Función primaria y funciones secundarias del sistema de alarma

Whilst I accept mental ill health has features which correspond with realist ontology, like Oliver’s (1990) social model of disability and Clare’s (1980) ‘socio-therapeutic’ approach, I am unable to exclude psychological and sociological aspects which contribute to the aetiology of mental ill health. Both these approaches focus on the person’s social position, and the inadequacy of support within society. These correspond to a social constructionist paradigm, a term introduced by Berger and Luckmann’s (1966) in his seminal work, ‘The social construction of reality’. Social constructionism was my initial philosophical position which emanates from my career within the disability field, dominantly underpinned by the social model of disability. I shared the belief that multiple definitions and interpretations of mental ill health are historical (Foucault, 1988) and are an interaction between people and groups in a social system and once habitualised, become institutionalised (Berger and Luckmann, 1966). However, the in-depth examination of mental health as part of this study made me question my previous philosophical assertions, which will be explored further below.

Social constructionism challenges traditional knowledge founded upon objectivity and posits truth as relative to and created by human interactions (Berger and Luckmann, 1966) and discourse (Foucault, 1989). The term ‘discourse’ is defined differently depending on theoretical preferences. It was first documented by Foucault (1989) who defined discourse as a system of representation through language to form discursive formations. He argued that knowledge is created through discourse and is a joint production within a particular historical time and culture. Foucault’s definition of discourse focuses on what statements are made rather than how they are made (Elder-Vass, 2010), a position not conducive to this study as the focus is on how the discursive practices within the discourse are made.

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Fairclough (1995, p.14) adds that ‘a discourse is a way of signifying a

particular domain of social practice from a particular perspective’. For

example, both medical and biological discourses within mental ill health are particular discourses which are dominant (Rogers and Pilgrim, 2003; Busfield, 2001; Beresford et al., 2010), normative and have contributed heavily to the practices of psychiatry and pharmacy (Pilgrim, 2015). Other inconspicuous discourses, like the social model of disability, focus on the deficiencies in society rather than the focus being on the individual (Oliver, 1990).

This philosophical approach does not refute reality’s independence of human beings and discourse, but suggests we have beliefs about our versions of reality and therefore cannot be appraised against reality (Burr, 2003). This suggests the examination of the causes of mental ill health is an impossible task as they go beyond our ability to explore, which is why some mental health scholars assert this exploration should be excluded from mental health research (Pilgrim, 2015).

Some scholars posit mental ill health as a construction of modern medicine. For example, Laing (2010) suggested auditory hallucinations can be experienced by every person, rather than solely people with a psychiatric condition. Auditory hallucinations are common for people who have experienced some form of abuse (Leuder and Thomas, 2000) or traumatic event (Morrison, 1998), which refutes mental ill health stemming from a brain disorder, but places mental ill health in the social domain. Therefore social constructionism posits no objective truth that is waiting to be discovered, but truth is relative to and created by human interactions (Berger and Luckmann, 1966). It can be argued that researchers influenced by scientific and medical discourse, which presents a version of reality dissimilar to another observer from a different historical time, makes research a social product (Sayer, 2000).

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As social constructionism asserts the presence of multiple realities constructed by discourse and can be context-specific (Burr, 2003), the researcher and researched co-construct meaning (Holstein and Gubrium, 1995; Kvale, 1996; Mertens et al., 2011). Foucault (1990) also suggests knowledge is inextricably related to power in that it is created and perpetuated by those who have power and the means to communicate; i.e. the researcher. But he also suggests power is involved in the creation and use of knowledge.

Both suggest meaning is not discovered but constructed by different people in different ways in different situations (Crotty, 1998; Turner, 1995). For example, homosexuality up until 1980 was incorporated in the American’s Psychiatric classification system, Diagnostic and Statistical manual of mental disorders, third edition (Fawcett and Karban, 2005). While homosexuality does not equate to a mental disorder in many countries today, some still view it as an illness even within the same countries which celebrate it. Consequently the conception of mental ill health is inescapably connected to the social context, cultural history, social positioning of people (Shotter and Gergen, 1989; Houston, 2001) and social processes (Burr, 2003), but is not simply from the reasoning of a single person but collaborating interpretations by multiple people (Miranda and Saunders, 2003).

Within the context of nurse and midwifery education, legislation reinforces the premise that students with a mental health label may receive reasonable adjustments to study and register as a nurse (NMC, 2010b). On the contrary, mental health nursing discourse provides an alternative view where people with a mental health label require treatment and care. This corresponds to Billig (1997) who argues that the same person can use conflicting repertoires within the same situation or conversation.

Social constructionists assert the person as discursively constructed through language, which suggests a person’s behaviour and experience is

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altered by discourses (Burr, 2003). Since language is social and cultural, it then posits that our perception of reality is socially and culturally constructed. Access to various discourses asserts meaning is discursively constructed as we talk and reinvent meaning over time (Foucault, 1989) including how we experience and understand illness (Conrad and Barker, 2010). Adopting social constructionism is problematic in that any view is defendable and that no view is preferable. Rorty (1979) goes further and suggests there is no transcendental position as there is nothing to say about what is out there. He postulates that no descriptions are closer to reality than others. Fairclough (2005) argues that certain extreme positions of social constructionism should be rejected as the causal powers of discourse is absent from this ontological framework. However, Gergen (2001) acknowledges the misunderstandings of social constructionism and in particular relativist ontology depicts its position as denying the existence of a reality beyond discourse. On the contrary, he asserts that discourses are divorced from the world of materiality (Gergen, 1999).

Critical realists suggest social constructionism presents what Bhaskar (2008) calls the ‘linguistic fallacy’ where ontology is reduced to discourses only and excludes reality beyond discourse. This mirrors the social model of disability (Oliver, 1990) which relinquishes any dialogue of impairment, functional limitation and knowledge created by the medical profession. While social constructionists consider discourse is paramount in constructing the social world (Nikander, 2008), the position disengages and excludes references to aspects like embodiment and power, which may not be experienced through language but is connected to its various textual elements (Hook, 2001).

Parker’s (1992) definition, which fits comfortably with the critical realist position, defines discourse as a set of statements that bring together social objects into being. Parker (1992) suggests looking beyond the individual when attempting to understand the meaning within language. He asserts that discourses do not describe the world, but categorise it (Parker, 1992)

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and produces a particular version of events (Burr, 2003) known as discursive practices which make and remake constructs as people talk. Discourses are shaped by the potential and restrictions of the material and social world; both viewed as ontological, meaning they are independent of thought, but have a relationship with discursive practices (Sayer, 2000). This is not a static process but constantly changing over time or with a single human interaction (Taylor, 2001) irrespective of what people think (Sayer, 2011).

A further difficulty adopting only a social constructionist position of mental ill health is its inability to consider the social world outside of people’s perceptions and understandings. As a result it underrates how the body engages with the knowing person (Barnes, 2012), suggesting a consolidation of ontology and epistemology. Busfield (2001) adds that its sociological foundation creates a barrier with doctors, patients and families who consider it to exclude the actuality of pain and suffering or that the physiological aspect of mental health is socially generated (Williams, 1999; Pilgrim, 2015). Horwitz (2002) also considers the approach as limiting because while the concept of mental illness is being socially constructed, the natural reality of what is being constructed is still present.