychiatry and sociology, where does it leave the social investigation of mental
health problems and mental health services? There are a few answers which are evident
and some have been noted already. Sociologists have become deskilled in epidemiology.
Psychiatrists have become weary and defensive about philosophical attack, so that wholly
legitimate questions about the role of their profession in society or their dubious
knowledge base are pre-emptively dismissed by allusions to ‘anti-psychiatry’. A blocked
dialectic has occurred, so the disciplines either do not talk or they talk past each other.
Despite the multiple sources of evidence about the social origins and consequences of
mental health problems, they have been weakly represented in recent health research,
which has placed a greater emphasis on social inequalities in physical morbidity and
mortality (Muntaner et al, 2000). In health inequality research, mental health status has
been afforded a central role as a mediator but has been studied less often as an outcome
of social forces (Wilkinson, 1995; Rogers and Pilgrim, 2003). One factor in this relative
lack of recent scrutiny of mental health outcomes is the loss of collaborative synergy,
which had previously existed, between psychiatrists and sociologists.
The mutual distrust between sociology and psychiatry over the past thirty years may
reflect an entrenched and irreversible alienation. If this conclusion is accurate and
prescient, then only a small rump of neo-Durkheimian sociologists will remain within the
fold of social psychiatry and conduct traditional epidemiological research (e.g. Kessler et
al, 1994). A more optimistic scenario is that of a greater (re-)engagement between the
17
disciplines. For this to occur, some compromises are probably needed on both sides.
Psychiatrists would need to concede the epistemological problems they inherit and the
professional self-interest, which has driven the most recent version of epidemiological
research.
Turning to sociologists, they too would need to step out of their disciplinary boundary
and re-appraise their potential contribution. Post-modern social theory, in particular, has
left many sociologists antithetical to, and de-skilled in, empirical projects. A consequence
is that the deconstruction of psychiatric knowledge has become a well-trodden but
inadequate substitute for considered and detailed explorations of mental health
inequalities. The sociological curriculum may need to re-introduce more robust training
in epidemiology to complement current preferences for social theory and qualitative
methods.
The recent orthodoxy of sociology may need to shift back to some version of realism
rather than of constructivism before a bridge with psychiatry can be re-discovered. There
are some signs of this where critical or sceptical realism is challenging social
constructivism. Critical realism accepts a weak version of social constructivism (that
knowledge is socially constructed and interests are at work in particular contexts) but
does not reject the possibility of discovering how a web of material reality causally
impacts
on
psychological
functioning
(Bhaskar,
1989;
Rogers
and
Pilgrim,
2005;Greenwood, 1994; Sayer, 2000).
Ironically, some psychiatrists, influenced by constructivism, make similar pleas for
methodological pluralism and multiple theorisations and they encourage sociological
inquiry into the practical world of their profession (Bracken, 2001). Thus, points of
engagement between constructivism and realism are evident or possible. Sociologists,
hamstrung by the nihilism of postmodernism, could discover that it is possible to be
empirical without necessarily being naively empiricist. Psychiatrists might discover the
advantages, not just the disadvantages, of making their discipline an object of critical
sociological inquiry. There are already signs that some social psychiatrists are willing to
18
take the risk of inviting sociological contributions of this kind (e.g. Thornicroft and
Szmuckler, 2001).
If some form of rapprochement is not negotiated between the two disciplines then
sociology will be reduced to the type of small, grudging and distrustful concession
permitted by psychiatric textbooks cited at the start of this paper. The risk will be created
of a whole raft of topics not finding a professional psychiatric audience related, for
example, to: the role of psychiatry in society; the sociology of psychiatric knowledge; the
social antecedents and consequences of mental health problems; the social aspects of
service contact; the role of the drug companies in shaping psychiatric theory and practice;
the new social movement of disaffected psychiatric patients; the social conditions
engendering or inhibiting personal well-being; and the relevance of race, class and
gender, when understanding people with mental health problems and the services they
encounter. Ground would need to be given, on both sides, to achieve this ambition of rediscovering a collaborative relationship between psychiatry and sociology. Until this
happens, social psychiatry may continue to exist as a fractured and precarious bridge
between the two disciplines.
References
American Psychiatric Association (1980) Diagnostic and Statistical Manual III
Washington: American Psychiatric Association.
Barton, W. R. (1959) Institutional Neurosis Bristol: Wright and Sons.
Bentall, R. P., Jackson, H. and Pilgrim, D. (1988) Abandoning the concept of
schizophrenia; some implications of validity arguments for psychological research into
psychosis. British Journal of Clinical Psychology 27, 305-324.
Boyle, M. (1990) Schizophrenia: A Scientific Delusion? London: Routledge.
19
Bracken, P. J. (2003) Postmodernism and psychiatry. Current Opinion in Psychiatry 16,
6, 673-677.
Bracken, P.J. (2001) Post-modernity and post-traumatic stress disorder. Social Science
and Medicine 53, 6, 733-743.
Breggin, P. (1993) Toxic Psychiatry. London: HarperCollins.
Brown, G. W. and Harris, T. (1978) The Social Origins of Depression London: Tavistock
Brown G. W. and Moran, P.M. (1997) Single mothers, poverty and depression.
Psychological Medicine 27: 21-33
Brown, G. W. and Wing, J. K. (1962) A comparative clinical social survey of three
mental hospitals. The Sociological Review Monograph 5: 145-171.
Carpenter, M. (2000) ‘It’s a small world’ mental health policy under welfare capitalism
since 1945. Sociology of Health and Illness 22, 5, 602-619
Clare, A.W. (1999) Psychiatry’s future: psychological medicine or biological psychiatry?
Journal of Mental Health 8, 2, 109-111.
Cook, J.A. and Wright, E.R. (1995) Medical sociology and the study of severe mental
illness: reflections on past accomplishments and directions for future research. Journal of
Health and Social Behaviour (Extra issue) 95-114.
Csernansky, J. G. and Grace, A. A. (1998) New models of the pathophysiology of
schizophrenia: editors’ introduction. Schizophrenia Bulletin 24, 2, 185-188.
Dohrenwend, B. P. (1998) A psychosocial perspective in the past and future of
psychiatric epidemiology. American Journal of Epidemiology 147, 3, 222-229.
20
Engel, G.L. (1980) The clinical application of the biopsychosocial model. American
Journal of Psychiatry 137, 535-544.
Falloon, I. and Fadden, G. (1993) Integrated Mental Health Care Cambridge: Cambridge
University Press.
Faris, R. E. and Dunham, H. W. (1939) Mental Disorders in Urban Areas: An Ecological
Study of Schizophrenia and Other Psychoses. Chicago: The University of Chicago Press
Fenton, S. and Charsley, K. (2000) Epidemiology and sociology as incommensurate
games: accounts from the study of health and ethnicity. Health 4, 4, 403-425.
Fernando, S. (1988) Race and Culture in Psychiatry. Tavistock: Routledge.
Forsythe, B. (1990) Mental and social diagnosis and the English Prison Commission
1914-1939 Social Policy and Administration 24, 3, 237-253.
Fryers, T., Melzer, D. and Jenkins, R. (2000) Mental Health Inequalities Report 1: A
Systematic Literature Review London: Department of Health
Gelder, M., Mayou, R. and Cowen, P, (2001) Shorter Oxford Textbook of Psychiatry
Oxford: Oxford University Press.
Goffman, E. (1961) Asylums Harmondsworth: Penguin.
Goldberg, D. and Huxley, P. (1992) Common Mental Disorders London: Routledge.
Greenwood, J.D. (1994) Realism, Identity and Emotion London: Sage.
21
Guze, S.B. (1989) Biological psychiatry: is there any other kind? Psychological Medicine
19, 315-323.
Hamilton, M. (1973) Psychology in society: end or ends? Bulletin of the British
Psychological Society 26, 185-9.
Healy, D. (1997) The Anti-Depressant Era. London: Harvard University Press.
Hoff, P. (1995) Kraepelin. In G.Berrios and R. Porter (eds) A History of Clinical
Psychiatry London: Athlone Press.
Hollingshead, A. and Redlich, R. C. (1958) Social Class and Mental Illness New York:
Wiley
Illsley, R. (1975) Promotion to observer status. Social Science and Medicine 9, 63-67.
Kessler, R. C., McGonagel, K. A., Zhai, S., Nelson, C. B., Hughes, M and Eshleman, D.
(1994) Lifetime and 12-month prevalence of DSM-III- R psychiatric disorders in the
United States. Archives of General Psychiatry 51: 8-19
Kleinman, A. (1986) Some uses and misuses of the social sciences in medicine. In D.W.
Fiske and R.A. Shweder (eds) Metatheory and Social Science Chicago: Chicago
University Press.
Kleinman, A. (1988) Rethinking Psychiatry. New York: Free Press.
Klerman G. L. (1989) Psychiatric diagnostic categories: issues of validity and
measurement, an invited comment on Mirowsky and Ross. Journal of Health and Social
Behavior 30, 26-30.
Kramer, P. (1993) Listening To Prozac New York: Viking.
22
Kutchins,H. and Kirk, S.A. (1997) Making Us Crazy New York: Free Press
Lawson A (1989) A sociological and socio-anthropological perspective. In The Scope of
Epidemiological Psychiatry. P. Williams, G. Wilkinson and K. Rawnsley (eds) London:
Routledge.
Lemert, E. (1967) Human Deviance, Social Problems and Social Control. Englewood
Cliffs: Prentice-Hall.
Link, B.G., Cullen, F.T., Struening, E., Shrout, P.E. and Dohrenwend, B.P. (1989) A
modified labeling theory approach to mental disorders: an empirical assessment.
American Sociological Review 54, 400-23.
Littlewood, R. and Lipsedge, M. (1997) Aliens and Alienists. (3rd Edition)
Harmondsworth: Penguin.
Marshall, R. (1990) The genetics of schizophrenia: axiom or hypothesis.? In R.P. Bentall
(ed) Reconstructing Schizophrenia London: Routledge
Miller, P. and Rose, N. (1988) The Tavistock programme: the government of subjectivity
and social life. Sociology 22, 2,
Mishara, A.L. (1994) A phenomenological critique of commonsensical assumptions in
DSM-III: the avoidance of the patient’s subjectivity. In J.Z. Sadler, O.P. Wiggins and
M.A. Schwartz (eds) Philosophical Perspectives on Psychiatric Diagnostic Classification
Baltimore: John Hopkins University.
Moncrieff, J. (2002) Drugs in modern psychiatry: A history of misrepresentation. Paper
presented at the Annual Conference of the Critical Psychiatry Network, Birmingham.
23
Moncreiff, J. and Crawford, M.J. (2001) British psychiatry in the 20th century –
observations from a psychiatric journal Social Science and Medicine 53(3): 349-356 Aug
2001
Muntaner, C., Eaton, W. W. and Chamberlain, C.D. (2000) Social inequalities in mental
health: a review of concepts and underlying assumptions, Health, 4 (1) 89-109.
Nazroo, J. (1998) Genetic, cultural or socio-economic vulnerability? Explaining ethnic
inequalities in health. Sociology of Health and Illness, 20(5): 710–30.
Ostler, K., Thompson, C., Kinmoth, A-L. K., Peveler, L., Stevens, L. and Stevens, A.
(2001) Influence of socio-economic deprivation on the prevalence and outcome of
depression in primary care: the Hampshire Depression Project. British Journal of
Psychiatry 178, 12-17.
Parker, I., Georgaca, E., Harper, D., McLaughlin, T. and Stowell-Smith, M. (1997)
Deconstructing Psychopathology London: Sage.
Pilgrim, D. (2002) The biopsychosocial model in Anglo-American psychiatry: past,
present and future? Journal of Mental Health 11, 6, 585-594.
Pilgrim, D. and Bentall, R.P. (1999) The medicalisation of misery: a critical realist
analysis of the concept of depression. Journal of Mental Health 8, 3, 261-74
Pilgrim, D. and Rogers, A. (1994) ‘Something old, something new’...sociology and the
organisation of psychiatry. Sociology 28 (2) 521-38.
Porter, R. (1989) A Social History of Madness, London: Weidenfield and Nicolson.
Prior, L. (1991) Mind, body and behaviour: theorisations of madness and the organisation
of therapy. Sociology 25, 3, 403-422.
24
Reid, M. (1976) The Development of Medical Sociology in Britain. Discussion Papers in
Social Research: University of Glasgow.
Rogers, A. and Pilgrim, D. (1991) ‘Pulling down churches’: accounting for the mental
health users’ movement. Sociology of Health and Illness 13, 2, 129-148.
Rogers, A. and Pilgrim, D. (2003) Mental Health and Inequality Basingstoke:
Palgrave/Macmillan.
Rogers, A. and Pilgrim, D. (2005) A Sociology of Mental Health and Illness (3rd Edition)
Maidenhead: Open University Press
Rosen, G. (1978) Madness In Society New York: Harper
Ross, C.A. and Pam, A. (eds) (1995) Pseudoscience in Biological Psychiatry: Blaming
the Body New York: Wiley.
Roth, M. (1973) Psychiatry and its critics. British Journal of Psychiatry 122, 374.
Sashidharan, S.P. (1993) Afro-Caribbeans and schizophrenia: the ethnic vulnerability
hypothesis re-examined. International Review of Psychiatry, 5: 129–44.
Sayer, A. (2000) Realism and Social Science London: Sage.
Sayce, L. (2000) From Psychiatric Patient to Citizen: Overcoming Discrimination and
Social Exclusion Basingstoke:Macmillan.
Scull, A. (1979) Museums of Madness Harmondsworth: Penguin
Shorter, E. (1997) A History of Psychiatry: from the Era of the Asylum to the Age of
Prozac. Chichester: Wiley
25
Srole, L. and Langer, T.S. (1962) Mental Health in the Metropolis: The Midtown
Manhattan Study New York: McGraw Hill
Stone, M. (1985) 'Shellshock and the psychologists', in W.F. Bynum, R. Porter and M.
Shepherd (eds), The Anatomy of Madness, Vol. 2 London: Tavistock
Szasz. T. S. (1961) The uses of naming and the origin of the myth of mental illness.
American Psychologist 16, 59-65.
Thomas, P. (1997) The Dialectics of Schizophrenia London: Free Associations Books.
Thomas, R., Evans, S., Gately, C., Stordy, J., Huxley, P., Rogers, A. and Robson, B.
(2002) State-event relations among indicators of susceptibility to mental distress in
Wythenshawe. Social Science and Medicine 921-35.
Thornicroft, G. and Szmukler, G. (2001) Textbook of Community Psychiatry Oxford:
Oxford University Press.
Wallace, E. R. (1994) Psychiatry and its nosology: an historico-philosophical overview.
In J. Z. Sadler, O. P. Wiggins and M. A. Schwartz, (eds) Philosophical Perspectives on
Psychiatric Diagnostic Classification. Baltimore and London: Johns Hopkins University
Press
Warner, R. (1985) Recovery from Schizophrenia: Psychiatry and Political Economy
London: Routledge and Kegan Paul.
Wilkinson, R.G. (1996) Unhealthy Societies: The Afflictions of Inequalities London:
Routledge.
Wing, J. K. (1978) Reasoning About Madness. Oxford: Oxford University Press.
26
Wittechen H.U. (2000) Epidemiological research in mental disorders: lessons for the next
decade. Acta Psychiatrica Scandinavia 101, 1, 2-10.
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