Social Construction of Mental Health Diagnosis and the DSM

Introduction: Diagnosis in Mental Health

Diagnosis is the process of applying labels to describe people's problems. Medical doctors do it: you have appendicitis, ulcers, heart disease, or cancer. Dentists do it: you have periodontal disease, cavities, or an abscessed tooth. Psychotherapists do it too: you are paranoid, bipolar or manic-depressive, depressed, or schizophrenic.

In medicine, people have conditions. In mental health, people are their conditions. They are depressed, schizophrenic, bipolar, and anxious. This is not a simple matter of differences in terminology. It represents how our society—and particularly how mental health practitioners—thinks of people with emotional and behavioral problems. It is part of the social construction of mental diseases. Through these differences in phrasing, people may lose their individual identities, at least partially, when labels are applied so decisively to them.

To understand this point, remember that one key difference between medical diagnoses and those in mental health is that the latter are largely social constructs rather than diseases of the body. Although some conditions are heavily influenced by biological factors—for example, schizophrenia and manic-depressive illness—all diagnostic categories in the field of mental health rely on social behavior. They are, in effect, reflections of social judgments placed on behaviors that we find discomforting and disturbing.

Mental health diagnoses are not accurate and direct reflections of physical conditions, even when they include physical components. If you have a virus, you have an alien organism inside your body causing damage. That is not the case in mental health. More importantly, identifying what is and is not included as a mental "disorder" serves certain social and political ends. Social values determine what behavior is acceptable and what is not, and unacceptable behavior can be labeled a disorder. The types of behaviors identified as "disordered" change as the values of society change.

In medicine, an ulcer is an ulcer, even though the means of diagnosing and treating it may change. In mental health, different disorders come and go; the frequency with which they are assigned waxes and wanes, and even the symptoms change from time to time—all through cultural, sociological, and political processes. A few decades ago, psychiatrists classified homosexuality as a mental disorder. However, pressure from gay and lesbian political coalitions forced the American Psychiatric Association (APA) to reassess its approach, and homosexuality has now been largely removed from the official list of disorders. Whether a behavior constitutes a mental disorder or simply a variation of normal behavior arises from these kinds of social valuing processes. These values—at least as much as any gains in our scientific knowledge—determine how we think about emotional disorders, what symptoms will be defined as "illnesses," and who bears responsibility for correcting the problems defined.

The Social Construction of Mental Illnesses

The U.S. Bureau of the Census was among the first to classify disordered behavior. In 1840, census workers identified individuals with disturbing behavior and classified them as either "idiots" (the scientific term of the time, implying a lack of intellectual abilities) or "insane," implying engagement in socially unacceptable and unusual behavior.

From the outset, these diagnoses served clear political and social purposes: to maintain records, to track problems in society, and to allow or prevent the use of certain resources. Few people then believed in the concept of mental or emotional illness, and doctors assigned little value to these labels for medical purposes. At some point, diagnoses became reified—they were treated as if they were true or real entities rather than abstract constructs—in the minds of clinicians and the public alike.

In 1952, the American Psychiatric Association published the first systematic and uniform list of "diseases of the mind" and their associated behaviors, called the Diagnostic and Statistical Manual (DSM). From the beginning, both the identity of the illnesses included in the official DSM and their symptoms were defined by vote. That might seem like a democratic way of defining illness, except that only those who made the diagnoses, treated the conditions, and otherwise financially benefited from having a large number of individuals qualifying for their services did the voting. There was little effort to verify, through independent evidence, that these behaviors arose from true diseases. A strong belief among the membership was sufficient for distinguishing between what was a problem of morality and what was a problem of illness. As a result, the nature of mental illness has always reflected the changing moral temperament and values of the time.

When, in 1979, the third version of the Diagnostic and Statistical Manual (DSM-III) removed homosexuality as a "disease," the behaviors themselves had not changed—only the social acceptance, significance, and value given to them by society and political forces had shifted.

Between the mid-1960s and the 1990s, societal acceptance grew for explaining behaviors as products of their "psychological roots." Over this period, an increasingly large variety of behaviors, previously attributed to lack of self-control or lack of morals, became identified as "psychological illnesses." As the view that social ills were at the root of these "illnesses of the mind" gained traction, the legal sanctions and prerogatives of diagnosing and treating these illnesses were extended beyond the medically trained to those holding degrees in social work, sociology, religion, and psychology. Expanding the workforce was probably necessary since the number of behaviors being identified as "illnesses" was growing rapidly. The number of professionals expanded as the number of disorders that needed treating grew—probably not a coincidence.

Of course, the fact that insurance carriers promised to pay for the treatment of those who met the APA's criteria for mental illness may have had something to do with the process of including more and more behaviors under the umbrella of "illness."

The DSM and the Politics of Diagnosis

Between 1952 and 1968, the number of accepted "diseases of the mind" grew from 66 to 111. By 1994, when DSM-IV was published, the number of recognized disorders had reached 397. Through forty years and four editions, the number of disorders increased exponentially as finer distinctions were made among symptoms and as more mental health practitioners came to identify certain classes of behaviors as requiring correction.

In the short period between the publication of DSM-III-R in 1987 and DSM-IV in 1994, either the labels or the criteria for over 120 disorders were changed; thirteen disorders were added; and eight conditions were eliminated. Once-popular concepts like "neurosis"—a term familiar to most people—were deleted and later reinvented with a different set of accompanying symptoms. Other categories were introduced and then voted out of existence because they were considered sexist.

While it is possible that these changes genuinely reflect advances in scientific knowledge, it appears more likely that they indicate efforts to adapt to a society whose values are in flux. Cancer or heart disease could not be voted in and out of existence on grounds of political sensitivity. If they were voted out of existence, would they cease to occur and kill people? Such evidence clearly demonstrates that mental health diagnoses are subject to powerful political influences and are therefore vulnerable to abuse by those forces.

A society that prefers to identify disharmonious behaviors as illnesses, addictions, and disorders—rather than as problems of morality, discipline, self-knowledge, or criminality—may have helped drive this process. Perhaps the medicalization of deviant behavior is endemic to a political system that has exhausted conventional methods of control and seeks new ways to manage unacceptable and disturbing conduct. Treating "sick" or "addicted" individuals is preferable to acknowledging that deviant individuals may voluntarily choose socially destructive and immoral behavior, because such an acknowledgment would require us to accept the failures and weaknesses inherent in an open, democratic society.

When one of the leading forensic experts on multiple personality disorder, Margaret Singer of the University of California at Berkeley, was asked to comment on the origins of a colleague's diagnosis of Ken Bianchi, the Hillside Strangler, she startled the PBS interviewer. She said we do not really know what creates such a person—he may simply be evil. How much more socially acceptable it is to call someone like this ill, or to say he is schizophrenic or paranoid. We contend that the more scientifically sounding diagnostic terms offer little or no more explanatory power than the philosophical term "evil." These medical terms, however, partly protect society from the sense of helplessness that terms like "evil" convey. Were such behaviors framed in less medical terms, we would have to confront the nature of a family and society that fosters such behavior and grapple with serious questions about the existence and teleology of evil. Medical terminology, even when it explains little, provides a rationale for strong institutional controls such as pharmacological treatment and hospitalization.

Conclusion and Findings

The same holds true for all other mental health and psychiatric diagnoses. They cannot and do not exist apart from their manifestations in a person's complaints or behaviors. In medicine, a condition is not dependent on the symptom—the symptom only assists in making the diagnosis; it does not determine it. A patient may have no gastric distress or other manifest symptoms and still have an ulcer. Many people, unfortunately, have cancer long before they have any symptoms. But we define mental illnesses by subjective reports and overt behaviors. By definition, the symptoms must be present.

The identification of psychiatric disorders always involves a social judgment and often implies a political agenda as well. The definition of behavior as a "problem" for clinical purposes hinges on what society desires—a social judgment—and on what is disruptive of the political order and its values—the political agenda. It is less concerned with what is objectively true than with what values it supports and maintains.

Research, though also influenced by political forces, is less driven by them than are clinical judgments. Because research methods are less culture-specific and are, by their nature, open to replication, their findings are more likely to be reasonably objective and free from political bias. But research requires funding, and political forces and cultural priorities inevitably influence such funding decisions.