In the light of the consumerist emphasis just noted alongside the psycho-social orientation of recovery-orientated service philosophies, typical now at the turn of the twenty-first century, the authority of bio-medical psychiatry is under particular challenge. Elsewhere, we have examined
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whether or not psychiatry is struggling with a particular legitimation crisis (Pilgrim and Rogers 2009). Since the 1980s, in the wake of deinstitutionalization and a new shared service commitment to recovery the profession has been under particular threat. This threat was noted in the British Journal of Psychiatry by Craddock et al. (2008):
This creeping devaluation of medicine disadvantages patients and is very damaging to both the standing and the understanding of psychiatry in the minds of the public, fellow profession- als and the medical students who will be responsible for the specialty’s future. On the 200th birthday of psychiatry, it is fitting to reconsider the specialty’s core values and renew efforts to use psychiatric skills for the maximum benefit of patients.
(Craddock et al. 2008: 6) This complaint from a group of conservative British psychiatrists reflected a new context in which other professionals could claim a mandate for authority which did not require medical training.
Moreover, user involvement and user criticism (see Chapter 12) have undermined the reputation of the very sort of medical authority the authors were demanding in their special pleading. Ironi- cally, psychiatry’s best chance of survival may well reside in concessions to such criticisms and power-sharing with other disciplines, rather than in attempts to re-establish old medical authority.
This question about the survival of psychiatry as a profession has been particularly evident since the contention provoked by the launch in 2013 of DSM-5, noted above and in Chapter 1.
British psychiatrists at times have noted that ICD, not DSM, is their official system of classification.
However, the arguments we have rehearsed in this chapter suggest that from a variety of direc- tions (including at times dissent from within the profession) the political and scientific problems of diagnosis, in principle, are likely to ensure that psychiatry remains precarious as a medical specialty for the foreseeable future.
Discussion
This chapter ends by drawing attention to the twin problems of uncertainty when discussing the mental health professions. The first problem is about the professions themselves. What are they up to? Are they concerned with ameliorating distress or with controlling deviant behaviour (or both)? To what degree are they effective in either of these roles? This question is addressed when we discuss treatment in Chapter 8. In whose interests do they work – themselves, their cli- ents, the general public, the State, patriarchy? What role does power play in their operations? Are they impartial benign practitioners or partisan oppressive enforcers of social conformity, deriv- ing their role from wider inequalities of power (based on race, class and gender)? Do they crush individuality or celebrate and construct it? Any critical student of the mental health professions or critical practitioner within their ranks is drawn to these types of questions in one form or another.
The second problem relates to the lack of consensus on the part of sociologists when attempt- ing to provide answers to these questions. Answers are provided but sometimes they concur with the work of others and sometimes they do not. The mental health professions represent a con- tested area of sociological inquiry, which is rendered less contentious by eclecticism but remains contested nonetheless. Post-structuralism is only an acceptable resolution for those accepting the epistemological current of post-modernism. Although many are part of that current, not all soci- ologists are post-modernists.
Both sides to this uncertainty characterize the discourse about mental health work at present.
Two questions in particular will continue to tantalize social scientists for the foreseeable future.
First, how do mental health professions with such a weak, controversial, contradictory and poorly credible body of knowledge (see Chapters 1 and 8) continue to maintain a mandate to regulate the lives of those they deem to be mentally unfit? Second, with the apparent mixture of coercive and
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non-coercive power operating in mental health work, how might the tensions and contradictions of the professions be understood?
The post-structuralists seem to come nearest to providing answers to these questions but they leave a number of loose ends. They notoriously ignore gender relationships (Rose 1990). They also understate the continuing role of coercive social control enjoyed by professionals and suffered by service users. Also, traditional epidemiological research seems to suggest that predictable inequal- ities in mental health derive from real differences between social groups, which are independent of a professional discourse or set of interventions. Arguably, professionals diagnose and respond to these differences, they do not simply create them in cahoots with other social actors. How then do we resolve questions about whether apparent differences in mental health between social groups are real outcomes of social inequality or constructed by-products of psychiatric discourse?
The work of mental health professionals is important to sociologists not only because of the character of their operations, strategies or practices. Professionals might also be deemed to account for the very existence of ‘the mentally ill’ in modern society on the one hand, or they might represent a set of occupations which respond to real socially determined forms of personal distress and social deviance defined by lay people on the other. Thus leaving aside traditional Weberian concerns about professional dominance, mental health work also raises Foucauldian ones about disciplinary knowledge and the reality or otherwise of mental illness.
This chapter has explored a variety of sociological approaches to mental health work. The diversity reflects wider unresolved disputes within the field of the sociology of the professions. In turn, these disputes are connected to divisions within social theory, with post-structuralism repre- senting the most recent participant in debates about how health professionals are to be understood in society. As we note in the latter part of the chapter, sociological currents outside work on the professions have also been influential in some investigations of mental health work. The sociologi- cal perspective taken determines the reader’s sympathy for, or criticism of, mental health workers.
Questions
1 Compare and contrast two perspectives from the sociology of the professions and apply them to mental health work.
2 ‘Mental health professionals and their patients are trapped in the same discourse’ – discuss.
3 Are mental health workers agents of the State?
4 Whose interests are served by the work of psychiatric professionals?
5 What advantages are offered by sociological eclecticism when understanding the mental health professions?
6 discuss the role of non-specialists in mental health work.
For discussion
Would you trust a mental health professional to help you if you were distressed? Consider this question by rehearsing what would encourage you to seek help and what would make you cautious.