charcot effect

Journal of Constructivist Psychology, 20:309–336, 2007Copyright C© Taylor & Francis Group, LLCISSN: 1072-0537 print / 1521-0650 onlineDOI: 10.1080/10720530701503843

THE CHARCOT EFFECT: THE INVENTIONOF MENTAL ILLNESSES

MARINO PEREZ-ALVAREZDepartment of Psychology, University of Oviedo, Oviedo, Spain

JOSE M. GARCIA-MONTESDepartment of Psychology, University of Almerıa, Almerıa, Spain

This article proposes the Charcot effect, in which clinicians describe whatthey themselves prescribe. It is argued that the Charcot effect can be a criticalinstrument for exposing how mental illnesses are invented in the process ofdeveloping diagnostic systems and conducting psychopharmacological research.We argue that the Charcot effect helps explain the expansion of depressionto epidemic proportions, the promotion of social phobia as a pharmaceuticalmarketing strategy, the profile of panic disorder according to the availablemedication, and the worse prognosis of schizophrenia in developed countries thanin developing countries. Having undertaken this review, we situate the Charcoteffect in relation to constructivist psychology.

We propose something called the Charcot effect, which takes itsname from the eminent French neuropathologist of the latenineteenth century, Jean-Marie Charcot (1825–1893). Charcot isrelevant here because he was well known for inducing an attackof hysteria under the assumption that he was describing it. Thispresumed description actually functioned as a prescription ofwhat was to be observed, so that Charcot himself was immersedin a self-confirmatory system. The admiration of the audience athis lectures served only to confirm this effect. The Charcot effectis as much a historical fact as a general clinical phenomenon.

As an historical fact it refers to Charcot’s study of hysteriafrom 1864 to 1893 at La Salpetriere, where he described thegrand attaque de l’hysterie (Shorter, 1992). As a general clinicalphenomenon, the Charcot effect may well be a phenomenon thatoccurs, to a greater or lesser extent, in all psychodiagnostic and

Received 1 March 2006; accepted 1 September 2006.This work was supported in part by Research Grant MEC-05-SEJ2005–00455.Address correspondence to Marino Perez-Alvarez, Departamento de Psicologıa,

Universidad de Oviedo, Plaza Feijoo, s/n. 33003-Oviedo, Spain. E-mail: [email protected]

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310 M. Perez-Alvarez and J. M. Garcıa-Montes

psychotherapeutic processes (Berkenkotter & Ravotas, 2002). Inprinciple, it is not difficult to accept that a certain structuringof patients’ problems in accordance with clinical theory andprocedures is found to some extent in all approaches. What drawsour attention to the case of Charcot is its theatricality. In anycase, the distance that allows us to consider it as an “historicalfact” also permits us to use it as a model for perceiving thesame phenomenon today, with ourselves as either the potential“Charcots” or his admiring followers.

In fact, the phenomenon designated here as the Charcoteffect was already identified by Karl Popper, in relation to psycho-analysis, under the name Oedipus effect, “to describe the influenceof a theory or expectation or prediction upon the event which itpredicts or describes: it will be remembered that the causal chainleading to Oedipus’ parricide was started by oracle’s predictionof this event” (Popper, 1963, p. 39). In any case, let us introducethe expression Charcot effect, which is probably more appropriatefor the phenomenon in question here. In examining the Charcoteffect, first we show its current relevance, with particular refer-ence to psychiatry. Second, we review four mental disorders (de-pression, social phobia, panic attack, and schizophrenia) withinthe perspective of their construction—or rather, “invention,” touse a more critical term. Third, we situate the Charcot effectsquarely within constructivist psychology. Finally, we point outsome perverse consequences of the Charcot effect for psychiatryand clinical psychology, and some possible alternatives.

The Charcot Effect Today

The Charcot effect remains with us, mutatis mutandis, in psychiatrytoday. And although psychiatry is the main concern of the presentwork, clinical psychology is by no means exempt from the effectsof this phenomenon. Within current psychiatry, the Charcot effectcan be discerned in diagnostic systems and psychopharmacologi-cal research, not to mention an entire serotonin culture.

With regard to diagnostic systems, taking the Diagnostic andStatistical Manual of Mental Disorders (DSM) as a reference, the firstthing we notice is the proliferation of typified disorders, especiallysince 1980 and the publication of DSM-III. Specifically, the 163disorders in the DSM-II (American Psychiatric Association, 1968)

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become 224 in the DSM-III (APA, 1980), and reach 374 by theDSM-IV (APA, 1994; with no additions in the revised text of 2000,which was merely a text revision).

Such a proliferation cannot reasonably be attributed to thediscovery of new natural entities that were “out there” waiting formore accurate diagnostic procedures. Nor does this mean that theprevious categories were natural entities. Indeed, our perspectiveholds that mental disorders are not natural kinds, but ratherpractical kinds arising more out of pragmatic conventions thansupposed objective essences (Zachar, 2001, 2003). In any case,what is important to stress is that the classification systems formental disorders serve various interests other than those of scien-tific progress. These would include the legitimization of psychiatryas a medical specialization dealing with supposed illnesses, therequirements of pharmaceutical companies for commercializingdrugs, and the system of third-party payers. According to Horwitz(2002), “The application of this system to the broad range ofproblems of psychiatric clients was not a triumph of science overideology, but rather a use of the ideology of science to justifycurrent social practices” (p. 74).

The greatest problem with diagnostic systems is that they endup creating their own objectivity. There is a process of namingand framing (Brown, 1995) through which diagnoses appear toreveal illnesses that are just beyond our ability to measure them,when, to the contrary, they are largely socially constructed. Thisprocess is somewhat complex, as it includes a whole series ofacademic, scientific, professional, and everyday practices, fromthe training of clinicians (text books and so on) and the scientificstyle of thought (theories, vocabulary, procedures) to professionalroles (diagnosing illnesses) and common sense itself (now duly“educated” by pharmaceutical marketing).

As far as psychopharmacological research is concerned, animportant aspect to highlight is the strategy of defining disordersby the effects of the drugs prescribed for them. The notion of“listening to the drug” was popularized by Kramer’s (1993) book,Listening to Prozac. The point is that the psychological changes in-duced by a drug are taken as a diagnostic criterion of the patient’sproblem, and, in turn, the supposed deficit remedied by the drugis taken as the cause of that problem. Thus, the improvementin mood produced by Prozac defines the depression, and the


supposed serotonin deficit for which it compensates would be itscause.

The use of medication for specifying the diagnosis also hasbeen incorporated into clinical practice. Thus, for example, asLuhrmann (2000, p. 49) noted,

if a supposed manic-depressive does not respond to lithium or to anotherof the mood stabilizers, a psychiatrist will wonder whether after all he’sschizophrenic. If a supposed schizophrenic is managed effectively onantianxiety agents or even without medication, a psychiatrist will questionwhether she is, in fact, schizophrenic.

This strategy of listening to the drug involves the reductionof a disorder to a list of symptoms. And we need scarcely add thatthese symptoms are those selected according to their sensitivityto the effects of the medication in question. In this way, thereis a kind of teleological adjustment of the diagnosis to the treat-ment. The psychiatric patient him- or herself ends up adaptingthe explanation of his or her problems (social and emotional)to a medical protocol devoid of any contextual consideration(Berkenkotter & Ravotas, 2002; Borges & Waitzkin, 1995).

Although this way of proceeding invalidates the diagnosis,it does not challenge either the convention or the conviction ofthe existence of an organic illness. Thus, the current psychiatriclore largely endorses a psychopharmacological model of illness.Specifically, experts usually postulate some type of biochemicalimbalance, most commonly in relation to serotonin. Regardlessof the confirmation of some biochemical imbalance correlativeto a mental disorder, the point is that such an imbalance doesnot in itself explain the experience of the disorder (depressiveor psychotic, for example). Neurochemical hypotheses do notsubstitute for or excuse social and personal construction. Indeed,it could be said that the imbalance theory in psychiatry functionsmore as a rhetorical device than as scientific evidence (Valenstein,1998).

The truth is that we are living in a serotonin culture (Healy,2004a), where it is taken for granted that serotonin deficit is thecause not only of depression but of a whole series of conditionsthat, curiously enough, improve on taking selective serotoninreuptake inhibitors (SSRIs), such as Prozac, Zoloft, or Paxil. A


biobabble has emerged that, despite using the language of chem-istry, is no more scientific than the psychobabble of earlier times.As Healy (2004a) put it, “now this psychobabble has been allbut replaced by an equally vacuous biobabble, which in turn hasconsequences for how we view ourselves, how we view the turmoilof adolescence or school underachievement or, finally, moral andcriminal culpability” (p. 264). It is in such a cultural context thatwe can identify the concept of neurochemical selves (Rose, 2003).The paradox in all of this is that, as Horwitz (2002) argued, “theascendant belief that ‘mental illnesses are brain diseases’ is duefar more to the cultural belief that only biologically-based illnessesare ‘real’ illnesses than to any empirical findings that the causesof mental disorder are brain-based” (p. 156).

If against such a background we consider the fact that psy-chopharmacological research and the corresponding diagnosticexpansion make use of marketing, it is easy to understand theculture that has been created. As far as psychopharmacologicalmarketing is concerned, it suffices to recall that it includes awide variety of strategies, such as direct propaganda that reachespatients via the media; the promotion of illnesses for the com-mercialization of drugs; the provision of symptom lists to gen-eral practitioners for quick diagnoses; the continual “education”of psychiatrists; the sponsoring of conferences, symposia, andcommissions; financial support for research; influencing scientificpublications; and the financing of patients’ associations thatdefend the illness model. Those still unaware of the currentsituation can be enlightened by authors such as Healy (2004a),Moncrieff (2003), Moynihan and Cassels (2005), or Valenstein(1998). The culture created is the serotonin culture we havedescribed, incorporating the concept of neurochemical selves.

Having explained how the Charcot effect can still functiontoday, we will describe how disorders are invented through it.The term “invention” is used here in a critical sense, to highlightthe artifactual aspect, in contrast to the supposed objective realityin which mental disorder categories are portrayed via diagnosticsystems and psychopharmacological research. This critical sensehas both an epistemological dimension, related to the way inwhich pharmaceutical matters are understood (Barry, 2005), andan anthropological dimension, given the harmony of illusionsthat can be achieved in a new diagnosis (Young, 1995). On the


other hand, the term “construction” is reserved for referring tothe actual construction of frames of meaning in the context ofpsychotherapy (Gergen, 2004; McNamee, 2002).

As a general phenomenon, the Charcot effect can be recog-nized in all mental disorders (and even in some general medicaldisorders). A particular history of each disorder would be neces-sary in order to perceive the part of their conception attributableto clinical theories and procedures, not to mention conventionsand interests. It would be a contextual history, as distinct frominternal histories such as, for example, that of Berrios (1996),whose supposed objective description of symptoms trimmed outtheir phenomenological, social, and historical background. Afterall, mental symptoms do not come through like teeth.

A contextual history can be found in Szasz’s (1961) historyof hysteria in his illustration of the “myth of mental illness”;in Hacking’s (1995) and Spanos’s (1996) histories of multiplepersonality, reconstructing the social processes surrounding thisdisorder; and in Young’s (1995) history of posttraumatic stressdisorder, showing the “harmony of illusions” on which it hasbeen invented. Leaving aside hysteria as an historical model, bothmultiple personality and posttraumatic stress constitute goodexamples of the current tendency for the creation of mentalillnesses following the Charcot method, despite the fact thatpsychopharmacological research is not especially implicated intheir construction. Because we are primarily concerned here withpsychopharmacological research (as well as the DSM diagnosticsystem), we will concentrate on other disorders. Among themost eligible candidates are depression, social phobia, and panicdisorder, without forgetting schizophrenia.

The Growth of Depression to Epidemic Proportions

Although the term “depression” dates from the second half of thenineteenth century (Berrios, 1996, p. 299), it did not become thewidespread diagnosis it is today until the late twentieth century.It is, indeed, precisely with the advent of new antidepressantsthat depression increased with respect to other diagnoses (Healy,2004b; Shorter, 2001). If we have to fix a date, this could be saidto have occurred after 1987, the year of the revised DSM-III andthe approval of Prozac.


Until publication of the DSM-III-R (APA, 1987), depressionwas a minor diagnosis. At the end of the nineteenth and inthe early twentieth century, “melancholia” was a more promi-nent notion than “depression.” Later in the century, with thedoctrinal dominance of psychoanalysis, anxiety disorders werediagnosed far more frequently than was depression. Depressionwas considered nothing more than a depressive neurosis, asreflected even in the DSM-II (APA, 1968). By the time the DSM-IIIarrived (APA, 1980), we were still in the era of anxiety (Healy,2004b; Shorter, 1997). It was not until 1987 and the DSM-III-Rthat depression caught up with anxiety in terms of its socialimportance, and perhaps overtook it. In psychopharmacologicalterms, the antidepressant era was beginning (Healy, 1997). Thehegemony of Valium was giving way to that of Prozac. Today,the prevalence of depression is estimated at 10% to 15% ofthe population, having reached epidemic proportions (Pignarre,2001).

The first antidepressants (imipramine and iproniazid) wereactually developed in the late 1950s, but because depression wasnot at the time a relevant disorder, the laboratories involved(Geigy, Ciba, and Sandoz, later merging to become Novartis)took no interest in their promotion. Nevertheless, in 1961 Merck,in its efforts to launch amitriptyline (practically identical toimipramine), distributed 50,000 copies of a book published thatsame year, Recognizing the Depressed Patient, by Frank Ayd, witha view to sensitizing doctors about the presence of depressionin general medicine. Although amitriptyline (Elavil/Triptizol)brought considerable advantages, we were, of course, in the era ofValium and Librium; antidepressants and depression had to waitfor their time to come (Healy, 1997, Chapter 2). This time wouldarrive with the approval of Prozac in 1987.

The rest of the story concerns the launching of Prozac. Itsapproval by the Food and Drug Administration in 1987 was essen-tially a passport to fame. This approval meant no more, in reality,than that the product could be called an antidepressant becauseit showed itself to have some effect on depression (fulfilling, infact, the minimum criteria). The drug’s license did not mean itwas effective in the sense that people should see it as the solutionto the diagnosed disorder (Healy, 2004a, p. 35). Marketing hasdone the rest.


For a start, the very trade name, Prozac—and even thedescription of its pharmacological action, “selective serotoninreuptake inhibitor” (SSRI)—shows commercial intelligence. Thename Prozac, rather than alluding to pharmacological properties,as trade names usually do, suggests, on the one hand, profes-sionalism, pro-, and on the other, hitting the right spot, -zac. Inturn, the description of the chemical action also hints that weare dealing with an “intelligent” drug, using the words selectiveinhibitor when, in fact, it does not act on a particular area ofthe brain (serotonin is present virtually all over the brain, andnot exclusively in the brain). In any case, there is a remarkablelack of connection between the advertisements and the scientificliterature (Lacasse & Leo, 2005). We are undoubtedly witnessinga triumph of marketing over science (Antonuccio, Burns, &Danton, 2002), within an unhealthy relationship between thepharmaceutical industry and depression (Healy, 2004a).

In addition to using these clever names, the manufacturingcompany, Eli Lilly, would take it upon itself to sell, in additionto the drug’s efficacy, its safety (compared to the early antide-pressants, with their side-effects) and its freedom from addictiveeffects (which had been the downfall of the benzodiazepines).Furthermore, the effectiveness of Prozac would not be reducedto the remedy for a disorder (first depression and then others),limited to helping us “get well,” but would help us to get “betterthan well,” paving the way for cosmetic psychopharmacology. Asthe reader may recall, the expressions “better than well” and“cosmetic psychopharmacology” come from the work by Kramer(1993). What highlights the success of these expressions is thatsolutions such as Prozac fit in perfectly with current values (Elliott,2003; Elliott & Chambers, 2004). Thus, Prozac is representedin popular culture through metaphors such as magic bullet, life-saver , upper/elevator , or genetic corrector , and is associated withexperiences such as life change, happiness, self-esteem, and newpersonality (Montagne, 2001).

The reality is that the new antidepressants represented byProzac are not as effective as the classical ones, particularly in se-vere depression (Anderson, 2000; Fremantle, Anderson, & Young,2000); nor are they immune from side effects, among themsuicide, violence, and mania (Breggin, 2003/2004; Glenmullen,2000; Healy, 2005, Chapter 4). But by the time this became


evident, depression had already grown to epidemic proportionsand was understood in chemical terms. Indeed, people havelearned to frame a large proportion of life problems in terms ofdepression, including those that are closer to the cosmetic realmthan that of treatment per se. At the same time, they have learnedto see depression in chemical terms. However many possiblepsychological and psychosocial explanations of depression thereare, and however obvious it is to see it as a life experience, peoplehave been converted to a belief in chemistry. “Like religious con-version, capitulation to a biological version of depression’s causesand proper treatment is accomplished through a socializationprocess that entails a radical transformation of identity, a ‘processof changing a sense of root reality’“ (Karp, 1996, p. 82).

This capitulation to the biological version of depression is acase of what Gergen (1994) called the cycle of progressive infirmity,discussed further below. In any case, it is worth mentioninghere something of great interest to constructivist psychology:personal responsibility within social influence. According to ourconception of constructivism, individual persons are essentiallythe authors of the systems of meanings about their worlds andexperiences (Perez-Alvarez & Garcıa-Montes, 2004, 2006). Theproblem represented by depression is especially relevant for ap-proaching this question, given the fact that it concerns—perhapsmore clearly than other disorders—personal meaning and experi-ence of the world and of one’s own life. People’s adherence to bi-ological explanations and solutions (in this case, for depression),however strongly influenced by the propaganda, is nevertheless apersonal decision and creation. Such adherence, far from beinginevitable, occurs in the context of other possible constructions.Thus, for example, both common sense and psychological thera-pies offer alternative constructions. It is suggested that biologicalcapitulation may be related to the personal construction consist-ing in self-exempting oneself from responsibility, preferring toblame the brain (Valenstein, 1998) and take Prozac as a way oflife (Elliott & Chambers, 2004).

The Promotion of Social Phobia as a Commercial Strategy

The promotion of social phobia as a distinct clinical entity hasbecome a classic example of pharmaceutical marketing of a


commercial strategy for the promotion of drugs (Moynihan,Heath, & Henry, 2002). Thus, it is no coincidence that socialphobia has gone from being a rare disorder in 1980 to being thethird most common psychiatric diagnosis, after depression andalcoholism, by the end of the 1990s (Moncrieff, 2003). In thespace of some 10 years, it nearly quintupled its prevalence, goingfrom 2.75% at the beginning of the 1980s to 13.3% by the early1990s (Horwitz, 2002, p. 95).

Even though social phobia is clearly a questionable diagnosticcategory, given the heterogeneity of its symptoms (Hofmann,Heinrichs, & Moscovitch, 2004), and in any case its markedlyinterpersonal condition (Alden & Taylor, 2004), it has the status ofa clinical entity, and indeed functions as a mental disorder (APA,2000). From the constructivist point of view, it is interesting toconsider how this has come about.

Above all, it should be pointed out that social phobia repre-sents a clear case of the conversion of a social and personal prob-lem into a medical one (Moynihan et al., 2002). The initial prob-lem would be none other than shyness (in turn a construction,in this case more mundane than clinical). Although traditionallyshyness was not a problem, but rather a personal characteristicand even a social style, it began to be problematized in the1970s in response to certain social changes. These changes hadto do, above all, although not exclusively, with heterosexual roles,whereby both feminine shyness and masculine shyness (“reserve”)ceased to be the acceptable patterns they had been (McDaniel,2001). The fact that social phobia affects males and femalesequally (or even, unlike other phobias, affects males more; APA,2000) is in line with these social changes that became discerniblein the mid-1970s, when women’s liberation movements began tochallenge male privilege in many fields (McDaniel, 2001).

What is important to emphasize is that these personal socialproblems were shrewdly capitalized upon by the pharmaceuticalsindustry, becoming among the most widespread medical prob-lems in clinical psychiatry at the end of the 1990s. Thus, this con-version into a clinical problem is concerned more than anythingwith the history of psychopharmacology (Healy, 1997, 2004a).

In this regard, one of the leading players was the pharmaceu-tical company GlaxoSmithKline (GSK). GSK set out to market theSSRI-type drug paroxetine (Paxil in the United States and Seroxatin Europe). Although Paxil is known as an antidepressant, the


depression “market” was already covered by Prozac. Thus, it be-came necessary to find another niche—namely, social phobia or,more generally, social anxiety. Indeed, social phobia became morecommonly known as social anxiety, a less stigmatizing term, anda wider one, so that it included a larger number of people whorecognized themselves as socially self-conscious (Healy, 2004a, pp.27–28). For the launching of Paxil, GSK hired the advertisingagency of Cohn & Wolfe, so as “to position social anxiety disorderas a severe condition. This occurred before Paxil was even ap-proved for the treatment of this condition, in order to give Cohn& Wolfe time to start ‘cultivating the marketplace’“ (Moynihan &Cassels, 2005, p. 121). The objective was to promote social phobiaso as to create widespread recognition of Paxil as the first and onlytreatment for the condition, as can be seen on the Cohn & Wolfe(n.d.) website. The strategy consisted in sensitizing the public to aneglected disorder. The awareness-raising campaign was based onthis slogan: “Imagine being allergic to people. You blush, sweat,shake—even find it hard to breathe. That’s what social anxietydisorder feels like” (Moynihan & Cassells, 2005, pp. 121–122).Obviously, this problem has a remedy, which is none other thanthe advertised drug.

The propaganda of the drug advertisers implied that theproblem preceded the solution—namely, that awareness of thedisorder came first, and that invention of the medication wasa subsequent event motivated by this discovery. The reality ofthe constructive process was, in fact, very different. In reality, itbegan with a solution, a medication that needed to be marketedand therefore required a problem to which it could be applied.Although the solution preceded the problem, in the end thingswere arranged so as to make it seem that the problem precededthe solution—as though social phobia had been out there withoutbeing diagnosed, just waiting to be discovered. This process inno way means that people do not, in fact, have the experienceof social phobia or anxiety. After all, the social construction of adisorder implies the experience of illness (Brown, 1995).

The Construction of Panic Disorder in Accordancewith the Medication

Panic disorder provides another example of the promotion of acondition in accordance with the marketing of a drug. Indeed,


it is now considered a typical case of this phenomenon in thehistory of psychiatry (Shorter, 1997). Even so, panic disordermerits a comment here, more than merely a mention, insofaras it illustrates certain aspects of the invention of mental illnesscategories that, although present in those already mentioned(hyperactivity, depression, social phobia), can more easily be seenin relation to this diagnostic category. We are referring specificallyto the construction of the clinical condition according to themedication, listening to the drug instead of to the patient.

For a start, we should bear in mind that panic disorder ac-tually constitutes anxiety trimmed down to its somatic symptoms,in particular, the paroxystic state it involves. Thus, panic seemsto lend itself to medication. In fact, panic disorder became adisorder in its own right in the DSM-III (APA, 1980) due tothe influence of promoters interested in seeing its response tomedication—specifically, to antidepressants (Healy, 1997, p. 193).However, at that time panic disorder was an uncommon diagnosis(as were depression and social phobia). It would have to waitfor its promotion throughout the 1980s to become a frequentlydiagnosed disorder and to reach the epidemic proportions of the1990s, as Shorter (1997) pointed out.

This promotion, as is well known (see, e.g., Healy, 1997;Shorter, 1997; Valenstein, 1998), was mainly the responsibility ofUpjohn laboratories, bent on opening up a market for a newbenzodiazepine called alprazolam, which would be sold underthe brand name Xanax. It was therefore not surprising that panicdisorder was known colloquially as the “Upjohn illness.” Thus, itcould be said that the determination to find a new space for anantidepressant such as alprazolam was due in large part to thefact that the field of depression was already being cornered by theSSRIs (i.e., Prozac).

When all is said and done, the question, of course, is whetheralprazolam works for the problem of anxiety called panic disorder.The answer is yes, but not sufficiently for it to be considereda therapeutic advance. Indeed, the presentation of its results atconferences and in scientific journals was not without controversy.Worthy of note in this regard are the criticisms leveled by Britishpsychiatrist I. Marks, who claimed that studies on alprazolam hadbeen controlled in a biased manner by Upjohn and who drewattention to the fact that behavioral therapy had shown more


lasting effects than alprazolam in an independent study (Healy,1997, pp. 196–197).

It is important, therefore, to see how, after all of this, panicdisorder is dealt with in the DSM-IV-TR (APA, 2000). It is definedby the “temporary and isolated appearance of intense fear or un-ease, accompanied by four (or more) of the following symptoms”from a list of 13: palpitations, sweating, trembling, sensationsof shortness of breath, feeling of choking, chest pain, nausea,feeling dizzy, disrealization, fear of losing control, fear of dying,paresthesias, and chills. Note that the condition has now not onlybeen trimmed down to the somatic symptoms (with respect to thetraditional anxiety condition), but all possible antecedents andconsequents have been omitted, as though the crisis were an “out-break” without sense and, as described, “isolated.” Given that thediagnosis concentrates on the subjective phenomenology of thesymptoms (Did it happen suddenly? Was your heart beating fast?Did you feel as if you were going to die?), it is easy to imagine howthe clinician’s questions find confirmation in the patient, who inturn senses confirmation on hearing such appropriate questions,thus completing a self-explanatory circle (a la Charcot).

Consequently, the symptoms of the disorder are more likelyto serve the statistical protocol than clinical understanding andexplanation. Thus, there is a tendency to listen to the medicationrather than to the patient. “Listening to Xanax” would, in thiscase, be an appropriate title. If we listened to the patient, wewould see that the panic has its antecedents (its “why?”) and itsconsequents (its “what for?”)—or, as Capp and Ochs (1995) wouldsay, its grammar—which certainly falls outside of the defineddisorder. What is certainly the case is that, once more, the clinicaldiscourse fails to correspond to the sense of the disorder withinthe person’s life (Borges & Waitzkin, 1995). Thus, far from beingan isolated outbreak, as though it emerged from the void (asaccepted by clinician and patient), it has its causes: its materialcause or content in problematic situations and its final cause inthe attempt to resolve those situations. What we are talking abouthere is a “grammar of panic,” in which clinicians of a nosographicbent would be illiterate, a grammar that can be interpreted in avariety of ways, such as through discourse analysis (Capp & Ochs,1995), clinical behavior analysis (Dougher, 2000), or social games(Szasz, 1961).


Whether or not panic has much to do with hysteria, psychi-atric research can be seen as a kind of hysteria in the sense ofbeing satisfied with playing out a “methodological drama” (Orr,2000). Orr, a social researcher, actually passed herself off as apatient in a clinical trial with Xanax in the 1980s. As a result,Orr (2000) dismisses psychiatric research that defines diagnosticconditions based on their symptoms’ sensitivity to medication,calling such research “performance methodology.” On constitut-ing a teleological spectacle in which the diagnosis is establishedby the treatment, as Orr argues, the psychiatry itself demonstrateshysteria because it confuses the real event in the patient’s life withthe event resulting from the method that supposedly establishesits empirical character (2000, p. 63).

The Poor Prognosis of Schizophrenia as a Possible Effectof Clinical Practice

Schizophrenia is often presented as the last bastion of mentalillness with a neurobiological basis, so that it would not be subjectto a process of construction as are other disorders, such asthose already discussed. Thus, Horwitz (2002) himself marked outschizophrenia as an exception, together with manic–depressivepsychosis and psychotic depression, from the creation of men-tal illnesses. Horwitz endorsed the concept of mental disorderproposed by Wakefield (1992), according to which there wouldbe some internal dysfunction at the base of such disorders. Inthis regard, the universality of schizophrenia usually is seen ascorroboration of its condition as independent of culture.

Wakefield’s (1992) conception assumes a natural design ofmental functioning, with respect to which we can define “internaldysfunction.” In this sense it is an essentialist conception, asthe author himself acknowledged (Wakefield, 1999). However,it is problematic to assume that there are essences or inherentqualities in an individual that would represent the truth of his orher abnormality. Indeed, abnormality, far from being a humanessence, is more a social construction (Stanley & Raskin, 2002).As Zachar argued in relation to Wakefield’s conception, mentaldisorders are not “natural kinds” but, rather, “practical kinds”constructed on a pragmatic basis (Zachar, 2001, 2003). At thesame time, neither can schizophrenia’s supposed universality be


taken as proof of biological pathogeny, because there are alsocultural universals, such as norms, prohibitions, role transitions,deviations, and so on. Thus, even without denying some possiblebiological condition, it seems clear that schizophrenia is notexempt from the processes found in other disorders. In thisregard, the data show that patients today, in the psychotropicera, spend on average more time in the course of a psychiatriccareer in a hospital than they did before modern drugs came “onstream” (Healy, 2004b, p. 236). Likewise, it is important to notethe current tendency advocating early preventive interventionwith psychosis, which may extend diagnoses and expose to theadverse effects of medicines people who might never actuallydevelop psychoses or schizophrenia (Moncrieff, 2003).

However, the area of greatest interest here almost certainlyconcerns the different course and results in schizophrenia be-tween developed and developing countries, according to theinternational studies commissioned by the World Health Organi-zation, begun in 1967 and 1978. The major conclusion of thesestudies—perhaps unexpected, but repeatedly confirmed—is thatschizophrenia has a better course and result in developing coun-tries than in developed countries (Hopper & Wanderling, 2000;Warner, 2004). This finding seems paradoxical, if we consider thatdeveloped countries have better treatment conditions, includ-ing antipsychotic medication. Indeed, only 16% of developing-world subjects, versus 61% of cases in the developed world,were taking antipsychotic medication throughout the follow-upperiod (Warner, 2004, p. 167). It would seem that the betterthe treatment, the poorer the prognosis. Indeed, it looks asthough people in less developed countries also fail to developsuch an “advanced” schizophrenia as those in more developedones. It should be stressed, moreover, that these findings areresistant to possible sources of bias that could discredit them,such as differences in follow-up, arbitrary grouping of centers,diagnostic ambiguities, selective outcome measures, gender, andage (Hopper & Wanderling, 2000).

How can this be? Naturally, nobody is saying it is antipsy-chotic medication that makes things worse. Even so, antipsychoticmedication, as the chosen treatment it is in developed countries,goes hand-in-hand with a whole series of social practices befittinga conception of illness (with supposed biological basis and a


tendency toward chronicity). This involves, in turn, a neglect ofother conditions of a vital (more than biological) nature. It isprecisely these other conditions of a vital nature on which maydepend a better prognosis, and therefore the better recovery fromschizophrenia in developing countries.

These conditions imply a wholly different conception of thedisorder. Thus, psychosis may be seen in traditional cultures as atransitory delirium, from which the person will not take long torecover. The belief system itself probably offers an explanationof external causes, liberating the patient and his or her familyfrom possible stigma. Likewise, there is no separation of patientsfrom their social roles; rather, they maintain their integration inthe group to which they belong. Consequently, neither personalidentity nor social status is at stake. In sum, greater normalizationof the psychotic episode seems to bring with it better chances ofrecovery.

On the other hand, in Western societies, with their clinicalculture, a first psychotic episode would probably be seen as asymptom of a mental illness requiring immediate antipsychoticmedication. The symptom, particularly if it is hallucinations ordelusions, alarms both the family and the clinician, while itsattenuation through medication brings calm as well as confir-mation of its appropriateness (Lally, 1989). Observation andrest, probably including hospitalization, would be the subsequentsteps. Consequently, listening to the drug becomes the clinician’smain task. Normally, if the symptoms subside, the medication ismaintained for a period; if they do not subside, it is increased orchanged. In the meantime, hospitalization and medication—partand parcel of being ill (in this case, mentally ill)—separate thepatient from current or expected social roles. As discussed below,this may constitute the beginning of a dislodging from normalsocial roles and enrollment instead in a schizophrenic pathway.An abundant literature on labeling theory analyzes this process(e.g., Scheff, 1999).

Thus, the course and result of schizophrenia are found to belinked to the society of reference, and we encounter the paradoxthat more developed clinical practices also appear to bring agreater “development” of schizophrenia. This may indicate that,given an “onset and prodromal phase,” there is a certain marginwith regard to whether schizophrenia develops into a chronic


problem. It is therefore relevant to consider studies about theonset of schizophrenia.

These studies show that the main antecedent of schizophre-nia is the loss of expectable social roles, together with anxietyand depression (Hafner et al., 1999; see also Dohrenwend, 1999).Furthermore, it should be borne in mind that this onset tendsto occur in early adolescence, when the adoption of social rolesis decisive for personal identity (Harrop & Trower, 2001)—suchidentity being implicated in schizophrenia (Estroff, 1989; Fab-rega, 1989). Thus, if we consider how the alarm produced by“psychotic episodes” leads to the immediate prescription of med-ication, we can see how social-role dislodgement can result inadopting instead the role of a mental patient.

Against this background, it is relevant to introduce the notionof career mental patients (Aneshensel, 1999; Karp, 1996). Inthe case of schizophrenia, this process of engulfment, as Lally(1989) put it, is marked by important transitional events (suchas hallucinations, repeated hospitalizations, medication or sup-plementary security income), which weave the patient into thecourse of the illness. This process is now so normalized in Westernsociety that we cannot say societal forces convert patients into astereotypically defined role and identity, or that patients want totake advantage of the “good deal” hospitals provide. Rather, it isthe case that patients strive to maintain a positive view of the self ascompetent (Lally, 1989, p. 263). The point here, however, is thatmental illness in accordance with the established clinical practicesmay function as an alternative career to more productive lifecareers.

However, the career of schizophrenia is not inevitable, tojudge from the differences in prognoses between countries.Despite the fact that the clinical standards of Western societyencourage the concept of career mental illness, they could equallybe reoriented toward normalization, amounting to a move frombiological psychiatry to social psychiatry. Worthy of mention inthis regard are the research and clinical procedures developed byRomme and Escher (2000). The primary aim of their approach“is to make explicit the relationship between individual historyand the voices. In other words, to take it out of the realm ofpsychopathology and put it into the context of people’s life-problems and their personal philosophy” (2000, p. 10).


Romme and Escher’s approach involves, then, a new analysisof the experience of hearing voices outside the illness model.Note, first, that they speak of “hearing voices,” rather than“auditory hallucinations.” Thus, it is still possible in developedcountries to normalize unusual experiences and perhaps, in turn,improve the prognosis for schizophrenia. Relevant studies in thisregard would be those referring to the Open Dialogue Model(Seikkula, Alakare, & Aaltonen, 2001a; 2001b; Seikkula & Olson,2003) and the Dialogical Model (Lysaker & Lysaker, 2004, 2006).

Situating the Charcot Effect on the Map of Constructivism

We have used the Charcot effect, an historical case, as a criticalinstrument for exposing clinical practices, in particular thoseof psychopharmacology. Our analysis has shown how mentaldisorders, far from being the supposed natural entities withbiological bases they are claimed to be, are constructed entitiesof a historical–social nature. Having said this, there is a needfor greater specification of constructivism as understood here,given the variety of constructivist theories. To this end, the mostappropriate approach seems to be to situate the Charcot effecton the map of constructivist psychology drawn up by Raskin(2002), which distinguishes three broad types of constructivism:personal construct psychology, radical constructivism, and socialconstructivism, each with its variants.

In general, it could be said that the Charcot effect fits inwith Gergen’s (1994, 2004) cycle of progressive infirmity. As thereader will recall, four interconnected phases can be identifiedin this cycle: (1) deficit translation, whereby life’s problems areconverted into the sacred or professional language of mentaldisorder; (2) cultural dissemination, which turns mental disor-ders into common, everyday concepts; (3) the cultural construc-tion of illness, consisting in the social practices that teach usto be mentally ill; and (4) vocabulary expansion, which estab-lishes a thorough medicalization and psychologization of every-day life. The disorders previously analyzed provide an excellentdemonstration of this cycle of progressive infirmity. Thus, theCharcot effect would fall within the frame of Gergen’s socialconstructionism.


Nevertheless, our conception presents certain differencesthat preclude it from complete identification with social construc-tionism, and especially its postmodern variant. These differencesspecifically concern the relativist and relational emphasis of so-cial constructionism (Raskin, 2002). In contrast to this relativistemphasis, the constructivism defended here is committed to theidea that some constructions can be better than others. Thus, wehave used the term “invention” to characterize the construction ofmental disorders promoted by psychopharmacological research,largely for commercial reasons. The constructions of disordersderived from listening to the person (rather than to the drug)are considered here as more appropriate to the nature of theproblem. In contrast to social constructionism’s emphasis on therelational and conversational as the source of individual mentallife, here we defend the role of people themselves in the con-struction of their personalities, including forms alternative to thedominant tendencies—for example, as authors responsible fortheir own lives rather than as patients dependent on the Charcoteffect of the moment. These differences with respect to social con-structionism lead to personal constructivism, in relation to whichwe need scarcely mention the personal construct psychology ofGeorge Kelly. Kelly’s perspective stresses humanistic aspects morethan cognitive ones, through an emphasis on self-determinationand the creation of personal meaning (Raskin, 2002). Even so,it would be necessary to consider personal construct theory interms of a conative psychology, of behavioral and contextual flavoralong the lines, for example, of Sarbin (1997). In this context,we might highlight the self-constructive nature of the personalityas a work of art, including the poetry of subjective experience(Perez-Alvarez & Garcıa-Montes, 2004, 2006).

Our approach also has implications related to radical con-structivism. Here once again it differs in relation to the theoriesof reference (e.g., Maturana, 1988; von Glaserfeld, 1995). Incontrast to the epistemological constructivism that characterizesradical constructivism, according to which human beings areclosed systems that cannot accede directly to external reality(Raskin, 2002), our constructivism would constitute a kind ofhermeneutic constructivism. But even within the hermeneuticperspective, ours would be more of a behavioral hermeneutics, inGeertz’s (1986, p. 379) sense. Behavioral hermeneutics has its root


metaphor in drama, as employed in anthropology (e.g., Turner,1982). In relation to the issue in question here, dramaturgicaltheory does not involve consideration of the person as a closedsystem, but rather as being in contact with others (as radicalconstructivism in some way involves). The person would always besituated in a context of action, in accordance with a contextualistontology (Mancuso, 1993). Even places themselves contribute tothe human drama (Sarbin, 2005). This means that the worldaround us is considered an objective reality, previous to the entryon the stage of any person in particular. After all, as Bruner (1990)pointed out, when we enter life the play is already well under way.

But just because objective reality is real and objective doesnot mean that it is not constructed; or put another way, the factthat it is constructed does not mean it is not real and objective.Thus, we would have to talk about the cultural constructionof clinical reality, in the sense established by Kleinman (1980,pp. 35ff ). The phenomenon designated as the Charcot effectwould be a clinical reality of this type. However, precisely becauseit is a constructed reality, this reality is susceptible to alternativeconstructions, in Kelly’s sense, once more. Thus, for example, ifdifferent roles from the normal ones are brought into play, bothfor patients and professionals, alternatives to accepted clinicalrealities can be constructed. This state of affairs may appearquixotic. But perhaps precisely what is required is a quixoticattitude, consisting in beginning to act in another way, as thestarting point for thorough personal and social change. We referhere to the “quixotic principle” introduced in psychology bySarbin (see Perez-Alvarez, 2005; Perez-Alvarez & Garcıa-Montes,2004), in which we recognize the fixed role therapy proposedby Kelly. If many of the patients who have succumbed to therole of mentally ill are encouraged to play a different role intheir everyday lives, they would probably have opportunities toincorporate new perspectives on life and on their experience ofthemselves.

This is precisely what occurs in behavioral activation therapy(Jacobson, Martell, & Dimidjian, 2001). This therapy consistsbasically in replacing the pattern of avoidance characteristic of thedepressive situation by one of behavioral activation. The objectiveis that clients engage in their lives in ways that modify theirenvironment to increase their contact with sources of positive


reinforcement. The result is that the behavioral activation itselfchanges cognitions and emotions, being thus more parsimoniousthan cognitive therapy (whose efficacy is perhaps due, in reality,to its element of behavioral activation). Although behavioralactivation does not refer to fixed role therapy, it is easy to perceivea certain affinity between the two. As far as our issue here isconcerned, both would be seen as demedicalized alternativesto “mental disorders.” In sum, if we had to briefly define theconstructivism endorsed here, we might say that it is a personalconstructivism of a dramaturgic nature.

The Charcot Effect and Its Consequences for Psychiatryand Clinical Psychology

In addition to the cultural consequences associated with the cycleof progressive infirmity, the invention of mental disorders alsohas perverse consequences for psychiatry and clinical psychologythemselves. For while the culture of therapy gives prominenceto psychiatrists, it also carries a threat. As people in generaldiscover for themselves the nature of their disorders and therecommended treatments, the clinician’s specialized knowledgebecomes redundant. Thus, for example, the biologically orientedpsychiatrist is practically reduced to being a dispenser of pre-scriptions, and indeed, much of this work can be and is done bygeneral practitioners—and it is no coincidence that this role forprimary care agents is a priority objective of psychopharmaceuti-cal marketing. If patients do not arrive with their own diagnosis,the general practitioner can apply a brief questionnaire sufficientfor making the corresponding prescription (Spitzer, Kroenke, &Williams, 1999). On the other hand, if psychiatry were actuallycapable of identifying the supposed biological causes of disorders,it would die of its own success, because such disorders would ceaseto be psychiatric and become neurological or of another medicalspecialization, in a process that has occurred over the history ofpsychiatry (Shorter, 1997). In the meantime, and paradoxically,psychiatry survives by virtue of the failure to discover the allegedbiological causes that legitimate it as a branch of medicine.

As far as the perverse consequences for clinical psychologyare concerned, these are perceived in its adherence to the medicalmodel, consisting of a psychological discourse of deficits parallel


to that of neurobiology. Thus, in place of the neurobiologicalexplanation would be a psychological one, also relating to inter-nal mechanisms; in place of medication would be therapeutictechniques, assuming a specificity that does not exist either inpsychopharmacology or in psychotherapy. Indeed, specificity inpsychotherapy is by no means established, despite all its claims(Baskin, Tierney, Minami, & Wampold, 2003; Wampold, 2005).The point is that the medical model of psychotherapy is detri-mental to a contextual model (psychosocial, interpersonal, andcultural), which would be more in keeping with psychology. Infact, the great debate in psychotherapy is between the medicalmodel and the contextual model (Wampold, 2001). Thus, themission of the contextual model would be twofold: on the onehand, to promote the demedicalization of clinical psychology and,on the other, to develop its own line as an alternative.

It is interesting to note that the controversy is not betweenpsychiatry and psychology. Although psychiatry is currently domi-nated by psychopharmacology, it has a critical (“antipsychiatric”)tradition that would not be out of place in the contextual per-spective. Relevant approaches in this respect would be, amongothers, critical psychiatry (Moncrieff, 2003), social psychiatry(Romme & Escher, 2000), the cultural phenomenology of expe-rience (Jenkins & Barrett, 2004), and postpsychiatry (Bracken& Thomas, 2005). For its part, clinical psychology, howevercognitive–behavioral, subscribes nevertheless to a medical model,as already argued. Thus, the “medical model versus contextualmodel” debate is not between psychiatry and psychology, butbetween, on the one hand, a discourse of deficit and the cor-responding cycle of progressive infirmity and, on the other, thedevelopment of alternative constructions and the consequent em-powerment of persons. Nor is it a question, obviously, of whetherdisorders are constructions but, rather, of what type of construc-tions they are. Here we have criticized constructions as mentalillnesses and have, in fact, spoken of “inventions.” But we endorseconstructions as transformations of sense open to new meanings(Gergen, 2004; McNamee, 2002; Raskin & Lewandowski, 2000).In any case, escape from this discourse of deficit and culturalweakening that has resulted from the invention of mental dis-orders is no easy task. Nevertheless, given that we are dealingwith cultural constructions, there is a possibility that things can


be reconstructed in another way. Even so, it would be a gradualprocess that has to begin by making an alternative presence feltin a context where things are already functioning in a particularway. A key point in this process, as Gergen (2004) argued, isto break the existing circle that links the vocabulary of deficitand payment of the costs of medical attention. That is, it wouldbe a question of eliminating the requirement of diagnosis andreducing dependence on medication. If only to demonstrate thatthis process is no utopia, we might cite some alternatives to thetreatment of “psychotic symptoms” because, in the end, these“symptoms” constitute the bulwark of the medical model thatdominates in psychiatry and clinical psychology. Of relevance inthis respect would be Making Sense of Voices (Romme & Escher,2000), Open Dialogue (Seikkula & Olson, 2003), and the DialogicalModel (Lysaker & Lysaker, 2004; 2006); in a similar line, we mightalso mention the reconstruction of a personal narrative (Dimag-gio, 2006). All of these approaches—which basically consist oflistening to the voices of people with psychotic crises, insteadof “listening to the antipsychotics”—show a notable reduction inthe need for medication and hospitalization and, in the end, fordiagnoses of mental illnesses.

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