Critical realism: a philosophical framework for ... - Wiley Online Library

Original article

Critical realism: a philosophical framework for the study of gender and mental health Michael Bergin* MMedSc BSc (Hons) RPN RGN; John S. G. Wells† PhD MSc BA (Hons) PGDip(Ed) ‡ RPN RNT and Sara Owen PhD BA BEd RMN SRN RNT *Lecturer in Nursing, Department of Nursing, and †Head of the Department of Nursing, School of Health Sciences, Waterford Institute of Technology, Cork Road, Waterford, Ireland, and ‡Professor of Nursing, University of Lincoln, Faculty of Health, Lincoln, UK

Abstract

This paper explores gender and mental health with particular reference to the emerging philosophical field of critical realism. This philosophy suggests a shared ontology and epistemology for the natural and social sciences. Until recently, most of the debate surrounding gender and mental health has been guided either implicitly or explicitly within a positivist or constructivist philosophy. With this in mind, key areas of critical realism are explored in relation to gender and mental health, and contrasted with the positions of positivism and constructivism. It is argued that critical realism offers an alternative philosophical framework for the exploration of gender issues within mental health care. Keywords: critical realism, positivism, mental health, constructivism, gender, ontology and epistemology.

Introduction Current gender studies not only explore the division between masculine and feminine they also challenge the division between ‘gender neutral’ and ‘gendered’ (Holter, 2005). In other words, ‘gender neutral’ fails to acknowledge the similarities and diversities that exist among and between men and women. The growing literature surrounding gender identifies complexities

Correspondence: Michael Bergin, Lecturer in Nursing, Department of Nursing, School of Health Sciences, Waterford Institute of Technology, Cork Road, Waterford, Ireland. Tel.: +353 (0) 51 845549; Fax: +353 (0) 51 302150; e-mail: [email protected]

in the gender order (Connell, 1987, 2000, 2002, 2005; Butler, 1990, 2004; Brod & Kaufman, 1994; Lorber, 1994; Mac an Ghaill, 1996; Whitehead, 2002; Kimmel, 2004; Kimmel & Messner, 2004) with ‘gender as diversity’ as opposed to ‘gender-as-difference’ now emerging as a central theme (Annandale & Hunt, 2000, p. 25). Connell (2002) argues most people combine masculinity and femininity in differing ways. He uses the term ‘gender order’ to refer to the ‘structural inventory of an entire society’, i.e. the historically created arrangements of power relations for men and women (Connell, 1987, p. 99). This evolving complexity in the gender order with a multiplicity of masculinities and femininities challenges the business of mental health related research and practice.

© 2008 The authors. Journal compilation © 2008 Blackwell Publishing Ltd Nursing Philosophy (2008), 9, pp. 169–179

169

170

Michael Bergin et al.

Gender is a key sociocultural influence on health (Courtenay, 2000) and a critical determinant of mental health. It is suggested that strategies for reducing risk in mental health cannot be gender neutral as the risks are gender specific (World Health Organisation, 2001). Arguably the social and biomedical domains of mental health and illness should be linked through an interdisciplinary research approach that clarifies and understands the terms ‘sex’, ‘gender’, and ‘gender difference’ (World Health Organisation, 2004). Therefore, a health strategy based on such a knowledge base requires a movement towards a more ‘gender sensitive approach’ (Miers, 2000, 2002; Khoury & Weisman, 2002; World Health Organisation, 2004; Women’s Health Council, 2005a, 2005b). This paper explores these issues with particular reference to the emerging philosophical field of critical realism. Critical realism is considered a ‘third way’ between positivism and relativism (Wainwright & Forbes, 2000; Danermark et al., 2002; Robson, 2002) and possesses an ‘emancipatory’ potential for mental health care research and practice (Wainwright & Forbes, 2000; Williams, 2003). This potential is evident through the ‘double inclusiveness’ of critical realism, insofar as it has the capacity to include the insights of other metatheoretical perspectives without reducing our understanding to their biased and somewhat limited positions; to a view of the world that ontologically goes further to include multiple domains of reality – the empirical, actual, and real (Bhaskar & Danermark, 2006). In this regard, this paper explores and contrasts Bhaskar’s (1978, 1989) distinctive features of realism. The concepts gender, mental health and illness are explored with some possibilities for critical realism as an alternative framework offered.

Critical realism Critical realism is a relatively new philosophical approach that suggests a shared ontology and epistemology for the natural and social sciences (Sayer, 1992). It claims to merge and resolve ‘ontological realism, epistemological relativism, and judgmental rationality’ (Archer et al., 1998, p. xi). The term critical realism evolved from the expressions ‘transcendental realism’ and ‘critical naturalism’ (Archer et al., 1998)

with the ‘critical’ component similar to a ‘transcendental’ notion of ontology that moves beyond what is immediately evident or experienced, similar to Kant’s philosophy of transcendental idealism. However, realism reveals differences from transcendental idealism, in particular, an external and independent reality exists that is separate to our perceptions and understandings (Collier, 1994; Danermark et al., 2002). The philosophical basis of critical realism has been largely associated with the British philosophers Roy Bhaskar and his mentor Rom Harré, with more recent contributors, including the works of Archer (1995), Collier (1994), Danermark et al. (2002) Lawson (1997), Manicas (1987), Outhwaite (1987) and Sayer (1992, 2000). Bhaskar (1978, 1989) promotes a transcendental argument to put forward a realist approach to science. Included among the distinctive features of his account of realism are (1) reality as differentiated and stratified; (2) causality, generative mechanisms and emergence; and (3) the intransitive and transitive aspects of knowledge. These three features will be used to explore critical realism as a potential philosophical framework for the study of gender and mental health. This provides a more inclusive understanding for gender and mental health that goes beyond positivism and constructivism.

Reality as differentiated and stratified: beyond positivism and constructivism Critical realism is first and foremost concerned with ontology and starts from questions about what exists. As Bhaskar (1978) argues, a philosophy of reality must begin with a theory ‘of being’ (ontology) as distinct from a theory ‘of knowledge’ (epistemology). Having identified what ‘is’ or what exists, critical realism then moves to focus on questions concerning the creation of knowledge about that existence (Frauley & Pearce, 2007). This is a key difference that distinguishes critical realism from other metatheoretical positions. Furthermore, Bhaskar (1998) suggests that reality is differentiated and stratified. Three different domains of the social and natural world are distinguished; the real, the actual, and the empirical. These three domains need to be briefly outlined and


Critical Realism, Gender and Mental Health

how mechanisms events and experiences are represented and overlap via these domains. Realist domains of reality Sayer (2000) outlines two points in relation to the real domain. First, it is all that exists (natural or social) despite whether we experience it or not or have knowledge of its disposition. Second, it is the ‘realm of objects, their structures and powers’ (p. 11) that can produce events in the world and it is the transitive aspect of science to identify this realm. It is in this domain that mechanisms (what makes something happen in the world) events and experiences exist. The actual domain refers to what happens in reality when the powers or mechanisms of the real are activated, and events and experiences are produced (Collier, 1994; Sayer, 2000; Danermark et al., 2002). The empirical domain is comprised only of what we experience (directly or indirectly); however, not all events are experienced (Collier, 1994). The domain of the real is distinct and greater than the empirical domain. However, the empirical is in a ‘contingent relation’ to the domains of the actual and the real (Outhwaite, 1998). Therefore, a realist ontology acknowledges that powers may exist that are not yet exercised. A feature of reality is that ‘there is an ontological gap between what we experience and understand, what really happens, and – most important – the deep dimension where the mechanisms are [real domain] which produce the events’ (Danermark et al., 2002, p. 39). This has the potential to allow us to understand how we could be from that which we currently are not; e.g. oppression/controlled versus freedom (Sayer, 2000), or from being mentally healthy to mentally ill. For instance, we may experience and have an understanding of a mental illness; however, realist ontology allows us the opportunity to explore independently such illness within the domain of the real and to discover the generative mechanisms that may be producing such an illness (event). Reality as stratified Reality is also viewed as being stratified, whereby generative mechanisms belong to different layers or

strata of reality (Collier, 1994). For example, strata can include the ‘physical’, ‘chemical’, ‘biological’, ‘psychological’, ‘social’, ‘economic’ . . . among others (Bhaskar, 1978, p. 119). It is this stratified ontology that differentiates critical realism from other ontologies, in so far as they only engage the actual or the empirical domains of reality with no recognition of an independent reality. This real domain is beyond what we experience or observe and has powers that can be activated or not (Sayer, 2000). This stratification allows new mechanisms to be created that are referred to as emergent powers (Danermark et al., 2002). In keeping with these stratified principles, two or more features of the world may combine to produce a new event or experience; however, such occurrences can not be reduced to their components only, even though such components are necessary for their being. A much cited example is water and it being quite different from its components, for hydrogen and oxygen are highly flammable (Sayer, 2000). Positivism is based on an understanding that reality is objective, tangible and singular and experiences are what can be observed – a science that is value free (Robson, 2002). It attempts to find regularly occurring events or patterns in order to generate predictions. Popper’s (1959) notion of science as hypotheticodeductive with the falsification of hypotheses is critical for a knowledge of reality. A key principle in the delineation of theory as scientific or non-scientific is whether propositions are tested with efforts made to refute them (Crotty, 1998). On the other hand, constructivism, as a dominant position within sociology, holds a fundamental belief that ‘reality is not selfevident, stable and waiting to be discovered, but . . . a product of human activity’ (Rogers & Pilgrim, 2005, p. 15). This reality is socially constructed and what exists is dependent upon a person’s interpretation and understanding of that reality (or multiple realities) and it’s socially produced knowledge (Guba & Lincoln, 1994). This creates a tendency towards an ‘epistemological relativism’ and a ‘judgemental relativism’ (the notion that we cannot have satisfactory criteria for selecting which knowledge is more appropriate and closer to the truth than others); e.g. theories cannot be falsified. However, critical realist ontology (differentiated and stratified) challenges both a relativist


171

172


tendency and a positivist reductionist approach (Bhaskar, 1978, 1986; Sayer, 2000). This argument is further advanced from a health perspective. Much research into health has often failed to understand inequalities within a complex social world (Popay et al., 1998; Williams, 2003). There is an epistemological limitation evident here, in terms of positivists confusing prediction (and description) with both causation and explanation (Forbes & Wainwright, 2001; Frauley & Pearce, 2007). Also, constructivism has limitations, especially in its proliferation of the linguistic fallacy where the ‘being’ is reduced to our discourse only, and also, the epistemic fallacy that suggests that ‘being’ can be reduced to or analysed in terms of our knowledge only (Bhaskar, 1978). Critics suggest that constructivism is unable to consider the social world as greater than people’s interpretations of it, to a social world that also includes structural and institutional aspects that are in some ways independent of an individuals thinking (Pawson & Tilley, 1997). Williams (2003, p. 52) suggests that constructivism is ‘falling prey to the epistemic fallacy’ and cites ‘disease, for example, . . . is patently more than just a social construct, however important the latter might be. Disease labels . . . describe but do not constitute disease. The reality of disease . . . is not exhausted by our descriptions of it. If only it were!’ With this in mind, mental health and illness is often portrayed through various paradoxical positions, and it is often quite difficult to determine what theories are more factual and real (Littlejohn, 2003). Moreover, within both psychiatric classification systems (Diagnostic and Statistical Manual of Mental Disorders DSMIV and the International Classification of Disease ICD-10), diagnostic categories and their knowledge base are often challenged and disputed, as some tend to appear and disappear over time (Manning, 2001). Additionally, Carpenter (2000) in arguing for the development of a critical realist framework for the study of gender inequalities of health, cautions against the pitfall of the anthropic fallacy and constructivism. This fallacy and the ensuing anthropocentric bias explains ‘being in terms of human being’ only (Bhaskar, 1998, p. 642), and this hinders an under-

standing of the complex relations, of and between, the natural and the social and its potential impact on mental health and illness.

Causality: beyond positivism and constructivism Critical realism is both analytical and critical of the social practices it studies, and also, of the existing theories that explain such practices (Sayer, 2000; Robson, 2002). Sometimes social practices can be based upon existing theories that may be real or not, e.g. gender and the natural attitude (gender as a natural expansion of sex). If gender relations are understood only as something that is natural as opposed to a product of socialization, then explanations of inequality are also viewed as natural or biologically determined, understandings that are not totally real and potentially fallible (Sayer, 2000). Equally, what is portrayed as mental illness by the medical profession influences our understanding (Payne, 2006) and subsequent care. As already stated, such understandings are often challenged and disputed, as some illnesses tend to disappear over time. If such accounts and their actions are identified as being inconsistent, potentially inaccurate or untrue, then a stimulus for change is offered (Sayer, 2000). Sayer (1992) suggests that many have held the view that if individuals (micro) were more clearly understood, then the configurations of society (macro) could be greatly realized, a view that is challenged as being quite ambiguous. For instance, Sayer (1992) points to the fact that we cannot explain a person’s ability to think by mere reference to the cells that constitute the person. The fact that the properties of the components of an entity, e.g. water (hydrogen and oxygen) cannot explain their combined effect suggests that the world is not only differentiated (domains) but also stratified (Sayer, 1992; Danermark et al., 2002). Causality from a critical realist perspective is the process of ‘identifying causal mechanisms and how they work, and discovering if they have been activated and under what conditions’ (Sayer, 2000, p. 14). Realists, therefore look beyond what is directly observable within the



domain of the empirical, to what is not there with equal and often more importance and endeavour to offer more comprehensive explanations (Danermark et al., 2002). Whereas positivists focus on ‘causeeffect’ relations through lawful patterns of thinking (Sarantakos, 1993) – a ‘successionist’ view of causality; realists redefine laws so that they are better understood as explanatory and non-predictively normic (events being the outcome of mechanism interplay); rather than being ‘constant conjunctures of events’ (Potter & López, 2001, p. 10). In contrast, constructivism explores complex individualized social realities and therefore view causality as the process of constructing meaning that is a result of human activity that does not occur in a linear way (Appleton & King, 2002; Rogers & Pilgrim, 2005). An example of critical realism being critical of the social practices it studies is around the area of health inequalities. Because of the philosophical constraints of positivism and constructivism, factors that are often invisible to existence, not capable of being measured or not expressed by the researched are quite often missed during the research process (Wainwright & Forbes, 2000; Williams, 2003). Critical realism addresses this by initially trying to understand, and more importantly, attempting to produce in-depth explanations of the ‘causal mechanisms’ and how they exert effect and if they have been triggered and under what circumstances they have been activated (Sayer, 2000). For example, Wainwright & Forbes (2000) outline the importance of power relations and health inequalities. They suggest that ignoring or failing to explore underlying mechanisms within capitalism, such as exploitation or alienation, can result in partial and weak explanations only for health inequalities. To address these issues requires realist questions that engage ‘counterfactual thinking’ (fundamental to retroduction) that assists to ‘distinguish between what can be the case and what must be the case, given certain preconditions’ (Sayer, 2000, p. 16). This approach offers a framework for greater understanding of how gender and the multiplicity of masculinities (hegemony, subordination, marginalization, complicity) (Connell, 2005) and femininities can impact on the mental health

of individuals. The gendered patterns of mental illness and inequalities between men and women are explored later.

Intransitive and transitive dimensions of knowledge Critical realism argues that science is a social product (Sayer, 1992), and makes a fundamental distinction between two dimensions of knowledge, namely, the intransitive and transitive (Bhaskar, 1998; Sayer, 2000; Danermark et al., 2002). From a realist perspective, science aims to understand this intransitive dimension of reality through socially produced theories (transitive) that are potentially fallible and limited. In other words, the intransitive refers to the real entities or objects of scientific knowledge that constitute the natural and social world (Outhwaite, 1987). It can include and extend to all that exists (ontology) (Bhaskar, 1978). The transitive includes the established facts, theories, models, paradigms, and techniques of inquiry available to a particular scientific discipline or individual (Bhaskar, 1998) – the epistemological (Danermark et al., 2002). Such theories, models and paradigms may compete and challenge each other; however, the world that they are about (intransitive) remains constant (Collier, 1994). In other words, although our understanding and theories (transitive) of the world may change, this does not necessarily mean that the world or reality (intransitive) that they are about changes also (Sayer, 2000). This is particularly true in relation to the natural world; however, the social world is more complex as it is socially constructed and cannot independently exist without some knowledge (Sayer, 2000). In this regard, Bhaskar’s (1998) Transformational Model of Social Activity and Archer’s (1995) Morphogenetic Approach view both structure and agent as separate strata and neither can be ‘reduced to, explained in terms of, or reconstructed from the other. There is an ontological hiatus between society and people, as well as a mode of connection (viz. transformation) . . .’ (Bhaskar, 1998, p. 37). This connection may limit the actions of agents through existing structures, and simultaneously such actions may replicate or change social structures (Danermark et al., 2002), whereby


173

174


the ontological or intransitive reality of the social world is changed. As Sayer (1992, p. 119) notes, social structures (gender) may exist only where people (re)construct them; however, their powers are often ‘irreducible’ to those people. For that reason an understanding of individuals sometimes requires a ‘macro regress’ to the social institutions in which they are situated, as well as a ‘micro regress’. Therefore, when we study the social world we need to explore the interplay of both (Danermark et al., 2002). According to Bhaskar (1998) constructivism collapses the intransitive dimension of ‘being’ to a discourse about ‘being’ – the ‘linguistic fallacy’. In other words, it fails to recognize that there is more to reality than what is articulated through the language of individuals (Wainwright, 1997). With this in mind, Busfield (2001) highlights a philosophical difficulty with social constructivism and mental illness, whereby concerns regarding the language of social constructs and mental illness may lead some (service users, providers, and families) to resist such understandings as they may feel such language does not fully accept the real difficulties and suffering (pain) involved with a mental illness. In this regard, critical realism accepts the premise that mental illness exists within our discourse; however, what denotes or constitutes such illness may exist beyond our discourse. This understanding would allow for a fallibility of our knowledge and understanding (Sayer, 2000) about what constitutes any particular mental illness and justifies a position of a world (mental illness) that is independent of what we may think it to be. From a health perspective, constructivism has made significant contributions in explaining health inequalities and how people construct meaningful understandings of their health (Wainwright & Forbes, 2000). A view that reality could be external of our beliefs and knowledge is denied, while positivism, on the other hand, tries to distinguish between knowledge that is objective, empirical and verifiable (value neutral science) and knowledge that is not (Crotty, 1998; Robson, 2002). However, some limitations for an understanding of mental health and illness from these perspectives have been outlined with the potential for a critical realist framework presented. This potential is explored further.

Explanations of mental health and illness: possibilities for critical realism Traditionally, sociological and biological explanations for health and illness have often assumed polarized positions (Bird & Rieker, 1999). In recent times, the literature on how sex (biological) and gender affect the health of both women and men is expanding (Payne, 2006), with an understanding that neither one alone influences mental health and illness. Carpenter (2000) argues that a critical realist framework has potential for research on health and illness; however, this has yet to be achieved. He suggests that this is a suitable process for achieving a balance between ‘. . . structure and process, and analysis of biology and culture . . .’ (p. 47), and suggests that a realist framework facilitates this process of amalgamation of knowledge because it makes no basic distinctions between the importance of medicine and sociology. Mental illness in both women and men draws on ‘sex’ and ‘gender’ based explanations (Payne, 2006). For example, Scott (2000) in her review of research into women’s and men’s mental health highlights the effects of oestrogen (among other possible physiological causes) in the differing psychopathological profiles of men and women across the life span; while Emslie et al. (2006) showed how some men engage aspects of hegemonic masculinity (control, power, dominance) as part of their recovery from depression. While for other men conforming to such masculinity could contribute to suicidal behaviour. Therefore, gender is significant for mental health and illness. It influences the power and control men and women have in relation to their socioeconomic position, roles, social status, and access to resources and treatment, and is also critical in determining a person’s vulnerability and exposure to mental health risks in society (World Health Organisation, 2001).

Current explanations of mental health and illness While the biomedical perspective has been the dominant paradigm for understanding mental health and



illness (Hannigan & Cutcliffe, 2002), various other perspectives suggest that the subject area is highly disputed (e.g. Hollingshead & Redlich, 1958; Goffman, 1961; Szasz, 1961, 2007; Foucault, 1967; Laing, 1969; Chesler, 1972; Brown & Harris, 1978; Scheff, 1981; Penfold & Walker, 1983; Showalter, 1987; Ussher, 1991; Busfield, 1996). Mental health and illness is therefore portrayed through various and sometimes paradoxical positions, making it difficult to determine what theories are more factual and real (Littlejohn, 2003). Social causation theory accepts that major mental illnesses are valid and real diagnoses and tries to determine if any associations between social disadvantage (poverty, class, gender, age) and mental illness exist using objective empirical methods (Rogers & Pilgrim, 2005). For example, depression is said to occur whereby a set of vulnerability factors or certain situations are identified (loss, low intimacy, class) that may predispose people to psychiatric illness, thus highlighting the importance of social issues in relation to the causation of mental illness (Brown & Harris, 1978). Foucault (1967) maintains that the body is a social construct and focuses his ideas about mental illness in terms of unreason and irrationality. His emphasis on the mind as opposed to the body highlights the claim of mental illness as a social construct. Ussher’s (1991) exploration of the concepts gender and ‘madness’ deconstructs both concepts and recognizes discourses of ‘madness’ and its connections with other discourses of misogyny, power, sexuality, and badness. She endeavours to establish whether women’s ‘madness’ is a ‘misogynistic construct’ or a mental illness. While she does not provide any single solution, the pervasiveness of misogyny within patriarchal societies may explain some of women’s obedience with professional groups (medicine, psychology) that offer a partial explanation for mental illness. Although critical realism encompasses such explanations for mental illness, partially due to the fact that it accepts a ‘weak’ social constructivist position and also materialist causes; notes, that the socially defined nature of this knowledge does not suggest that it cannot identify other external explanations that can be real and independent of any one person (Sayer, 2000).

Possibilities for critical realism While the significance of social constructivist language and mental illness is acknowledged, in particular, its challenge to how the body is represented in medical science, it is argued, however, that it has also restricted sociological study of mental illness, e.g. the reality that some people experience severe pain as a consequence of mental illness (Busfield, 2001; Mulvany, 2001). Consequently, there is a growing number within the field of mental health (Greenwood, 1994; Busfield, 1996, 2001; Pilgrim & Bentall, 1999; Rogers & Pilgrim, 2005), chronic illness and disability (Williams, 1999; Bhaskar & Danermark, 2006), health (Carpenter, 2000; Wainwright & Forbes, 2000; Forbes & Wainwright, 2001; Williams, 2003) and research (Danermark, 2002; Danermark et al., 2002; Robson, 2002; Bhaskar & Danermark, 2006; Downward & Mearman, 2007) that view critical realism as an alternative framework. Pilgrim & Bentall (1999) make the case that current medical views of depression are vague, perplexed and lacking as a basis for framing mental health difficulties. They argue that current understandings of the concept ‘depression’ are inadequate as a basis for research and required therapeutic interventions. Research into the ‘cognitive and biological mediators of distress’ require a more restricted research focus, e.g. areas such as low self-esteem and fatigue. They also suggest that the concept is deficient for a full investigation of the social and political circumstances that contribute to ‘human misery’ and suggest a critical realist framework as a more informed approach, as opposed to ‘medical naturalism and social constructionism’ (p. 271). Payne (2006) outlines the mixed evidence that supports a biological (sex) risk for depression in men and women and reviews the evidence that links depression to a number of gendered factors. Danermark (2002) for example, argues that emotions cannot be understood or explained by reference to mechanisms at only one level (chemical, physical, psychological, social) or the fact that we cannot explain a person’s ability to think by ‘reference to the cells that constitute them, as if cells possessed this power too’ (Sayer, 1992, p. 119). With this in


175

176


mind, Greenwood (1994) suggests that empiricism and social constructivism either ‘ignore’ or present ‘impoverished’ explanations by confining the social aspects of identity and emotion ‘to the social dimension of our theories or discourse about identity and emotion’. He offers a realist theory that is independent of socially constructed theories while still recognizing the social dimension of identity and emotion. Equally, he does not challenge or present any ‘threat’ to the ‘objectivity of psychological theories . . . or their empirical evaluation’ (p. viii). As already stated, a difficulty with social constructivist language and mental illness is that in the past there was avoidance in recognizing that some people with a mental illness experience severe pain and discomfort as a result of altered and/or disturbed cognitive functioning (Mulvany, 2001). In highlighting this issue, Busfield (2001, pp. 5–6) succinctly states ‘social construction has become very loose and imprecise and, because of its epistemological and ontological connotations can generate hostility towards sociological ideas about mental disorder from doctors, patients and families who feel it rejects the reality of the pain, difficulty and suffering involved in mental disorder’. A possible way of addressing this issue is through the notion of embodiment (Seymour, 1998; Connell, 2002; Krieger, 2005), with a particular concentration on ‘embodied irrationality’ (Mulvany, 2001). This allows a person with a mental illness to make sense of their biological experiences, while equally acknowledging the experience within a social domain. This creates a more sophisticated and informative understanding of the experience of illness within a biological and social context (Mulvany, 2001). Additionally, in identifying Rosenberg’s (1992) theory of the ‘social framing’ of illness, Busfield (2001) suggests that this offers an understanding of ‘illness [that] varies across time and place, but does not suggest any denial of the material reality of the phenomena that come to be constituted as disease or disorder. . . . whilst also recognising the importance of the social processes . . .’ (p. 5), a position that is apposite with the philosophical principles of critical realism.

Critical realism and research methodology Recent claims for critical realism as a metatheory and methodology for research are convincingly argued for by Bhaskar & Danermark (2006). In their words, ‘. . . critical realism is . . . the ontologically least restrictive perspective, insofar as it is maximally inclusive as to causally relevant levels of reality and additionally maximally inclusive insofar as it can accommodate the insights of other metatheoretical perspectives. This, . . . the “double inclusiveness” of critical realism’ (p. 294). Given the philosophical constraints of positivism and constructivism, critical realism supports a wide range of research methods (Sayer, 1992, 2000). Both quantitative and qualitative research methodologies are valued and the choice of research methods should depend on the type and focus of the study and what is hoped to be learned (Sayer, 1992, 2000). Sayer (2000) distinguishes between intensive (qualitative) and extensive (quantitative) research designs, and it is closely argued, that critical realism through its encompassing ontology bridges the dichotomy associated with both research approaches and allows research to reach areas that were not possible within traditional approaches (Sayer, 1992, 2000; Archer et al., 1998). Similarly, Danermark et al. (2002) present a mixed model design for research that they refer to as ‘critical methodological pluralism’, an approach that combines both intensive and extensive research practices. Arguing for an interdisciplinary approach for economics, Downward & Mearman (2007) demonstrate how critical realist ontology and retroductive reasoning (retroduction) can be linked to a mixed-methods triangulation. Retroduction as a thought operation allows the researcher to move and obtain knowledge of the properties that are necessary for a phenomenon to exist. This type of reasoning is about discovering and explaining events by assuming and identifying mechanisms that are capable of producing such events (Sayer, 1992). On the other hand, inductive and deductive reasoning are concerned with confirming and giving reasons (justifying) for events or phenomenon (Frauley & Pearce, 2007). Counterfactual thinking is essential to retroduction, whereby the



researcher’s experiences and knowledge and their ‘ability to abstract and to think about what is not, but what might be’ is significant (Danermark et al., 2002, p. 101). In so doing, the researcher is able to move beyond a particular ‘ontic context’ to another, thereby creating explanations that involve ontological depth (Downward & Mearman, 2007). Central to this approach is the ontological-methodological link whereby researchers can integrate various research traditions, and in the process strengthen the defence of research within a critical realist understanding (Lipscomb, 2008). Various disciplinary boundaries are surpassed that engage and combine the best of both qualitative and quantitative research methodologies without taking on board their respective philosophical limitations. Guided by a critical realist metatheory allows various understandings and explanations for gender, mental health and illness to coexist and avoids the incomplete positions of positivism and constructivism. Therefore, various mechanisms at the biological, psychological, social and cultural levels need to be more clearly understood for an enhanced delivery of care for gendered human beings with a mental illness. In essence, gender and illness needs to be conceptualized in a way that does not reduce the biological to the social or vice-versa (Williams, 1999, 2006) and offers an understanding of the world that is ontologically stratified with emergent powers. In other words, critical realism through its ontologically focused research has the potential to draw attention to new ways for research and produce knowledge that would not be arrived at using the traditional philosophical frameworks.

Concluding comments Most debate surrounding gender and mental health have been guided either implicitly or explicitly within a positivist or constructivist philosophy. The merits and limitations of these established frameworks have been outlined. The central argument of this paper is a consideration of critical realism as an alternative. The philosophical principles of critical realism merit exploration within mental health related research and practice. In particular, a critical realist philosophy

offers a framework that can explore gender and mental health without dismissing that which is already known. It allows the biological (sex) and social (gender) domains of knowledge for mental health and illness to coexist, without either being reduced to or defined by the other. The challenge now is moving beyond what is already known to the domain of what is unknown for the development of ‘comprehensive, cumulative and theoretical deep explanations’ (Wainwright & Forbes, 2000, p. 274). Arguably, this can be achieved for gender and mental health within a critical realist framework. Moreover, critical realism avoids a conflation of the ontological and the epistemological and allows coexistence for ‘sex’ and ‘gender’ within mental health related research and practice. Additionally, as a philosophical framework it brings together the known, and goes beyond in our ‘desire to put the world back together again, with critical emancipatory promise and potential to boot’ (Williams, 2003, p. 66).

References Annandale E. & Hunt K. (2000) Gender inequalities in health: research at the crossroads. In: Gender Inequalities in Health (eds E. Annandale & K. Hunt), pp. 1–35. Open University Press, Buckingham. Appleton J.V. & King L. (2002) Journeying from the philosophical contemplations of constructivism to the methodological pragmatics of health services research. Journal of Advanced Nursing, 40(6), 641–648. Archer M. (1995) Realist and Social Theory: The Morphogenetic Approach. Cambridge University Press, Cambridge. Archer M., Bhaskar R., Collier A., Lawson T. & Norrie A. (1998) Critical Realism: Essential Readings, Critical Realism: Interventions. Routledge, London. Bhaskar R. (1978) A Realist Theory of Science, 2nd edn. Harvester, Brighton. Bhaskar R. (1986) Scientific Realism and Human Emancipation. Verso, London. Bhaskar R. (1989) Reclaiming Reality. Verso, London. Bhaskar R. (1998) Philosophy and scientific realism. In: Critical Realism: Essential Readings, Critical Realism: Interventions (eds M. Archer, R. Bhaskar, A. Collier, T. Lawson & A. Norrie), pp. 16–47. Routledge, London. Bhaskar R. & Danermark B. (2006) Metatheory, interdisciplinarity and disability research: a critical realist perspective. Scandivian Journal of Disability Research, 8(4), 278–297.


177

178


Bird C.E. & Rieker P.P. (1999) Gender matters: an integrated model for understanding men’s and women’s health. Social Science and Medicine, 48, 745–755. Brod H. & Kaufman M. (1994) Theorizing Masculinities: Research on Men and Masculinities. Sage Publications, Newbury Park, CA. Brown G.W. & Harris T.O. (1978) Social Origins of Depression. Tavistock, London. Busfield J. (1996) Men, Women and Madness, Understanding Gender and Mental Disorder. Palgrave Macmillan, Hampshire. Busfield J. (2001) Introduction: rethinking the sociology of mental health. In: Rethinking the Sociology of Mental Health (ed. J. Busfield), pp. 1–16. Blackwell Publishers, Oxford. Butler J. (1990) Gender Trouble: Feminism and the Subversion of Identity. Routledge, London. Butler J. (2004) Undoing Gender. Routledge, Oxfordshire. Carpenter M. (2000) Reinforcing the pillars: rethinking gender, social divisions and health. In: Gender Inequalities in Health (eds E. Annandale & K. Hunt), pp. 36–63. Open University Press, Buckingham. Chesler P. (1972) Women and Madness. Avon Books, New York, NY. Collier A. (1994) Critical Realism: An Introduction to Roy Bhaskar’s Philosophy. Verso, London. Connell R.W. (1987) Gender and Power. Polity Press and Blackwell Publishing, Cambridge. Connell R.W. (2000) The Men and the Boys. University of California Press, Berkeley, CA. Connell R.W. (2002) Gender: Short Introductions. Polity Press and Blackwell Publishing, Cambridge. Connell R.W. (2005) Masculinities, 2nd edn. Polity Press and Blackwell Publishing, Cambridge. Courtenay W.H. (2000) Constructions of masculinity and their influence on men’s well being: a theory of gender and health. Social Science and Health, 50, 1385– 1401. Crotty M. (1998) The Foundations of Social Research: Meaning and Perspectives in the Research Process. Sage Publications, London. Danermark B. (2002) Interdisciplinary research and critical realism: the example of disability research. Journal of Critical Realism, 5, 56–64. Danermark B., Ekstrom M., Jakobsen L. & Karlsson J.C. (2002) Explaining Society, Critical Realism in the Social Sciences, Critical Realism Interventions. Routledge, London. Downward P. & Mearman A. (2007) Retroduction as mixedmethods triangulation in economic research: reorienting economics into social science. Cambridge Journal of Economics, 31, 77–99. Emslie C., Ridge D., Ziebland S. & Hunt K. (2006) Men’s accounts of depression: reconstructing or resisting hege-

monic masculinity? Social Science & Medicine, 62, 2246– 2257. Forbes A. & Wainwright S.P. (2001) On the methodological, theoretical and philosophical context of health inequalities research: a critique. Social Science and Medicine, 53, 801–816. Foucault M. (1967) Madness and Civilization: A History of Insanity in the Age of Reason. Tavistock, London. Frauley J. & Pearce F. (2007) Critical realism and the social sciences: methodological and epistemological preliminaries. In: Critical Realism and the Social Sciences, Heterodox Elaborations (eds J. Frauley & F. Pearce), pp. 3–29. University of Toronto Press, London. Goffman E. (1961) Asylums. Penguin, Harmondsworth. Greenwood J.D. (1994) Realism, Identity and Emotion: Reclaiming Social Psychology. Sage Publications, London. Guba E.G. & Lincoln Y.S. (1994) Competing paradigms in qualitative research. In: Handbook of Qualitative Research (eds N. Denzin & Y.S. Lincoln), pp. 105–117. Sage, Thousand Oaks, CA. Hannigan B. & Cutcliffe J. (2002) Challenging contemporary mental health policy: time to assuage the coercion? Journal of Advanced Nursing, 37(5), 477–484. Hollingshead A.B. & Redlich F.C. (1958) Social Class and Mental Illness. Wiley, New York, NY. Holter, Ø.G. (2005) Social theories for researching men and masculinities: direct gender hierarchy and structural inequality. In: Handbook of Studies on Men and Masculinities (eds M.S. Kimmel, J. Hearn & R.W. Connell), pp. 15–34. Sage Publications, Thousand Oaks, CA. Khoury A.J. & Weisman C.S. (2002) Thinking about women’s health: the case for gender sensitivity. Women’s Health Issues, 12(2), 61–65. Kimmel M.S. (2004) The Gendered Society, 2nd edn. Oxford University Press, Oxford. Kimmel M.S. & Messner M.A. (2004) Men’s Lives, 6th edn. Pearson Education, London. Krieger N. (2005) Embodiment: a conceptual glossary for epidemiology. Journal of Epidemiol Community Health, 59, 350–355. Laing R.D. (1969) The Divided Self: An Existential Study in Sanity and Madness. Penguin, Harmondsworth. Lawson T. (1997) Economics and Reality. Routledge, London. Lipscomb M. (2008) Mixed method nursing studies: a critical realist critique. Nursing Philosophy, 9, 32–45. Littlejohn C. (2003) Critical realism and psychiatric nursing: a philosophical inquiry. Journal of Advanced Nursing, 43(5), 449–456. Lorber J. (1994) Paradoxes of Gender. Yale University Press, New Haven and London. Mac an Ghaill M. (1996) Understanding Masculinities. Open University Press, Buckingham.



Manicas P.T. (1987) A History and Philosophy of the Social Sciences. Blackwell, Oxford. Manning N. (2001) Psychiatric diagnosis under conditions of uncertainity: personality disorder, science and professional legitimacy. In: Rethinking the Sociology of Mental Health (ed. J. Busfield), pp. 76–94. Blackwell Publishers, Oxford. Miers M. (2000) Gender Issues and Nursing Practice, Sociology and Nursing Practice Series. MacMillan Press, Hampshire. Miers M. (2002) Developing an understanding of gender sensitive care: exploring concepts and knowledge. Journal of Advanced Nursing, 40(1), 69–77. Mulvany J. (2001) Disability, impairment or illness? The relevance of the social model of disability to the study of mental disorder. In: Rethinking the Sociology of Mental Health (ed. J. Busfield), pp. 39–57. Blackwell Publishers, Oxford. Outhwaite W. (1987) New Philosophies of the Social Sciences: Realism, Hermeneutics and Critical Theory. MacMillan, London. Outhwaite W. (1998) Realism and social science. In: Critical Realism: Essential Readings, Critical Realism: Interventions (eds M. Archer, R. Bhaskar, A. Collier, T. Lawson & A. Norrie), pp. 282–296. Routledge, London. Pawson R. & Tilley N. (1997) Realistic Evaluation. Sage Publications, London. Payne S. (2006) The Health of Men and Women. Polity Press, Cambridge. Penfold P.S. & Walker G.A. (1983) Women and the Psychiatric Paradox. Eden Press, Montreal, QC. Pilgrim D. & Bentall R. (1999) The medicalisation of misery: a critical realist analysis of the concept of depression. Journal of Mental Health, 8(3), 261–274. Popay J. Williams G., Thomas C. & Gatrell A. (1998) Theorising inequalities in health: the place of lay knowledge. In: The Sociology of Health Inequalities (eds M. Bartley, D. Blane & G. Davey Smith), pp. 59–84. Blackwell, Oxford. Popper K.R. (1959) The Logic of Scientific Discovery. Basic Books, New York. Potter G. & López J. (2001) After postmodernism: the new millennium. In: After Pstmodernism: An Introduction to Critical Realism (eds J. López & G. Potter), pp. 3–16. The Athlone Press, London. Robson C. (2002) Real World Research, 2nd edn. Blackwell Publishing, Oxford. Rogers A. & Pilgrim D. (2005) A Sociology of Mental Health and Illness, 3rd edn. Open University Press, Berkshire. Rosenberg C.E. (1992) Introduction. In: Framing Diseases: Studies in Cultural History (eds C.E. Rosenberg & J. Golden), pp. xiii–xxvi. Rutgers University Press, New Brunswick, NJ.

Sarantakos S. (1993) Social Research. MacMilan Press, Hampshire. Sayer A. (1992) Method in Social Science: A Realist Approach, 2nd edn. Routledge, London. Sayer A. (2000) Realism and Social Science. Sage Publications, London. Scheff T. (1981) The role of the mentally ill and the dynamics of mental disorder: a research framework. In: The Sociology of Mental Illness – Basic Studies (eds O. Grusky & M. Pollner), pp. 54–63. Holt, Rinehart and Winston, Orlando, FL. Scott L.V. (2000) A physiological perspective. In: Women and Mental Health (ed. D. Kohen), pp. 17–38. Routledge, London. Seymour W. (1998) Remaking the Body: Rehabilitation and Change. Routledge, London. Showalter E. (1987) The Female Malady: Women, Madness and English Culture, 1830–1980. Virago, London. Szasz T. (1961) The Myth of Mental Illness. Hoeber-Harper, New York, NY. Szasz T. (2007) Coercion as Cure: A Critical History of Psychiatry. Transaction Publishers, Piscataway, NJ. Ussher J. (1991) Women’s Madness, Misogyny or Mental Illness? Harvester Wheatsheaf, Hertfordshire. Wainwright S.P. (1997) A new paradigm for nursing: the potential of realism. Journal of Advanced Nursing, 26, 1262–1271. Wainwright S.P. & Forbes A. (2000) Philosophical problems with social research on health inequalities. Health Care Analysis, 8, 259–277. Whitehead S.M. (2002) Men and Masculinities. Polity Press, Cambridge. Williams S.J. (1999) Is anybody there? Critical realism, chronic illness and the disability debate. Sociology of Health and Illness, 21(6), 797–819. Williams S.J. (2003) Beyond meaning, discourse and the empirical world: critical realist reflections on health. Social Theory and Health, 1(1), 42–71. Williams S.J. (2006) Medical sociology and the biological body: where are we now and where do we go from here? Health, 10(1), 5–30. Women’s Health Council (2005a) Women’s Mental Health: Promoting a Gendered Approach to Policy and Service Provision. The Women’s Health Council, Dublin. Women’s Health Council (2005b) Integrating the Gender Perspective in Irish Health Care Policy: A Case Study. The Women’s Health Council, Dublin. World Health Organisation (2001) Mental Health: A Call for Action by World Health Ministers, Gender Disparities in Mental Health. pp. 73–92. World Health Organisation, Geneva. World Health Organisation (2004) Gender in Mental Health Research. WHO, Geneva.


179