Canadian Journal of Sociology Online September-October 2007
Shelley Z. Reuter's study of agoraphobia offers an important contribution to the growing body of social science and humanities research on mental illness and the professions that research and treat it. One of only two book-length, critical examinations of the disease (the other, Women Who Marry Houses by Robert Seidenberg and Karen DeCrow, was published in 1983 by McGraw-Hill), the particular strength of Reuter's work lies in its deft weaving of sociological and historical analysis so that neither approach gets short shrift. As a result, Narrating Social Order offers an important corrective to writing that tends towards ahistorical renderings of the social relations that shape diseases of the mind and, conversely, to writing that tends towards asocial renderings of the historical relations that shape such diseases. The reader thus comes away with a clear understanding of the way psychiatric knowledge about and treatment of agoraphobia has changed over time (although Reuter, a Foucauldian, is careful to avoid presenting her account as a linear history); the relationship between different approaches to agoraphobia and the social, political, and economic contexts in which they emerge; and the immersion of the production of knowledge about those labeled "agoraphobic" in power relations and processes of social ordering and exclusion.
These contributions are based on painstaking research. Reuter collected the entire corpus of English-language psychiatric writings about agoraphobia from 1871 (when German neurologist Carl Friederich Otto Westphal published his groundbreaking article "Die Agoraphobie") to the present. Included in this data set are the first four versions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and their precursors, to which Reuter devotes a chapter of the book. Through close readings of the manuals, Reuter highlights the difficulty practitioners have had in defining and classifying agoraphobia and demonstrates how they actively help to produce notions of the normal and the abnormal, rather than simply diagnosing self-evident, preexisting conditions.
Within a broad framework concerned with the politics of classification and social ordering, Reuter focuses, in particular, on three key themes: i) agoraphobia in the context of gender, race, and class; ii) the shift from an emphasis on biopsychosocial explanations (particularly psychoanalysis) for mental diseases to an emphasis, in the past three decades, on narrowly biogenic explanations; and iii) agoraphobic embodiment, or the materialization of the body through the category agoraphobia. In exploring these themes, Reuter draws on social theory and empirical research from the sociology and history of medicine to complement her analysis of her primary sources. The writings of Michel Foucault on genealogy, the politics of knowledge, regimes of the normal, biopower, and the history of madness are particularly prominent. But Reuter also engages with feminist theorists, medical anthropologists, and historians of psychopharmacology to produce a wide-ranging, interdisciplinary analysis.
Readers familiar with feminist and Foucauldian-inspired work on health and illness will likely not find the broad arguments Reuter develops surprising. That diseases are social (as well as biological) productions imbued with cultural assumptions is an axiom of scholarly work in this area. The conclusion to the book, in which she draws together the work of several scholars (including Annemarie Mol on enactment and Judith Butler on reiteration) in order to present a theoretical approach designed to overcome the material-discursive divide in approaches to the body, represents Reuter's main conceptual intervention. But readers who are already convinced of the inextricability of these two levels of analysis will find this a useful distillation of like-thinking, rather than a provocation to conceive the relationship between them differently.
What Narrating Social Order does offer, however, is an invaluable study of how the social construction of illness has unfolded in one particular instance. Moreover, it does so in a way that highlights the complexity and unevenness of this process. Reuter reveals, for example, that agoraphobia was more prevalent in men until the First World War, at which time it underwent a process of regendering so that it became, and remains to this day, a diagnosis primarily attached to women. The author offers a multilayered explanation for the recasting of intense domesticity among bourgeois women as pathological rather than normal behaviour. She considers explanations that focus on middle-class women's changing experience of public space during this period and theorizes the "invention" of agoraphobia both as a form of social control and as a legitimate means for some women to avoid new public responsibilities. In addition, she suggests that the emergence of shell shock among thousands of men returning from war forced psychiatrists to recognize hysteria as not solely a female problem and thus left agoraphobia with the valuable function of demarcating appropriate feminine gender identity.
In a fascinating discussion of recent case histories, Reuter reveals that the diagnosis and treatment of agoraphobia is still highly gendered. When men get categorized as agoraphobic, we learn, the goal of their treatment is usually to get them back to work. When women get diagnosed with the condition, their rehabilitation is designed to get them back to shopping. "One therapist," Reuter writes, "whose patient, 'Helen,' also suffered from an inability to shop for groceries, had Helen visit the supermarket twice a week, including busy Saturday mornings, and remain there for at least an hour" (p. 81).
Such seemingly mundane, but somewhat eerie prescriptions are as much a reflection of class norms related to proper production and consumption as they are of gendered thinking, Reuter argues. She also shows how racial logic, albeit deeply submerged, is at work in such narrations. The assumed and normative subject of the disease has been, and remains, unambiguously white, but the silence around issues of race in psychiatric writing about agorophobia, Reuter argues, reveals much about the discipline's racial thinking. Agoraphobia was, she contends, constructed as a nervous "disease of civilization" (a term borrowed from historian Laura Briggs) and as such was an option available only to privileged whites.
But what of the present? Demonstrating, again, a commitment to detail and complexity, Reuter points to a 1990 U.S. study that found the incidence of agoraphobia was greater among African American women of the lowest socioeconomic status than among white women. While the research did not explore why this might be the case, Reuter observes, incisively, that the sudden appearance of women of colour on epidemiology's radar is at once "counter intuitive" and "entirely predictable: counter intuitive, given the history of agoraphobia as a "white" disease, and predictable, given how racism, economic disadvantage, and a well-entrenched skepticism towards the medical profession might make entering into public places — and psychiatric treatment — traumatic, if not impossible.
While at times the amount of detail Reuter provides threatens to overwhelm her analysis, overall, her writing exudes a reassuring sense that no piece of data has been overlooked, and no interpretive angle left unexplored. Narrating Social Order thus has the distinction of offering not simply the first critical sociology of agoraphobia, but a series of observations and insights that will endure.
Samantha King
Queen's University
http://www.cjsonline.ca/reviews/agoraphobia.html
September 2007
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