Pilgrim David & Rogers Anne. Disabilities: Insights from across Fields and around the World. Editor: Catherine A Marshall, et al., Volume 2: The Context: Environmental, Social, and Cultural Considerations, Praeger, 2009.

Disability theory provides the basis for a new direction of analysis from which to understand the societal barriers faced by people with mental health problems in Western countries. Disability theory, drawing as it does on a social approach to disability, has the power to reorient analysis from a focus on the individual to the wider mechanisms and processes of social oppression, discrimination, and exclusion. Disability theory also has the capacity to illuminate the various social and economic restrictions and sources of disadvantage encountered by people with a diagnosis of mental illness. Although disability theorists have been criticised for adopting an oversocialized perspective, it does provide a corrective to the overly individualized perspective by situating problems in the social context and referring explicitly to processes of social invalidation.

This perspective is important for all forms of disability, but in the case of mental health, another dynamic comes into play about the extent of social invalidation associated with people who, according to themselves or others, are mentally disordered. As Fabrega and Manning (1972) pointed out more than 25 years ago, “mental illness” is more stigmatizing than other conditions because it is not possible to disassociate the disability from the self or person. The very notion of “mentally disordered,” which is applied as a general term to cover those with a diagnosis of mental illness, personality disorder, or substance misuse, has the dubious implication that there is a readily definable fixed or stable notion of mental order. In this chapter, we examine the extent to which social forces determine mental health problems. Second, we consider lay and professional reactions to psychological difference.

Epistemological Starting Points

In reviewing the nature of mental health problems, different views are scattered across communities of interest (i.e., professionals, patients and their significant others, politicians, researchers). Three views are addressed here. The first is medical naturalism (also referred to as psychiatric positivism), which is reflected in orthodox psychiatric theory and practice and was championed at the end of the 19th century by Emil Kraepelin. This assumes that mental disorders are separate naturally occurring, fixed phenomena (like gasses or type of metal) and are embodied in the individual who has “schizophrenia” or “depression.” This reflects an epistemic fallacy (i.e., that the world simply is what its investigators believe it to be at a moment in time) and is typical of naive realism in medicine and other uncritical expressions of natural science when applied to human science.

The second view is social constructionism (i.e., where subject precedes object—the inverse of the first view). The work of Szasz (1961) was noted in this regard, though as we discuss later, his arguments may paradoxically legitimate one type of disability but not other forms.

The third view, and the one we have taken in this chapter, is that there is a reality of distress and madness that can be studied, but we must proceed cautiously and skeptically at each step. This position of critical realism (e.g., Pilgrim & Bentall, 1998 ) suggests that knowledge about mental disorder is socially negotiated, thus supporting the arguments about context-specific social constructions, but also acknowledging there are stable features that can be examined. For example, we know that conditioned fear (i.e., anxiety states) is reportable not only in all societies but even across mammalian species. Similarly, misery can be invoked experimentally in animals (i.e., learned helplessness), but human beings attribute particular meanings to these states, meanings that are biographically unique and socially and historically situated. As for madness, it is readily recognized by social actors. However, the social value or disvalue that is attached to madness can vary. For example, on one hand, there is a relationship between depression and creativity and mania and industrious success and, on the other hand, a complete social discrediting of those with a diagnosis of schizophrenia.

Social Forces as Determinants of Mental Health Problems

We use the notion of “social forces” here in a broad and inclusive way, which is consistent with a critical realist view of world. This approach insists that causes and meanings need to be understood together, rather than one or the other being privileged or discounted. We hope that our position avoids the opposition set up at times between naïve realists and radical constructivists (Rogers & Pilgrim, 2005 ). The former are naive about meanings and judgments that are inherently social. The latter insist that “everything is socially constructed,” thus displacing material reality as the dominant research focus and replacing it with the concept of ideas in action (discourses).

The largest obstacle to our understanding of the social model in mental health research is biological reductionism—the strong tradition within orthodox psychiatry to reduce all mental health problems to brain diseases. In this sense, both physical and psychological disabilities are accounted for by the medical, rather than social model of disability. In the case of physical disability, the body is the testing ground for social order (the ability of the impaired person’s body to sense, communicate, and move in a way that befits a given role in society). Generally, this type of social judgment is not the initial consideration in relation to mental health problems. Instead, rule infractions (rather than role failure) are the first pressing concern in mental illness—the way people conduct themselves. Although clinicians may emphasize the presence or absence of mental disorder as a clinical government, it is the way people speak and act in context that determines a diagnosis (or formulation) of mental abnormality. Moreover, formally codified attributions of mental illness are usually preceded by lay attributions by the prospective patient or their significant others. Because mentally disordered patients are judged by themselves or others as being impaired in their ability to function, the social definitions of impairment and the social forces that impact on mental illness are both important.

Economic Deprivation

Disadvantages typically associated with poverty, such as poor education, low pay or unemployment, poor neighborhoods, and poor living conditions, aggravate both physical and mental health (Fryers, Melzer, & Jenkins, 2000 ; Rogers & Pilgrim, 2003). Class position predicts both morbidity in its broadest sense and longevity in its specific sense. Not only do the poor consistently die younger, this pattern of early death is amplified in poor people who also have a psychiatric diagnosis (Knapp, 2001).

Labor market effects are reliant on the presence or absence of government-provided income maintenance and on the circumstances in which a person becomes unemployed. In most developed countries, unemployed people obtain welfare payments. These payments ensure that poverty is relative, not absolute, and that resources are available to sustain food and shelter. In many developing countries, this safety net is absent. For example, Patel (2001) noted that in India during the 1990s, bonded low-paid farmers lost everything when a monsoon destroyed their crops. They were thrown into absolute poverty, and suicide levels dramatically increased.

Some forms of unemployment may actually be linked to improvements in psychological wellbeing (for example, a good retirement package, inheriting wealth, or winning the lottery). Thus, although the absence of paid work is not inherently bad for mental health, the context of that unemployment is important to consider. The worst mental health is found not in unemployed people, but in those on low pay and with poor task control or on short-term contracts. This situation is sometimes called “inadequate employment” or “underemployment” (Dooley, Prause, & Ham-Rowbottom, 2000 ). The best mental health accrues from high wages, good task control, and permanent employment. Thus, unemployment may affect morale but work, especially poorly paid work, brings with it peculiar stressors, as well as low status and inadequate earnings. Low paid work leads to poverty in the domestic arena and, during work time, brings with it tedious and unfulfilling tasks.

In the case of becoming unemployed, however, its effects can be compounded by multiple losses (Fryer, 1995 ). Identity for many is bound up with work roles; unemployment results in a loss of identity. Daily meanings are bound up with the routines of work, so unemployment can represent a loss of daily structure. For some, being unemployed is a source of shame. For those whose income level drops significantly, there is the direct impact of financial stress.

Economic cycles create advantages and disadvantages to individuals. For example, one generation of young people might encounter a period of growth and can access the labor market readily. The next generation may be less fortunate. Those in insecure employment will be buffered from its effects during times of full employment, but in more economically depressed times, they will be very vulnerable (Kasl, Rodrigues, & Lasch, 1998 ).

Ecological Effects

Environmental factors begin to affect current and future mental health status from the womb onward. For example, substances that cross the placenta can influence neurological development, which in turn can have a behavioral impact after birth. With regard to loss, abuse, and neglect, these contextual factors impinge on the developing child. The etiology of mental disorders remains controversial (Read, Agar, Argyle, & Aderhold, 2003 ; Whitfield, Dube, Felitti, & Anda, 2005 ), but environmentalists have argued that consistent benign child-rearing is at the center of positive adult mental health. In contrast, abuse, particularly sexual abuse, in childhood is highly correlated with contact with mental health services (Pilgrim, Rogers, & Bentall, in press).

It has been known since the 1930s that psychiatric diagnosis is geographically distributed (Faris & Dunham, 1939 ). These early Chicago studies demonstrated that not only were poorer people more likely to have a psychiatric diagnosis, illness appeared more frequently in poorer areas. However, the ecological fallacy highlights that that not all people in poorer areas are poor, and not all are prone to mental health problems. Thus, ecological effects are evident, but where a person lives is not the only determinant of his or her mental health status.

Urban life generally is more “psychonoxious” than rural life (Paykel, Abbott, Jenkins, Brugha, & Meltzer, 2000 ), not withstanding our knowledge about pockets of rural poverty. This effect is due to more social disorganization and environmental stressors (crime, vandalism, noise, litter, and motor traffic) in urban areas. In areas of concentrated poverty, the impact at the individual level is profound and negative. Not surprisingly, in these neighborhoods, there are raised levels of depression, anxiety, and substance misuse (Aneschensel & Succoff, 1996 ).

Apart from the direct exposure to the external ambient hazards of stress in these local contexts, people are less likely to have regular supportive social networks, particularly if there is a high turnover of residence (Sampson, 1988 ). Some particularly deteriorated localities contain higher rates of presentation of depressive symptomology (Ross, 2000 ) in all social groups, including those with higher levels of economic capital. Similarly, aggregate neighborhood income predicts levels of diagnosis of schizophrenia and substance misuse (Goldsmith, Holzer, & Manderscheld, 1998 ).

Some localities provide more “opportunity structures” than others as a result of the cultural and environmental possibilities for stress-free or health-giving public behavior. For example, two neighborhoods may be grossly equivalent in terms of income, but one may have safer streets and more spacious green park areas for safe exercise than the other. Generally, more affluent neighborhoods provide more opportunity structures than poorer ones (Ellaway & Mcintyre, 1998), emphasizing the fact that social position can be defined as either an individual or a neighborhood characteristic.

Race, Ethnicity, Gender, and Age

In the British context, two groups of ex-colonized people (i.e., those with historical origins in Ireland or the West Indies) have higher rates of psychiatric diagnosis than other groups (Rogers & Pilgrim, 2005 ). The fact that the Irish are typically white suggests that ethnic minority status may be more important to consider than racial background. The epidemiological data on those from the Indian subcontinent is more ambiguous in that not all studies show higher rates of diagnoses.

In the postcolonial context, a complicating factor is the type of migration involved, which could be either forced on or desired by the migrant. These different conditions could determine whether migration is experienced with hope or in a state of trauma and loss, thus influencing mental health status.

Although much has been researched and written about gender and mental health, its relationship to detrimental outcomes remains unclear (Rogers & Pilgrim, 2005 ). Although more women than men are recorded as having mental health problems, this may be due to the fact that women present more often to primary care settings and because they live longer than men (and so have a higher prevalence of both dementia and depression in old age). In contrast, men are overrepresented in coercive mental health services (e.g., forensic services). Women are more likely to be diagnosed with panic disorder and depression than men, whereas men are more likely to be diagnosed with substance abuse and personality disorder (especially antisocial personality disorder). Thus, if diagnoses are examined, then any overall differences in the incidence of mental health problems between genders disappear.

Across the life span, mental health problems are unevenly distributed. Young children and very elderly people are most at risk, creating a U-shaped distribution. This suggests that the notion of a middle-aged crisis is a myth. Indeed, some studies have suggested that people in their fifties and sixties enjoy the best mental health (Rogers & Pilgrim, 2003 ). Yet the investment in service resources tends to be concentrated in the working years age group (services for older people, children, and adolescents receive less investment in the United Kingdom). This financial pattern gives us a hint that mental health services may be more about social regulation for socioeconomic efficiency than an equitable response to need.

Social Forces as Determinants of Judgments about Psychological Difference

The foregoing section has explored what we know to date about the social causes of mental illness. It has emphasized predictable differences in society based on structural divisions of class, race, gender, and age, with the first of these having the greatest salience. However, we caution against naive realism. It would be possible to concede the causal role of social factors, but still operate within a naive realist view of the world. Put simply, we could think of social factors being part of a biopsychosocial mix of etiological factors to explain the existence of mental disorder but stop thinking socially from that point onward. We argue instead that although social factors are demonstrably causal of mental disorders, it is a value judgment as to why mental disorders are deemed to be problematic. These value judgments reflect inherently social processes. In other words, mental disorders are not self-evident, naturally occurring phenomena that are global and transhistorical. Instead, our position is that they reflect forms of deviance from or defiance of moral order and socioeconomic efficiency.

Although no society has been indifferent to those who are distressed or act in an unintelligible way, how these differences have been valued has varied over time and place. For example, in antiquity, Socrates considered madness and sanity to have equal value. Psychological distress, as a social problem, has only emerged relatively recently in developed countries following the return of “shell-shocked” combatants returning from the World War I. Depression and anxiety states were framed as forms of disability, and government policies emerged to deal with problems that were stress-related (Stone, 1985 ). Prior to that in the 19th century, the sole medical discourse was about madness and the assumption that it was a genetically determined brain disease (even though records of asylum admissions would frequently refer to social or family triggers for lunacy). Similarly, drug abuse and recurring personality problems that became medicalized in the middle of the 20th century were previously framed as forms of fecklessness and immorality.

If we examine the current mixture of psychosocial problems that are subsumed under the broad rubric of mental disorder, we find a typology consisting of:

1. Those who act in idiosyncratic unintelligible ways that arouse anxiety and perplexity in others;
2. Those who are miserable and know that they are miserable;
3. Those who in the past would have been seen as weak, antisocial, dysfunctional, and feckless (a range of views exist within this group about whether they have a psychological problem).

The first cluster would receive diagnoses of schizophrenia or bipolar disorder. The second would be described as suffering from the common mental disorders of anxiety and depression. The third group would include those with diagnoses of substance misuse and personality disorders. Each group in its own way reflects a social frame for value judgments.

In the case of the first group, a fundamental meta-rule of intelligibility in modern societies has been violated. This point was at the center of well-known deviancy theories developed in the 1960s (e.g., Goffman, 1961 ). Adult citizens are expected to act in ways that others understand. If a person breaks a rule and then cannot or will not offer a persuasive account of that rule transgression, then the ascription of serious mental illness eventually occurs. Moreover, once a person is labeled in this way, most or all of his or her conduct thereafter is accounted for in the eyes of others by the presence of illness. This same argument applies to those in the third group.

With regard to the second group, deviancy theorists would label this as a transgression of emotional rules, which can be ascribed to the self as well as by others. According to this view, we all learn from early childhood that there is a subjective state of “good enough” mental health (happiness, optimism, contentment, love of life, self-confidence, and confidence in others). We can contrast this against a wide range of feelings, some of which fail the positive test of psychological wellbeing. To use the phrase of Thoits (1986) , we learn when we are breaking “feeling rules.”

What has changed over the past century in Western societies is that the three groups, which represent different styles of rule infraction, have been associated with different levels of governmental interest. So-called mental health policy has been characterized by a twin track approach. On the one hand, there has been a tendency to construct a legal apparatus to ensure the proper (i.e., lawful) social control of those in group 1 and some of those in group 3. On the other hand, the government’s obligation to respond to self-defined distress has been expressed through general health policy (delivered in primary health care settings).

Mental Health and Citizenship: The Contradictory Imperatives of Coercion and Recovery

Although the social model of disability is applicable in the mental health field, a special dynamic of invalidation needs to be considered.

• First, people express particular fears and prejudices, which can be either unique attributions about those with mental health problems or exaggerated forms of stigmatization that are present for all disabled groups.
• Second, it is commonplace for governments in developed societies to install unique forms of legislation that define the conditions under which some people with a diagnosis of mental disorder are lawfully controlled.
• Third, powers created by that unique legislation are usually delegated to health and social care professionals. Each of these issues will now be considered.

Concern, Prejudice, and Stigma in the Public Domain

Those who are sane by common consent have traditionally been concerned with three interweaving political demands. The first demand is that those who arouse fear or perplexity in others should, in some way or another, be dealt with by agents of the government. In this sense, all psychiatric crises are social crises because they are triggered by a judgment in the public arena that something has to be done. The second demand is that those agents of the government should act fairly and reasonably, combining social control and a duty of care (i.e., legal paternalism or parens patrie). The third demand is that those who are truly sane should not be dealt with as if they are in the wrong category. For example, public concern about “wrongful detention” dominated the voting discourse at the turn of the 20th century around mental health legislation reform (Bean, 1980 ). The main public concern related to the unfair detention of the sane but not to the rights of the insane.

By the mid-20th century, ethical concerns were being expressed about the use of the coercive detention and treatment of Soviet dissidents. Ironically, these claims were made by Western psychiatrists who were happy to detain their own “truly insane” patients at home (Bloch & Reddaway, 1978 ). Thus, the tendency to treat psychiatric patients as being undeserving of citizenship (until proven otherwise) has a long history and is reflected in the political economy of disability. Once a person has been deemed to have lost his or her reason, then citizenship can be removed legitimately until a case is made to reverse the decision. It was only later that century when the demand for duty of care (irrespective of the legitimacy of one’s detention) was also expressed by the public. Today, the general public tends to demand that mentally disordered people should, when necessary, be removed from society. At least in many Western countries, such as the United Kingdom, there is a general belief that removal should be achieved in a caring manner with restorative intent.

Studies of decision making about mentally disordered conduct suggest that agents of the government (health and criminal justice personnel) do not roam society searching for patients to diagnose and treat. On the contrary, the decision making has usually already been made in the public domain. For example, police officers who remove patients from public spaces to a place of safety for psychiatric assessment typically do so at the request of the public. Similarly, families vary in their tolerance of psychological deviance before they call health professionals to validate the decisions that have already been made about the identified patient (Coulter, 1973 ).

Prejudice and stigma about those who are acting unintelligibly is not new and can be traced back to antiquity (Rosen, 1968 ). To act in an unintelligible way is to break an implicit social contract in most complex societies. Role-rule compliance is expected, and a transgression of this meta-rule demands explanations or excuses from the rule breaker. If these are not forthcoming, then the deviant individual is deemed to automatically warrant social rejection. What has varied over time and place, though, are norms about the threshold and outcome of that social rejection. For example, some societies detain more patients than others. Some societies have treated those detainees well, whereas others have treated them brutally. The worst-case scenario was the systematic elimination of patients under the Nazi regime (Meyer, 1988 ). The powers of professionals to act within that range from benign paternalism to murder and persecution are ultimately derived from and legitimated by public norms and expectations.

Politicians: Their Moral and Socioeconomic Priorities

In light of the foregoing discussion of public prejudice and decision making, politicians are sensitive to public demands in liberal democracies. However, in societies where this type of responsiveness to public demand is not a main driver of political decision making (i.e., authoritarian regimes of both left and right), psychological difference provokes the need to impose coercive control. In other words, the government apparatus has a vested interest in controlling psychological deviance for more than one reason. On the one hand, politicians reflect, shape and respond to a moral order. The role-rule failures committed by people with mental illness are likely to stimulate and legitimate a mandate for political repression to preserve the status quo. On the other hand, those who are unable or unwilling to follow rules and fulfill role expectations represent a potential burden to economic efficiency. Thus, both the moral and socioeconomic order are concerns for politicians.

The response of politicians in liberal democracies is twin-track. The first track provides a legal framework to define when and if mentally disordered people should be coercively controlled. Confusingly and euphemistically, this is usually called “mental health legislation.” Indeed, the political discourse about mental health is mainly limited to discussions or analyses of legislative frameworks of this type. The other track relates to the equally confusing notion of “mental health services.” The latter is a relatively new term. Previously, these services were called psychiatric services (reflecting their medical dominance). Before that, there were not services at all but “mental hospitals” and, even earlier, “asylums.” Mental health services offer places of protected treatment and restoration (psychiatric therapy and rehabilitation). They are about doing good and ensuring access to help; services are not (knowingly or primarily) about social control on behalf of others.

However, in what sense are these services about mental health? Instead, they are overwhelmingly about the containment and or treatment of mental illness. In what sense are they services? Only in the sense that they have more than one client. Thus, the notion of consumer or customer, which is applied more frequently now, is problematic. Although some services may serve the interest of some people who have accessed them on a genuinely voluntary basis, they also serve many third-party interests, such as relatives, strangers in the street and the court system. For many psychiatric patients, professional interventions are imposed rather than requested.

Therapeutic Social Control: Role Conflict and Strain in Mental Health Professionals

The interaction of public and government interests in defining and responding to mental disorder leaves their servants (“mental health professionals” ’) in an ambiguous role. The ambiguity, involving a mixture of therapeutic intent and a paternalistic willingness to remove liberty and intervene without consent, has provoked much professional debate. At one extreme, the libertarian psychiatrists (such as Szasz) provide an early constructivist critique of mental illness, suggesting that mental illness is a myth because minds can only be sick in a metaphorical sense. Szasz also insisted that coercion should have no part in helping those with “problems of living.” When this happens in the modern therapeutic state, psychiatric staff act like witch finders, not healers.

The professional orthodoxy within psychiatry has ignored these unpalatable accusations and favored the idea that mental disability is a primary and natural pathology (not a secondary and constructed product) and that it ipso facto requires paternalism. From this idea stems the doctor’s right to treat, which is privileged over the patient’s right to liberty. Indeed, during the 20th century, psychiatric leaders consistently lobbied to ensure their right to treat.

A contradiction can be noted in the recent rhetorical shift toward a recovery model in psychiatric services and in the assumption that the disabling impact of stigma is purely a matter of public ignorance. Many psychiatrists and mental health professionals see themselves as part of the solution, not part of the problem. Patients are encouraged to seek help early (implying dire consequences further down the line if they “fail to engage with services”). They are encouraged to define recovery by compliance with treatment rather than by their access to everyday experiences of citizenship. There is an assumption that noncompliance with medication is an irrational act rather than one based on the patient’s knowledge and informed decision making.

Thus, on the one hand, patients are encouraged to be collaborators in their treatment plans and informed consent is prioritized, but on the other hand, professionals reserve the right to treat on a compulsory basis and to ensure patient compliance. This paradox triggers dilemmas in the relationship between professionals and patients about balancing risk taking and risk minimization, with the continual threat of accusations from third parties that a patient poses a “risk to self or others,” something that the third parties believe should be prevented by mental health professionals.

Health professionals are Janus-faced. Potentially, they could be advocates and collaborators, advancing the individual and collective rights of patients in localities to enjoy fuller citizenship. However, at the same time they are often restricted by their constructs of difference, which focus on reified diagnostic categories. They also, consciously or unconsciously, use conservative decision making. If they are charged with a duty of care, which is reinforced by the powers (and thus responsibilities) arising from mental health law, then they will not be blamed for coercively controlling the low-risk patient. However, they will be blamed if they take a risk that results in an incident of harm to self or others. This conservative decision making will work against the rights of patients to be free in favor of risk avoidance.

The Relationship between Primary and Secondary Deviance

In the light of the discussion of social determinants of mental health problems and followed by a consideration of the social context of judgments about the value of psychological difference, a tension can be considered by those interested in applying disability theory to mental disorder. For example, it could appear that social determinists have it both ways. On the one hand, it can be reasonably argued from the evidence that social causes (e.g., the social origins of depression) are sound enough. Oppressive social forces and material deprivation make a significant contribution to the generation of human misery. On the other hand, those emphasizing destigmatization and social valorization would seek tolerance of misery and even its positive valuation.

This contradiction revolves around values. Is misery simply an example of psychological difference that is unfairly stigmatized and socially excluded by those around the identified patient? Or is misery an indication of a failure of our common humanity? This tension is even more evident when we consider those who seem to break the social rule of intelligibility. Putting aside arguments about the validity of diagnoses, such as schizophrenia, when some people speak in ways others do not understand (i.e., thought disordered or delusional) or report sensory experiences not seen or heard by others (i.e., hallucinations), under which form of social arrangement might these forms of conduct be valued rather than devalued? In a Western context, where rationality governs daily activity in the home, street, and workplace and holds us all to account in our moment-to-moment activity, the meta-rule of immediate social intelligibility dominates.

Those who are unable or unwilling to comply with this meta-rule are immediately vulnerable to social rejection. Counterexamples can certainly be found, but these are largely in preindustrial or traditional societies (e.g., the ability to have visions or hallucinate could have positive connotations about extraordinary spiritual powers and insights). The ancient philosophers were ambivalent about the value of madness. For Socrates positive aspects of mad rapture included prophesying (a “manic art”), mystical initiations and rituals, poetic inspiration, and the madness of lovers (Screech, 1985 ). At the same time, Rosen (1968) noted that in ancient Greece and Rome madness was associated stereotypically, as today, with aimless wandering and violence. Thus, we cannot simply argue that the current ubiquitous rejection of madness is a postindustrial phenomenon, but this ambiguity is a useful point of reflection about the immutable pathologization of severe mental disorder.

Within the broad medical discourse of mental disorder, we can identify distinct groups using social criteria. In particular, a distinction is obvious between those who are fully aware of their rule infractions or their inability to fulfill role expectations (e.g., depressed or agoraphobic patients) and those who lack insight. The latter, which could be applied to acutely psychotic patients, has different implications to the former.

Those without insight are better understood in terms of direct social distrust and rejection (i.e., they act in a way that others find, frightening, threatening, or offensive). By contrast, those who are frightened or sad may be inoffensive to others (i.e., they often elicit sympathy and compassion). They knowingly break feeling rules, and their distress is evident to themselves not just others (Thoits, 1986 ).

Thus, the notion of mental distress does not do justice to the full panoply of mental disorder. It is a linguistic substitute or preferred euphemism for medical labeling, but it is just as limited in its capacity to comprehend the complexity of mental disorder. As we have shown, it is not always the patient’s distress that drives the social transaction, it is often the emotional reactions of others (i.e., pity, fear, disgust, and exasperation). This mixed emotional reaction explains why our commonsense reactions to psychological difference become enshrined in social policy as an admixture of paternalism, compassion and controlling rejection, with mental health services being given the responsibility of juggling all these impulses.

The more a society is rule-bound, the more there will be coercive control of psychological difference. But no society (old or new, liberal or authoritarian) is completely indifferent to rule infractions and role failure. These violations tend to bring with them a set of moral and political prescriptions, even if they vary across time and space. Coercion is not unusual in mental health services, whereas it is very rarely applied to people with physical impairments. This coercive nature limits the capacity of services to respond to the demands of citizenship that are articulated by the disability movement. Whereas barriers to person-centeredness and citizenship operate in relation to all people with a disability, the disproportionate lawful use of coercion creates a qualitative shift in the field of mental health.

Similarities and Differences between Physical and Psychological Disability

Given the arguments we have made in this chapter, we can ask whether disability theory (which has been derived strongly from the consideration of physical disability) can be applied to mental deviance. One challenge relates to whether all disabling processes apply equally to the range of conditions that fall within the ambit of health care organizations.

Some constructivists limit their critique to mental illness. For example, an early, and for some notorious, example came from the dissident psychoanalyst Szasz and his declaration about the myth of mental illness (Szasz, 1961 ). What he proposed was to legitimate the idea that physical illness was not socially negotiated but ontologically stable across time and place. However, the neat boundary that Szasz (1961) aspired to retain between true and mythological pathology was not readily available. One response from political science to this disputed boundary was to frame all illness as deviance (Sedgwick, 1982 ). A different response was from biomedicine: namely, hoped-for reductionism, under which all mental illnesses were assumed to be brain diseases (Baker & Menken, 2001; Guze, 1989).

The logical difficulty of isolating psychiatric labels for particular critical scrutiny is questioned by inflammatory conditions, such as rheumatoid arthritis, psoriasis, irritable bowel syndrome, and asthma. Similar to mental disorders, they appear to run in families. However, they do not follow precise genetic patterns. Also, like mental disorders, they have weak etiological specificity and poor treatment specificity. Analgesics, steroids, immunosuppressants, and even chemotherapies, developed for cancer, can be applied across a range of inflammatory conditions.

The overlap of features between physical and mental disorders, which cannot be denied, coexists with a unified cultural discourse in both the public and professional arenas that there really is some sort of fundamental distinction between mental and physical deviance. When a diagnosis of a functional mental disorder (e.g., major mental illnesses or personality disorders) is made, it is determined completely on a patient’s words or actions. This situation can even hold true for the diagnosis of organic mental illnesses, such as dementia. In contrast, it is rare for physical disorders to be diagnosed on grounds of symptoms alone.

Thus, although an overlap of epistemic features can be demonstrated between mental and physical illness, mental illness has become separate for most of us most of the time for a number of reasons.

• We tend to think of physical injuries, diseases, and ailments happening to us, whereas we are mentally ill. Mental illness implicates the whole self, which, as a consequence, becomes discreditable (Fabrega & Manning, 1972 ). However, to temper this distinction, we can note that occasionally this negative socioethical attribution has also been a feature of physical conditions, such as sexually transmitted diseases, tuberculosis, and cancer. Many forms of physical illness have been associated with shame and moral failure.
• The body is potentially explicable in physical terms, whereas human conduct can only be understood meaningfully via interpretive methods. Hermeneutics not biomedical science is implied (Ingleby, 1980 ).
• Coercion is commonly applied to those deemed to be suffering from mental disorders, but is rare for those with physical diagnoses. Mentally ill patients are deemed to lack cognitive capacity about their actions far more often than physically ill patients. In the latter case, mental capacity loss is either very temporary (e.g., concussed patient or a hypoglycemic diabetic) or is the result of serious brain trauma. The bulk of physically ill people, even when terminally ill, are deemed to retain their cognitive capacity, whereas people with psychiatric illness are usually considered to have lost their reason.
• At the turn of the 20th century, when institutional care was being eroded, a pecking order of citizenship could be seen in the disabled population. By the mid-20th century, the great bulk of physically disabled people were not in residential care, whereas those with mental health problems and learning disabilities were still overwhelmingly warehoused in institutions. Mental disability was therefore dealt with differently. This othering of people with mental disorders is also discernible generally in society. Stigma is attached to many forms of physical disability, but only epilepsy seems to evoke the same degree of fear, prejudice, and social rejections as mental disorder. These socioaffective responses are a ready platform to justify coercive containment and treatment.

These similarities and differences suggest that on the one hand, hard-and-fast distinctions between physical and psychological difference in society are difficult to construct. On the other hand, they are regularly distinguished, by both professionals and the public, particularly in societies that maintain and reproduce forms of fundamental Cartesian dualism. Probably the strongest distinction relates to the narrow preoccupation in the field of mental disorder with symptoms. Symptoms of mental illness tend to reflect incapacity in relation to role failure and rule infraction, whereas bodily signs of physical conditions are carried across all social settings.

For example, untreated Type I diabetic patients, with their extinct pancreatic cells, will simply die wherever they are. By contrast, people who hallucinate might be discounted as schizophrenics or valued as mystics depending on their social context. Thus, the sick role exists to signal and excuse role failure for those with both physical or psychological problems. However, a psychiatric diagnosis signals a much wider inability to be trusted to follow the rules when operating within a social framework of rationality or moral order. It is only when that moral order values the nonrational that the patient is permitted a socially valued position. Interestingly, nonrational thinking and behavior has its place in artistic and spiritual arenas, so the less a society values these aspects, the more dismissive it will be of psychological deviance.

Conclusion

This chapter examined mental disorder in the wider context of the relationship of disability to society to reorient analysis from a focus on the individual to the wider mechanisms and processes of social oppression, discrimination, and exclusion. We have adopted a form of weak rather than strong constructivism throughout, in line with a critical realist approach. The advantage of this approach is that allows us to accept evidence about the social determination of mental disorder, while giving due weight to the shifting and variegated value positions of communities of interest. Communities of interest include professionals, patients, and their significant others, all of whom are embedded within cultural norms about the tolerance or value applied to psychological difference in society.

Those norms vary across time and space—a fact that tempers any naive realist approach to the topic, as is found in the universalism of psychiatric positivism or medical naturalism. To give an illustrative example of this distinction, schizophrenia is a dubious social construction, but some people do hear voices that their fellows do not hear. The critical question then relates to the social value that is ascribed to voice-hearing in particular times, places, or cultures. Similarly, fear and sadness are universal and transhistorical phenomena (found in all mammals, not just humans) but the meanings and social value placed on them vary across time and place.

We also raised some questions in this chapter about the extent to which physical and mental health problems can be conceptually and socially conflated. Though socialized ourselves in Cartesian dualism, we tried to reflect on the dilemmas this creates for social science. At this stage of reflection we can identify similarities, ambiguities, and some persuasive distinctions. In other words, the two types of deviance have much in common, but there is a residual sense that mental disorder is different. This difference cannot be simply explained away by the conventions of lazy dualistic thought.

Several grounds were offered to support this conclusion, but the strongest relates to the overreliance on public and professional labeling of what incipient patients say and do rather than on any demonstrable deviation from anatomical or physiological norms. This preoccupation with rule infraction (rather than the focus on impaired roles that is usually associated with physical disability) leads to a shift in focus in dealing with mental disorder. Thus, the socioaffective dimensions to mental disorder are important to understand.

People with mental health problems are viewed as not complying with rules, in a variety of ways and to various degrees. In turn, this view produces a range of affective responses from nonpatients, including fear, loathing, perplexity, and exasperation. In turn, these strong emotional drivers create a social distance between the deviant and the nondeviant actors. In this field of othering we find the rationales or rationalizations for stigma, social exclusion, and therapeutic social control. In the case of mental disorder, this is disproportionately coercive and violates the norms of natural justice. With the exception of laws against terrorism, there are very few examples in liberal democracies where lawful detention without trial can be applied to the prospective rather than past conduct of adults. Mental health legislation is one of those examples.