There are three baseball umpires that are disputing.  The first one says, “I call ‘em as I see ‘em.”  And the second guy says, “Well, I call them as they are.”  And the third guy says, “They ain’t nothing until I call ‘em!” (taken from Constructive Therapies, Michael F Hoyt Ed. Guilford Press, 1994, P.34)

The third umpire above is the constructivist, since he understands he is authorised to ‘call’ or name an action. He is not reporting reality; he is actually creating the reality …the play is Safe! or Out!, by virtue of his call.

In mental health services we create ‘the reality’ by naming what we see. For example some behaviour such as deluded thinking may be labelled a psychotic disorder and called a ‘mental illness.’

Medicalising bizarre behaviour saved the mistreatment of those previously labelled as witches and ‘possessed’.  Doctors took over as psychology developed later, but the medicalising of behaviour is not straight forward.

What follows is a case study of a young adult woman, diagnosed with paranoid schizophrenia and treated for 10 years. It illustrates how there can be radically different labels to the one person.  These consequently shape the treatment offered, and the course of a person’s life.

Like the three umpires, we can look at the information in front of us (the client’s behaviour and reported history) and call it as we see it (eg schizophrenia); or we could criticise the first call and claim to give the real diagnosis; or thirdly we can recognise that how we are trained shapes the ‘lens’ through which we see the information.  This then determines what we see as relevant, noteworthy, or useful.  In turn this will shape our plan of intervention.

The Case of Josie

Josie was a young adult who lived with her mother. They migrated from a war-torn country.  They both spoke limited English. Josie rarely went out of the house, did not understand television programs, and the only news she got of the world was from her mother.  However, Josie’s mother had problems of her own.  Her fears infected Josie, making her wary of people.  Somehow she came to the attention of the authorities, and was deemed paranoid.  She was hospitalised, medicated and diagnosed with schizophrenia.

Josie was treated for 10 years in the standard way.  She had a number of psychiatric admissions, and in between she was treated by a psychiatrist who spoke her native tongue.  Eventually Josie was referred to Bill, a clinical psychologist.  He quickly decided that Josie did not have schizophrenia, but rather agoraphobia with avoidance.  Her life context had impacted her to be fearful and avoidant.  Together with her lack of language, Josie was not confident to go places and interact with others, which left her fearful belief system unchallenged.

Gradually inroads were made.  Bill negotiated with the psychiatrist to withdraw and cease her medication.  He arranged supports so that Josie could get out more; she learned more English, which meant she was able to gather information from more sources.  She then developed independent views, no longer reliant on her mother.  She eventually grew sufficiently confident and she moved out of home.  Josie then was able to develop a normal set of interests and activities and so lead a normal life.

What Can We Learn From This?

Josie may well have seen over a dozen psychiatrists and doctors over the course of her involvement with the psychiatric system, along with many other health professionals.  Why did she get started on antipsychotic medication, which she almost certainly did not need?  Why did she get a label of schizophrenia, instead of the more useful and less harmful one of agoraphobia?

Constructivism points to the trap that we can see what we look to findExpecting to find ‘mental illness,’ senior psychiatrists found it and called her behaviour, “schizophrenia.” This became the reality that everyone saw, even the consultant psychiatrist who spoke her native language.

Sadly Josie did not get effective treatment for 10 years.  We know that people diagnosed and treated for psychotic disorders have their lifespan reduced by 10 – 20 years, so she has been at risk of physical harm and perhaps psychological harm through her detentions.

Josie’s example highlights the risk that can come from diagnosing behaviour as ‘illness,’ rather than considering the person’s larger context.

This Is Not An Isolated Experience

Consider the debate about Bipolar Disorder and Bipolar Disorder Type 2…when is behaviour (eg moodiness) considered part of the normal continuum and when is it considered an ‘illness?’  Basically when a doctor says it is illness, is the answer; or actually a group of doctors and other professionals who by committee formulate the criteria to name a particular disorder. Then it becomes an official label in the DSM4 manual (one of the primary books used to classify psychiatric disorders.)

In practice it means that an individual doctor sees a patient, collects information about symptoms and history, views it through his or her professional lens, and decides whether to call it ‘illness.’  That is what happened to Josie above.  Those of high status named her as ‘ill’, then those with similar training, were inclined to see it in the same way.  Consensus is assumed; others with dissenting views see no point in arguing against a system that operates out of a dominant paradigm. And a life is changed.

An Italian female psychologist told me she used to do psychological assessments for a psychiatric ward. She would tell the psychiatrists from time to time that particular Italian patients were not “Bipolar;” their homicidal expressions to their husbands were their style, understandable in the Italian culture. Yet the psychiatrists dismissed this objection, continued with the medications and the psychologist gave up her attempts to educate the doctors about her culture.


Even if some Italians might disagree with her, it still illustrates the constructivist position that diagnoses are not objective – the most powerful in the professional hierarchy gets to name what is normal and what is ‘mental illness.’ Patients like Josie then experience the substantial consequences.

The following essays show that behavioural and psychological interventions do exist for mental disorders, even psychotic disorders.

(Go to Essay No 3.)