mental illness as a social construct (2015)

Mentally ill people are stigmatized. The situation parallels -isms such as sexism, racism, and heterosexism. Women, racial minorities, and the LGBTQ community have made progress fighting against these forms of discrimination and injustice. This progress should also extend to the mentally ill, so that being mentally ill is only difficult because of the illness, not because of stigma in addition to symptoms. If we see the situation of the mentally ill person as constructed, this may help lessen stigma. In this paper I will examine to what extent the situation of the mentally ill is a socially constructed situation.
One starting point for investigation would be to pose the question: does madness have an essence? This question may be too broad, however, so I will narrow it down to: does bipolar disorder have an essence? I choose to focus on bipolar disorder because of my first hand experience with it. I am manic depressive.
Bipolar disorder is a form of mental illness characterized by pronounced mood swings. Psychiatrists distinguish between mania, hypomania, and depression. An untreated manic-depressive will have manic episodes and depressive episodes. Hypomania, a mild form of mania, can be integrated with normal life, so that one can be highly functional at the same time that one is in an elevated state. Mild depression can also be integrated with life so that functionality isn’t impaired. But severe mania and severe depression are debilitating. They are very difficult to treat outside of a hospital setting. One may be treated at a hospital voluntarily or involuntarily.
The experience of these extreme states is not just a difference in degree, as in more depression or more mania. There is a difference in kind. One enters a different territory once a threshold is crossed. There is a point in bipolar disorder where no interpolation can restore the subject.
There are, however, medications that usually work to bring one within the bounds of normalcy. They tend to have side effects, but are remarkable effective. Talk therapy works to an extent as well, though it is not very effective in treating very manic people. Electro convulsive therapy also usually works, though it has side effects, especially memory loss.
Manic people do things that most people don’t do. They may preach on a subway car. The sermon may or may not be comprehensible. They may do risky things like walk through traffic. They may engage in blind destruction, destroying thousands of dollars worth of things. They may become convinced that they are God, or the President, or the Devil, or something else. They may spend money lavishly and have unusual generosity. They may not sleep or eat.
Similarly, depressed people act in an unusual way. They may not leave their house or their bed. They may not shower or eat. They may sleep an unusually long time or unusually little time. Depressed or manic people commit suicide at a rate much higher than the normal population. Depressed people lose interest in the things they used to enjoy. They may avoid social situations and profoundly isolate themselves. They may break down crying for no apparent reason. Though they may be intelligent charming people, they may lose their wit and their charm.
In addition to these changes in behavior, there are changes in how one feels while depressed or manic. The subjective experience of life while in these states is very different from the subjective experience of life while in a normal mood. Patterns of thinking change. One may become grandiose or full of nihilistic despair. Memory is affected, as is the sense of identity. A stable sense of self in the world is lost. Normal meanings of life disappear, replaced by other scenarios, some of which are positive and joyful, others sinister and full of self-loathing and self-reprimand.
Furthermore, one’s experience may change to include hearing voices that other people can’t hear, seeing things other people can’t see, and worst, smelling things that others can’t smell. A profound sense of isolation comes from these experiences and the stories that frame them. Mental illness is filled with drama, but it’s usually a drama that other people can’t seem to understand. It is often impossible to explain one’s experience while it is happening. One is pulled away from participation in ordinary life, and there may be a bliss in being removed from the world, but often there is a longing to get back to reality. This unfulfilled longing—either for a consummation of the madness through complete oblivion and transcendence, or for a return to the embrace of normalcy—creates suffering.
Psychiatrists call the state of well-being “euthymia”. When a manic depressive is neither manic nor depressed, but more or less in the range of mood that is simply the starting point for most people, they are considered to be euthymic. But even in this state of euthymia, even when in complete remission, bipolar disorder lurks in the shadows of experience. It may manifest as an anxiety based in a fear of the return of mania. Most manic depressives have anxiety disorders.
There is a sense of double identity as being both a crazy person who knows taboo regions of the soul, and being a normal person who others crazy people and identifies with a non-radical, peaceful, pragmatic view of life. This double identity is encapsulated by the notion, “when i was sick, I…”. One may want to pathologize oneself in order to belong to normalcy. In this convenient formula, one disowns a part of one’s experience by calling it sickness. But meanwhile one never completely forgets certain elements of madness, and this creates a doubleness: the healthy, socially correct self, and the sick, internally-ordered (not socially-ordered) self, who is startled to see his reflection in a mirror.
The social self accepts limitation, the sick self has a sense of limitlessness. One is praised, the other pathologized. One is accepted in the world without fanfare. The other is stigmatized. But really there is one person whose identity has been understood in a divisive way. The division comes from a way of understanding, for all experience of mania and depression is unified by the one experiencer, who persists through depression, mania and euthymia. But again, because of stigma, the only socially acceptable entity is the subject who is just the social subject who happens to have a disease.
This is unless one has become a cultic figure such as a poet of musician who creates from a place of madness. Occasionally one is given license to be crazy. Ironically, extreme states, such as may occur in a mystic or artist, are sometimes praised and commodified. They sell books or records and are fetishized. They become foundational for religious traditions. These are some of the same states that are so taboo and so readily pathologized.
Pathologization can be a step up from a non-illness understanding. Encountering a crazy person, we may understand them as transgressing social norms and end our understanding there. Or, we may see them as sick, and therefore not as transgressive. The transgressive person deserves punishment, we might reason, but the sick person needs care. The notion of sickness absolves the crazy person from the reprimands that would follow transgression.
But further insight reveals that the crazy person exhibits disowned elements of the soul which are impersonal. The act of othering, through stigma and disease understanding, enforces this rejection of the disowned elements. This self/other, normal/crazy distinction mirrors other distinctions, such as hetero/queer, white/black, male/female. These dualities are destructive, and one way of overcoming them is to move towards seeing experience as impersonal. There are traditions of impersonal monism which support this idea. It can be read out of the Gospel of John, and exists within Hindu traditions. It is to be found in idealist philosophy from 19th century Germany. It is also close to the Buddhist no-self doctrine. It is a very peaceful notion.
But before we take refuge in the metaphysical high ground of non-dual impersonal enlightenment, we must return to the question: does bipolar disorder have an essence? For even if we resist the impulse to other it, shouldn’t we acknowledge the claim that psychiatry and society make, which is that there really is such a thing as mental illness, and bipolar disorder really is what it claims to be: a mental illness that is an essential truth, whether we like it or not?
For me and for friends with bipolar disorder, this is not just a philosophical question. Are we really sick? Do we only have two alternatives—to accept the reality of being mentally ill or to be in denial of it? This is what is at stake: do we have to accept the stigma built into the notion of mental illness and make the best of things, or can we peacefully reframe psychiatry’s assertions? If bipolar disorder is essential, it is a reality we simply must live with. We must simply accept being labeled this way, for the label contains truth. But if bipolar disorder is not essential, and is in fact a social construct, if mental illness is a construct, then we can use the construct when it is useful and gently set it aside when it is not useful.
There are several reasons why we might want to call bipolar disorder real, as opposed to something that is socially constructed:
First is that it’s hereditary. We might reason that something hereditary is not a social construct.
Second, certain substances make it go away most of the time. There are manufactured drugs that control mood, but there is also lithium, an element on the periodic table, that by itself or in addition to manufactured drugs, is very effective as a mood stabilizer. This suggests that the disorder is biological, and we might reason that something biological is not socially constructed.
A third reason for considering psychiatry’s notion of bipolar disorder to be real and not socially constructed is that it helps so many people. Manic depressives who would otherwise have a very limited lifestyle are, thanks to psychiatry, able to live full lives. Rather than being debilitated by isolating and difficult manic and depressive episodes, they are able to participate in society and live a life rich with work and love. One might reason from this that it’s no social construct which provides these opportunities and benefits for the patient, but something which is actually real.
A fourth reason to say bipolar disorder is not socially constructed is the elegance of the psychiatric disease model. Just as we might say that in virtue of its simplicity and elegance, Einstien’s “e=mc2” is not some construct but a universal truth, we might say that bipolar disorder transcends the culture in which it was first formulated. Bipolar disorder is an incredibly simple and elegant way of understanding a certain type of madness despite its endless labyrinths and florid irrationality. One could reason that something so elegant should be considered above the realm of cultural constructs.
A fifth reason would be the consistency of manic people and depressed people. They show up in hospitals in recognizable patterns. It might be inferred from this that what psychiatrists are faced with is something real, not something that is a cultural construct. If it were a cultural construct, how would manic people be clearly out of control yet act manic in such a recognizable way? How would depressed people have the capacity to be so convincingly depressed?
These five considerations—heredity, the efficacy of medication, the benefits of treatment, the elegance of the disease model, and the consistency of patterns of mania and depression—might suggest that bipolar disorder has an essence. But what are the reasons to suppose that it has no essence?
To begin, there are such differences in how to relate to mania and depression that they break down as concepts. Here Giorgio Agamben’s concept of dividing distinctions is useful. In discussing the Apostle Paul, Agamben writes, “the messianic aphorism can be seen as a cut of Apelles that does not have any object proper to itself but divides divisions traced out by the law.” (Agamben, 50) Psychiatry makes the distinction between bipolar and not bipolar, which is related to the distinction mentally ill vs not mentally ill. Following Agamben’s interpretation of Paul, we can divide these distinctions with other distinctions.
To give an example of this, consider an artist like Charlie Parker, the famous jazz saxophonist. He had bipolar disorder. In the field of music, whether or not one is mentally ill is irrelevant. All that matters is how one plays. This is also true of race and gender. There are some musicians who would be sexist, racist, or stigmatizing of the mentally ill, but among the most serious musicians, these things don’t matter. When music is commodified and sold, age, gender, look, race, and other factors become important. But when serious musicians play for each other, these distinctions are completely subordinated by whether or not someone can play.
Charlie Parker’s music is sublime. He was a genius. A whole generation of musicians tried to sound like him or a variation of him. If bipolar disorder is essential, then he must have a mentally ill essence. As a manic depressive he must share with other manic depressives a common essence. But this essence only appears if we look a certain way. To a serious musician, in the field of jazz, Charlie Parker’s bipolar disorder does not show up. A musician might be concerned only with Parker’s rhythm, his articulation, his harmonic innovations.
Here Bourdieu’s notion of field is useful. According to Waquant’s explanation of Bourdieu, fields are “distinct microcosms endowed with their own rules, regularities, and forms of authority.” (Waquant, 268) It’s clear that art and psychiatry are different fields, and “rules, regularities and forms of authority” within the world of psychiatry don’t carry over into the field of art.
Parker was also a heroin addict, but neither drug use nor mental illness is important in understanding how Parker used upper harmonic extensions in his melodies, for example. The distinction good musician vs bad musician completely undercuts the distinction mentally ill vs non mentally ill. When looked at through the gaze of music, there is only genius, not pathology. And we can only call him bipolar if we pathologize him. And we can only say he shares the bipolar essence if we’ve established that he is bipolar. Thus the essentialness of bipolar disorder seems challenged by the introduction of a new distinction from a different field.
Someone might argue that he could be a great musician and mentally ill, but these two concepts are like oil and water—they cannot mix. He is only mentally ill when the field of psychiatry is introduced. Before that, he is only an eccentric genius. Psychiatry, I am arguing, has no claim on him that transcends the field of psychiatry.
Using Bourdieu’s model, we can say that psychiatry is a field, and its understanding of bipolar disorder is constrained by being situated within a field. If we understand madness within another field, such as art or mysticism, we will come up with a different language and way of making sense of what psychiatry calls bipolar disorder. In art, including music, we may see it as part of the artistic process. We may see it as an element of an artist that serves to establish him as an artist. In spirituality, we may see “mania” and “depression” as God’s presence and absence.
Three fields—psychiatry, art, and spirituality—intersect madness. The distinction mentally ill vs non mentally ill is cut in half twice, first by the distinction true art vs untrue art, and then by true God vs false God. If our poor subject is a true artist and is visited by the true God, is he also mentally ill? Or if we say his art is a sham and his spirituality is bogus, then and only then can we say that he is mentally ill? But then aren’t we relying on unreliable distinctions? Is the art field’s view definitive? Is the point of view of the spiritual experts definitive? Aren’t these fields routinely wrong? Jesus was considered a fraud and crucified then later was considered God by the Roman Empire. Many jazz albums we consider great were given terrible reviews when they first appeared.
Given that madness is understood differently in different fields, one might say that the different understandings are socially constructed. But the question remains whether there is some prediscursive reality that these different fields intersect and have partial understandings of. One might say that there is some thing, call it what you like, that psychiatry describes as best it can, and which art and spirituality grapple with. Just because they have different partial understandings doesn’t mean that there isn’t some structure of madness that isn’t up to us. Why can’t we talk about a structure of madness that is prior to our discourse?
This is precisely the problem. We can’t approach bipolar disorder without being situated within a field or what Bourdieu calls “habitus”, defined as,

‘the product of structure, producer of practice, and reproducer of structure, the ‘unchosen principle of all choices’ or ‘the practice-unifying and practice-generating principle’ that permits ‘regulated improvisation’ and the ‘conductorless orchestration’ of conduct. (Waquant, 268)

We can’t name madness without the appearance of the psychiatric equivalent of what Judith Butler calls “phallogocentrism.” (Butler, xxxi) Thinkers influenced by Lacan have argued that there are power relations within language, and there is estrangement in using language. As soon as the madman becomes a “patient”, he has yielded to a psychiatric interpretation. Psychiatry’s interpretation involves power relations. An example of these power relations is in how one learns to describe oneself as sick. This subordinates one’s experience to the “healthy” experience. Understanding oneself as mentally sick means lowering oneself before a more powerful being or society.
Calling psychiatric drugs “medications” enforces the notion of sickness. Using the language “disorder” implies a subordination before an “order”. Using the spatial term “bipolar” imposes a geometric order. When the patient describes himself as bipolar, he has chosen a notion of order as his point of reference. He has chosen this over the vast chaos of madness. He is healthy when he has conformed to this order. The order of euthymic health is linked with social notions of power. Much of being well is being a good member of society who contributes and who causes no problems.
But the situation is difficult conceptually because it seems that above and beyond social categories, beyond discourse, there really is something like equilibrium, loss of equilibrium, and regaining of equilibrium. No matter what we call it, or what power relations are involved, there are motions within the soul, there are structures to the soul, and there can be healing and suffering and insight. The frustrating thing is that there seems to be no way of talking about it that really works. Even the notion of equilibrium vs lack of equilibrium can turn into a stigmatizing value judgement quite easily: “that girl is unbalanced. Stay away from her”. Art seems better designed to express this territory. But we need to talk about bipolar disorder in words too. Every time a “mentally ill” “patient” talks about her “disorder”, she submits before a power structure that stigmatizes her.
One response to this would be to reject the psychiatric understanding and shift to spiritual or artistic understandings. One can try to use poetry to recast madness, for example. But one has to search carefully for spiritual and artistic idioms which are not already subsumed by the same power structures that lurk in psychiatry’s definitions and language.
Butler offers a model for resistance:

Where the uniformity of the subject is expected, where the behavioral conformity of the subject is commanded, there might be produced the refusal of the law in the form of parodic inhabiting of conformity that subtly calls into question the legitimacy of the command, a repetition of the law into hyperbole, a rearticulation of the law against the authority of the one who delivers it. (Butler, 82)

We can give a parodic reply to the interpolation of psychiatry. Mania and depression can be hilarious if cast a certain way. The experiences which psychiatry makes into bipolar disorder can be represented in comedic fashion. This loosens the grip that stigmatizing culture has on them. The comedy of Maria Bamford, who has bipolar disorder, is a good example of this. If we can see the absurdity of the human condition within mania and depression, the distinction mentally ill and mentally healthy yields to the distinction absurd vs non-absurd. Moreover, seeing humanity in the mentally ill subverts the notion of separation that is indispensable to stigma. If mania and depression are repeated as parody, we can see the difference between the human who parodies madness and the sick person.
The sick person is a serious situation. The person who parodies madness is just like everyone else because they can help us laugh. When they parody madness successfully, mental illness is no longer a serious situation. All that remains is shared humanity and the absurdity of our human situation. Depression is a source of much comedy. The enlarged consciousness of mania is also a source of a great deal of comedy. Here we have the distinction funny vs not funny cutting through the distinction crazy/sane.
Unfortunately, resistance to society’s unjust approach to mental illness can take a confused form. It can be directed towards specific individuals who treat the patient or to the institution of psychiatry as a whole. But mental illness stigma is better understood more radically as performativity.
According to Butler:

“For something to be performative means that it produces a series of effects. We act and walk and speak and talk in ways that consolidate an impression of being a man or being a woman…We act as if being a woman or being a man is actually an internal reality, something that’s simply true about us, a fact about us. Actually its a phenomenon that’s being produced all the time and reproduced all the time. So to say that gender is performative is to say that nobody really is a gender from the start.” (Youtube, “Judith Butler: Your Behavior Creates Your Gender)

Being normal is performative, in Butler’s sense, not just for gender and sexual orientation, but for non-craziness. Mental normalcy is established through repeated performances. Just as a heterosexual man may exaggerate his attraction to women in order to establish his heterosexuality, a mentally normal person may exaggerate his normalcy in order to not be seen as crazy.
It is in this sense, perhaps, that mental illness can most easily seen as constructed, even though there are real (possibly pre-discursive) differences between the mentally ill and the mentally normal. Just as Butler allows that there are differences between straight people and gay people which aren’t produced by discourse, yet argues that gender is performative, we can say that despite differences in mentally ill and normal people, our notion of being mentally normal is performative. (Youtube, How Discourse Creates Homosexuality)
We are constantly performing this normalcy. Part of this performance is rejecting things as crazy. This is why stigma exists. It exists in order to preserve our notion of mental normalcy, which is constantly under the threat of being subverted by an irrationalty and a potential to act on this irrationality that we must constantly disown. This mirrors the function of homophobia. Being homophobic and putting down gay people may seem to guard a person from their disowned homosexual desire. In the same way, we may profoundly stigmatize a crazy person to guard against the reality that there is a part of us who could act crazy and who has crazy thoughts that must be sidelined.
By pointing out that the social boundaries between mentally ill and mentally normal are performative, we could queer the notion of mental illness in a way that is influenced by Butler’s queering of gender. This queering of the boundary works well with the impersonal monist metaphysics mentioned above. We could say that our performative social distinctions are imposed on one primal monist identity. As we pull away from that identity, in which we are all the same, in which we are all the Absolute, we live within performative dualistic realities. Fear and desire constrain us, interpolation constitutes us, and we live estranged from our deepest selves. It is in this sense, then, that overcoming stigma can be seen as a way to grow spiritually. For as we shed our identification with what our performativity creates, we can dip into the pool of impersonal monist spirituality, with all of its profundity.
Mental normalcy is constructed performatively, but depression and mania are only partly performative. Some of depression can be alleviated by changing the way one acts. This is an insight of Cognitive Behavioral Therapy. Simply by changing patterns of acting, one’s mood may improve. Changing thought patterns is often helpful too, though it is not clear to me if depressive thinking counts as a repetitive performance. Perhaps depressive thinking is a performance done before oneself or between oneself and an internalized other. But either way, it is interesting to note that disrupting patterns of thought and behavior may relieve depression. But there does seem to be a deeper layer to depression, one which is not completely independent of thought and behavior, but also in some way prior to them. This is a reason to be compassionate to depressed people. Depression may be a series of patterns that are ultimately illusory, but if they are illusory, so is much of life and experience. We must be careful not to blame a depressed person for their depression. This mirrors the notion in discourse about homosexuality which seeks to honor homosexuality as something that one is born with, rather than as a willed refusal to be normal.
Mania is interesting because in one sense it consists of a series of performances, but these performances are of a special type. Something comes over a manic person and makes him act in an unusual fashion. He will act in a way that is consistent with other manic people, even if he has never met a manic person. It is as if he is following a script of mania without ever having read it. These performances do not seem compatible with Butler’s structure of performativity, which is essentially social. This suggests that mania is not socially constructed in Butler’s sense, but that it has some root that is deeper than repeated following of social scripts. We must entertain the suggestion that mania touches something deeper than what Butler’s theory of social construction can account for.
Just as we need to refrain from blaming the depressed person for her depression, we need to not blame the manic person for her mania. This is the connection to a deeper cause than the taking-up of socially enforced roles. Biology or childhood trauma start to seem like convincing causal explanations for bipolar disorder. It seems beyond any power-inflected social construct. But careful thought shows that biology is discourse and the notion of childhood experience is a way of framing something within a specific psychological discourse. As soon as we speak of biological mental illness we have called forth an apparatus of domination. As soon as we speak of childhood psychological trauma, we are speaking the language of psychology, with its field-specific constructs.
Essentially what I am arguing for is a limiting view of mental illness. We can talk about bipolar disorder using the language of psychiatry with an understanding of the limits of our discourse. Psychiatrists at the more elite hospitals I’ve been to have this orientation. The disease model is useful, they say, but is only a model. They wouldn’t presume to understand the essence of madness. They are merely interested in helping the person live the fullest, richest life possible. Using disease language is merely a means to this goal. There is no reality to bipolar disorder that exists outside the context of trying to help the patient. When that language is not helpful, it can be discarded.
But in my experience such an understanding is rare and only exists among the elite. Most of the psychiatric world takes its understanding more literally, and insists that its model has an essentialness to it: the patient really is sick, and this is a fact and not just a useful understanding. Moreover, among people who aren’t involved in psychiatry, someone acting crazy might be seen as having an essence of insanity. This perceived essence, a taboo insanity, is an object of fear that drives and perpetuates stigma. But if this “essence” that is so terrifying is really not an essence, then stigma can’t take hold in the same way. The manic depressive subject is a construction, made out of social performative constructs of normalcy. The manic depressive subject is constructed negatively, as being deficient in the performative acts and withheld acts that create a normal subject. The crazy person on the street is a socially constructed subject—socially constructed as crazy. Although labeled as crazy, this label is intersected by the notion that he is sick. He is also intersected by the notion that he is perhaps holy, or some type of radical artist. The notion of sickness is intersected by a social critique that pathologization is thoroughly social. We are left with an ethical question, for ethics intersects him as well. Is he ok? Do we need to help him? Do we need to learn something from him?
I believe it is possible to have an understanding that includes notions like heredity, the efficacy of medications, the consistency of manic and depressed behavior, the effectiveness of disease model treatment, and the elegance of the psychiatric disease model, without saying that this disease model corresponds to something real which is independent of the constructs of psychiatry. To call it real in this way would be say that it has an essence.
This is basically a Kantian move. Kant was interested in placing limits on metaphysics, by shoring in metaphysical speculation. Knowledge was possible for Kant, but not for anything independent of the mind. Similarly, I argue that we can approach madness in a way that helps or hurts, but we can never escape our social constructs when we do so. When psychiatry or people outside of psychiatry think they know a reality to madness that goes beyond social construction, injustice is likely to occur. They are likely to take a notion of disease or of some notion of insanity and hold it above the crazy person. As they subordinate the crazy person to this notion of disease or insanity, they run the risk of profoundly degrading him and disrespecting his humanity. The crazy person and the psychiatrist and non-psychiatrist onlooker are all made of the same cloth. We are all trying our best. What holds us together—a primal humanity—is much stronger than the socially constructed notions that seek to pull us apart.

Agamben, Giorgio. The Time that Remains, A Commentary on the Letter to the Romans. (Stanford, California: Stanford University Press, 2005)

Butler, Judith. Bodies That Matter. (New York: Routledge, 2011)

Butler, Judith. Gender Trouble. (New York: Routledge, 2007)

Butler, Judith. How Discourse Creates Homosexuality. https://www.youtube.com/watch?v=3VqvCndtYCg

Butler, Judith. Judith Butler, Your Behavior Creates Your Gender. https://www.youtube.com/watch?v=Bo7o2LYATDc

Waquant, Loic. Key Sociological Thinkers. Rob Stones, editor (Palgrave Macmillan, 2007)

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