Feminism & Psychology

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Social constructionist contributions to critiques of psychiatric diagnosis and

classification
Eugenie Georgaca
Feminism & Psychology 2013 23: 56
DOI: 10.1177/0959353512467967

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 F eminism
&
Special Issue Point of View
Psychology
Feminism & Psychology
23(1) 56–62
Social constructionist ! The Author(s) 2013
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DOI: 10.1177/0959353512467967

of psychiatric diagnosis fap.sagepub.com

and classification
Eugenie Georgaca
Aristotle University of Thessaloniki, Greece

In this paper, I provide an overview of social constructionist research on psychi-

atric diagnosis and classification and discuss its contribution to the ongoing criti-
cism of dominant practices in the field of mental health and of the medical model
upon which they are based. The basic premise of the social constructionist per-
spective is that experience, knowledge and practice are constituted through histor-
ically specific interpersonal, institutional and social processes. Research within the
social constructionist paradigm attempts to denaturalize phenomena that have
come to acquire a taken-for-granted character by highlighting the processes
through which these are socially constituted. In the field of mental health social
constructionist research focuses on highlighting the contingent, socially produced
character of categories of mental distress and of associated professional practices.
Within this paradigm, thus, classification, the dominant system of knowledge
regarding mental distress, and diagnosis, the practice of assigning a psychopatho-
logical category to a person, are not taken as given or as resources, but rather are
treated as topics of investigation in their own right. The aim is to examine how
these systems of knowledge and practice have come to take their current form, how
they are accomplished in practice and finally the consequences for mental health
institutions and for individuals in distress.
I will not deal here with the growing literature that examines the historical
development of psychopathological categories, deconstructs these categories and
discusses the role of commercial and professional interests in psychiatric classifi-
cation. I focus on empirical studies that analyze texts either of or about psychiatric
knowledge and practice. The studies I review belong to the discourse analytic
tradition in psychology, as well as to ethnomethodological and ethnographic
research in sociology and anthropology.

Corresponding author:
Eugenie Georgaca, Department of Psychology, Aristotle University of Thessaloniki, Thessaloniki 541 24,
Greece.
Email: georgaca@psy.auth.gr

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Georgaca 57

Investigating the diagnostic process

From a social constructionist perspective, diagnosis is not an act of discovery of a
pre-existing entity lying inside the sufferer and manifesting itself in symptoms but a
process of actively formulating a case, transforming the client’s experiences to
symptoms of a disorder and attributing a disorder to a person as an explanation
of the experiences reported. The diagnostic practice itself, then, is worth investigat-
ing in order to highlight the processes through which the transformation of a
person’s experiences and complaints to symptoms of a mental disorder is
accomplished.
Hak (1989, 1992) and Barrett (1996), working in sociology and anthropology
respectively, provide genealogical accounts of the transformations through which
intake clinical interviews between mental health professionals, prospective clients
and their relatives culminate in psychiatric reports. Hak (1989) convincingly argues
that psychiatric reports combine statements from the interviews, which are treated
as ‘findings’, and statements from the stock of psychiatric knowledge, which are
used to formulate the case. Clinical interviews are transformed into psychiatric
reports through selecting only information that fits the psychiatric formulation,
reformulating that information in psychiatric terms, objectifying clients through
systematic deletion of their perspectives, obscuring the professional’s participation
and fragmenting the client’s experience in order to fit into the standardized sections
of a psychiatric report (Barrett, 1996; Hak, 1989). In this way, the report produced
appears to be an objective and disinterested documentation of the client’s symp-
toms that supports the diagnosis given and the course of action recommended.
These studies document clearly the processes of reformulation through which a
psychiatric case is constructed out of information regarding a person’s distressing
experiences. Moreover, they show how this active process is systematically deleted
from the written record, so that the diagnosis appears as a self-evident decision
based on observed evidence.
The selective attention to information by mental health professionals is also
evident in a conversation analytic study of consultations between psychiatrists
and clients with a diagnosis of psychosis (McCabe et al., 2002). This study
showed that psychiatrists systematically pursued their agenda of checking the
frequency and severity of symptoms in relation to the medication taken. Not
only did they fail to engage with clients’ frequent attempts to talk about the content
of their symptoms, but their reactions indicated the interactional difficulty that
such attempts caused them. This reaction is consistent with the biomedical under-
standing of psychotic experiences as meaningless symptoms of an underlying
mental illness, with which neither professionals nor patients should engage. Once
a diagnosis is given and a person’s troubles are reformulated in psychiatric terms,
professionals’ interactions with clients actively encourage them to adopt this per-
spective when describing their experiences. This finding has been replicated in other
studies. Clients seem to learn, for example, through repeated interviews with
mental health staff, to self-select and volunteer from the range of their experiences
only those that are relevant to a psychiatric examination (Barrett, 1996). In her

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58 Feminism & Psychology 23(1)

ethnographic study of a psychiatric unit, Terkelsen (2009) described the various

strategies through which staff members coach patients into adopting a biomedical
explanation for their experiences, taking on the patient identity and assuming
responsibility for looking after themselves through constant self-monitoring of
their condition and compliance with medication.

Documenting the uses of diagnosis and classification in profes-

sional practice
In this section I move from research into the diagnostic process and client-
professional interactions to studies of the way in which diagnosis and classification
inform professional discourses and practices. Here the focus is on the construction
of cases in routine mental health practice through professional meetings and writ-
ten records as well as on the ways in which professionals draw upon medical dis-
courses when accounting for their practice.
A central site where patient cases are formulated is regular team meetings of
mental health professionals, in which patients are reviewed and decisions are taken
regarding their treatment. Studies of professional team meetings (Barrett, 1996;
Crepeau, 2000; Griffiths, 1998, 2001; Soyland, 1994) reach surprisingly similar
conclusions. The meetings appear to be sites of struggle between different mental
health professionals, more specifically between psychiatrists on the one hand and
non-medical professionals, i.e. psychologists, social workers and psychiatric nurses,
on the other. This struggle is reflected in competing conceptualizations of cases
using on the one hand a biomedical account, which portrays the patient in question
as a passive sufferer of a biochemical imbalance, uses a diagnostic label and cul-
minates in proposals for medical interventions, or on the other hand a social
account, which portrays the patient as an active agent with beliefs and desires,
locates the patient’s problems in the context of his or her personal and social
circumstances and is linked to supportive, practical and welfare interventions.
The negotiation of competing versions in the course of team meetings serves a
variety of functions regarding organizational requirements, staff workloads and
allocation of resources. What these studies clearly show is that diagnosis and clas-
sification, or more generally the application of a medical understanding to people’s
experience of distress, is not a straightforward and uncontested matter, but that it is
actively negotiated against other possible understandings. Moreover, competing
conceptualizations are tied up with power struggles between mental health profes-
sions, lead to different courses of action regarding intervention and, finally, serve a
variety of institutional functions.
Studies of written documents, on the contrary, reveal a more uniform way of
conceptualizing patients’ problems within the medical paradigm, possibly because
written records are permanent, more highly institutionally regulated and constitute
sites of demonstration of professional expertise, competence and accountability.
Written records, more than verbal exchanges, determine the way a person’s distress
is understood and treated within mental health institutions, as the person’s trans-
formation to a psychiatric patient is effected through a successive series of records

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Georgaca 59

that constitute interpretations of previous interpretations of the patient’s condition

(Barrett, 1996; Hak, 1992). Clinical records are effectively selective reformulations
of verbal accounts and previous records and their function is to construct a unified
story of the patient in question over and above the various stories told by the
different parties concerned, by prioritizing those elements that combine together
neatly to paint a picture of a mentally ill person. Clinical records are represented as
factual, neutral and objective descriptions and explanations of the patient’s history
and condition. This is achieved through systematically removing from the record
elements that indicate the professionals’ active role in formulating it and privileging
clinical observation over patient perspectives. The main functions of clinical rec-
ords are to render patient histories understandable, patients treatable and clinicians
knowledgeable and effective (Swartz, 1996).
The use of the medical discourse of diagnosis and classification by mental health
professionals is also apparent in studies which seek professional views on various
aspects of clinical practice. Starting with the process of diagnosis itself, it seems
that psychiatrists alternate between two modes of explanation for their diagnostic
decisions, an empiricist account, which presents diagnosis as an objective process of
identifying symptoms in a way that is consistent with scientific-medical understand-
ing, and a contingent account, which acknowledges the implication of the subject-
ivity of the diagnoser and professional inclinations in the diagnostic process
(Harper, 1994, 1995). The psychiatrists interviewed in Harper’s study shifted
between the two kinds of accounts depending on the context of the argument;
the use of each account served a variety of functions. On the whole, it seems
that the production of empiricist accounts enables professionals to retain their
scientific credentials while the use of contingent accounts allows an appeal to per-
sonal and contextual factors in order to explain elements of uncertainty and vari-
ability in diagnostic decisions. Similarly, when talking about depression in the
context of research interviews physicians were found to oscillate between a medical
understanding of depression as a biological condition and a more social under-
standing of the role of context in depression (Thomas-McLean and Stoppard,
2004). However, studies of the ways in which professionals account for controver-
sial issues, such as the use of ECT (Johnstone and Frith, 2005; Stevens and Harper,
2007), medication failure (Harper, 1999), adverse effects of medication (Liebert and
Gavey, 2009) and violent episodes in psychiatric wards (Benson et al., 2003) have
consistently highlighted the central role of medical discourse. Professionals justify
practices such as administering ECT or prescribing medication despite their con-
troversial character through on the one hand positioning their recipients as severely
mentally ill, stressing the biological basis as well as the chronicity and severity of
the patients’ symptoms, and on the other hand portraying themselves as expert
medical practitioners, who apply medical procedures while rationally weighing
risks and benefits.
The studies presented in this section highlight two central aspects of the role that
classification and diagnosis play in professional discourses and practices. On the
one hand, they demonstrate the flexible, contextually bound and functional char-
acter of the use of diagnosis and classification. Professionals draw upon a variety of

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60 Feminism & Psychology 23(1)

conceptual frames and lines of argumentation depending on the context and the
functions their actions are called upon to serve. On the other hand, these studies
highlight the dominance of medical discourse, which seems to serve as the back-
drop for the employment of other discourses and the fallback discourse when the
expert status of professionals is challenged. It is not accidental, I think, that pro-
fessionals will negotiate competing versions of client problems in team meetings
and will flexibly draw upon biological and social understandings when discussing
mental health issues in a neutral setting, but they will fully adhere to a medical
account in written records and when their practice is challenged. In professional
discourse openness and flexibility seem to be predicated upon the unquestionable
acceptance of the value of the medical model as the foundation of clinical practice.

Examining the consequences of diagnosis and classification for

persons in distress
Individuals in distress are positioned within the medical model as patients, sufferers
of a biological condition. The use of the medical discourse of mental disorders is
not restricted to the medical profession and mental health services but permeates
contemporary culture and is prevalent in the way people talk about their experi-
ence, even if they have never been in contact with mental health services. Discourse
analytic studies have shown that individuals with a diagnosis of depression
(Lafrance, 2007; Lewis, 1995) and premenstrual syndrome (Swann and Ussher,
1995) readily reproduce a medicalized version of their problems. Through the
appeal to medical discourse, participants’ troubles are separated from their self
and their life stresses and located within their body, and this gave their condition
legitimacy and enabled them to disavow responsibility for their distress. The par-
ticipants in these studies tended to draw upon other discourses as well, either in a
way that was complementary to medical discourse or as alternative understandings
of their distress, and this potentially allowed them to develop ways of understand-
ing their experience outside the dominance of the medical paradigm.
On the other hand, the positioning of a person as a patient in the medical
discourse, especially with regard to severe mental health problems, has serious
repercussions regarding the person’s agency and credibility. Individuals positioned
as patients find that the accounts of their experiences are undermined as products
of their disturbed mental condition and they often have to negotiate and actively
dispute their positioning as a patient and the meaning of that positioning in order
to regain credibility and self-determination (Benson et al., 2003) or to legitimate
their version of reality (Georgaca, 2000, 2004; Harper, 1995).
The studies presented above develop a critique of the concept of mental illness
through examining the consequences of the biomedical understanding of distress
for individuals experiencing it. Another fruitful line of investigation would be to
highlight alternative non-medical understandings of distress, as a way of publiciz-
ing and disseminating more empowering perspectives. Social constructionist
research has not gone very far in this direction, and this is arguably one of its
limitations.

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Georgaca 61

Conclusion
Social constructionist research on psychiatric classification and diagnosis has inves-
tigated the processes through which the dominant medical understanding of mental
distress is enacted in mental health practice and drawn upon to account for experi-
ences of distress both by mental health professionals and by people with experience
of distress. More importantly, it has highlighted the contextual and functional
character of the medical discourse and of other discourses, as well as the conse-
quences of these discourses for mental health theory and practice and for people in
distress. The contribution of social constructionist studies to the developing cri-
tiques of psychiatric classification and diagnosis, I would argue, is in the direction
of denaturalizing and destabilizing psychiatric knowledge and practice, thus open-
ing the way to alternative, more empowering understandings of and practices deal-
ing with distress. As to what these understandings and practices might look like,
social constructionist research has not had much to contribute to date, and possibly
this lies beyond its remit, to be pursued by other forms of research and even beyond
scientific investigation, in the realm of mental health activism.

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Eugenie Georgaca is a Senior Lecturer in clinical psychology at the School of

Psychology of the Aristotle University of Thessaloniki, Greece. She teaches,
researches and publishes in the area of clinical psychology, psychotherapy and
mental health, especially qualitative methodology, psychoanalysis and critical per-
spectives on psychopathology. She is the co-author of ‘Deconstructing
Psychopathology’ (Sage, 1995) and author of papers on psychotic discourse, delu-
sions, discursive approaches to analyzing psychotherapy, discourse analysis and
social constructionist notions of subjectivity.

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