Over the course of last year I have been working on a small project with Rachel Bingham examining the possibility of distinguishing ‘social deviance’ from ‘mental disorder’ in light of recent work on concepts of health. The result was an essay published recently in the journal Philosophy, Psychiatry & Psychology (21:3-September 2014).
In our response to Moncrieff and Stein we found it necessary to point out that in the writings of some critical psychiatrists and psychologists there is a problematic conflation of empirical with conceptual issues in relation to ‘mental disorder’. That section is reproduced below. Note that Criterion E is the final clause in the DSM definition of mental disorder. It states that a mental disorder must not solely be a result of social deviance or conflicts with society.
Mental Disorder: Separating Empirical From Conceptual Considerations
Let us begin by revisiting the conceptual basis of attributions of mental disorder. Criterion E is not, as we argued with Stein et al. (2010, 1765), conceptually necessary, but is of ethical and political importance given the historical context. Thus, notwithstanding the other criteria, a condition can only be considered for candidacy for mental disorder if “dysfunction” is present. What is a dysfunction? As Moncrieff puts it, there is a tautology in the definition of mental disorder where it is stated that a mental disorder reflects an “underlying psychobiological dysfunction” (Moncreiff 2014). Moncrieff argues that this is flawed because underlying processes have not been established, which renders the definition tantamount to saying that a dysfunction is a reflection of a dysfunction: a definition that adds nothing to our knowledge.
Here Moncrieff follows Thomas Szasz in finding a lack of resemblance to physical disorder to be the primary problem with the concept of mental disorder (see Fulford et al. 2013).1 In pursuing this, the critical psychiatrist not only fails to see the complexity of the concept of physical disorder, but also commits the same error as the biological psychiatrist. The latter implies that an ever longer awaited complete neurochemistry of mental health conditions would solve the conceptual problems. The former—the critical psychiatrist—implies the converse; that the absence of proof for the “existence of separate and distinct foundational processes,” as Moncrieff (2014) puts it, proves that mental health conditions are not disorders. As we have argued elsewhere, identifying the biological basis for a set of behaviors or symptoms does not in itself pick out what is pathological or disordered: for example, a complete description of the neurochemical states governing sexuality would not permit the inference that homosexuality is a disorder, any more than discovery of the neural correlates of falling in love or criminality would make these mental illnesses (Bingham and Banner 2012). Neurobiological changes—their presence or their absence—tells us about conditions when we find them by other means, but it does not tell us what is or is not a disorder. The same arguments could be run for underlying psychological processes. Consequently, emphasis on scientific progress or failure to progress in understanding the neurobiological correlates of mental health conditions does little to advance the conceptual debates, a point that may help to explain the impasse in the ongoing exchange between critical and biological psychiatrists.
Thus, although Moncrieff is right in pointing out that the term ‘dysfunction’ is redundant in the definition of mental disorder, she is wrong about the reason why this is so. It is not, as she claims, due to the point that no “separate and distinct foundational processes” (2014) that can ground dysfunction have been discovered empirically. After all, this leaves her open to the simple response that they actually have been, a response many biological psychiatrists do offer. The redundancy of the term ‘dysfunction’ in the definition of mental disorder is a result of conceptual analysis (and not empirical evidence), whereby it has not proven possible to define dysfunction in a way that excludes values. Here, we follow Derek Bolton in the view that once we “give up trying to conceptually locate a natural fact of the matter [dysfunction] that underlies illness attribution… then we are left trying to make the whole story run on the basis of something like ‘distress and impairment of functioning’” (2010, 332). We are left then with those things that matter in real life, the reasons that lead to healthcare being sought: usually the presence of significant distress and disability.
This is what the terms ‘dysfunction’ and ‘mental disorder’ pick out once we achieve some clarity on their referents. Stein is clearly aware of the problems inherent in defining dysfunction. However, somewhat surprisingly, the assumption that we can talk of ‘dysfunction’ over and above experienced factors (distress and disability in particular) arises through Stein’s commentary. In other words, although Stein has acknowledged the conceptual problem, in places he still writes as if there were a clear definition of dysfunction, without telling us what this would be. For example, he describes “situations when there is evidence of dysfunction, but an absence of distress and/or impairment” and gives the example of tic disorders which have no “clinical criterion (emphasizing distress and/or impairment)” (Stein 2014). We would argue that, despite the lack of explicit acknowledgement in DSM, tic disorders enter the manual because of their association with clinically significant distress and disability. It is important to avoid confusing the empirical questions (e.g., Why do people have tics? Can people have tics and not be distressed?) with the conceptual questions (e.g., When is a tic a disorder? Can tics be disorders if they do not cause distress or impairment?).
A further potential pitfall is to conflate the technical use of ‘dysfunction’ with the ordinary use of that term. This might occur where, on the one hand, we perceive a ‘dysfunction’ but on the other hand we are unable to say what the dysfunction consists of. When Moncrieff writes that dysfunction and distress are not co-extant, because, “people may neglect themselves and act in other ways that compromise their safety and survival without necessarily being distressed,” she is offering a description of behavior many would consider ‘dysfunctional’ in the lay sense (2014). Considered as a basis for conceptual analysis, however, this does not illuminate any “underlying psychobiological dysfunction”, which previous definitions aspired to do. Indeed, it is somewhat surprising that Moncrieff provides this counterexample rather than sticking to her argument that dysfunction in fact does not exist. In citing safety and survival, Moncrieff’s phrase does resemble the evolutionary theoretic approach (notably described in Wakefield’s Harmful Dysfunction Analysis), which as has been discussed widely elsewhere and noted in our paper, has fallen out of favor owing to problems with evolutionary theory specifically and naturalistic definitions in general. What of importance is left in Moncrieff’s putative definition if not underlying psychobiological and evolutionary dysfunction? We would argue: only the harm or threat of harm experienced by the individual, whether that harm is cashed out as distress and disability or as some other similar negatively evaluated experienced factor.
[NOTE: (May 2015) Essay and commentaries are now out in print: Click HERE]
Essay accepted for publication in the journal Philosophy, Psychiatry and Psychology
Written with Dr Rachel Bingham
Abstract and excerpt.
Abstract: Can psychiatry distinguish social deviance from mental disorder? Historical and recent abuses of psychiatry indicate that this is an important question to address. Typically, the deviance/disorder distinction has been made, conceptually, on the basis of dysfunction. Challenges to naturalistic accounts of dysfunction suggest that it is time to adopt an alternative strategy to draw the deviance/disorder distinction. This article adopts and follows through such a strategy, which is to draw the distinction in terms of the origins of distress with the relevant conditions. It is argued that psychiatry’s ability to distinguish deviance from disorder rests on the ability to define, identify and exclude socially constituted forms of distress. These should lie outside the purview of candidacy for mental disorder. In pursuing this argument, the article provides an analysis of the social origins of a form of distress with the personality and sexual disorders, and indicates in what ways it is socially constituted.
Keywords: Distress; Dysfunction; DSM-5; Cognitive Dissonance; Sexual Disorders; Personality Disorders
CAN PSYCHIATRY DISTINGUISH SOCIAL DEVIANCE FROM MENTAL DISORDER?
INTRODUCTION A number of leading figures in psychiatric nosology and the philosophy of mental health proposed various changes to the definition of mental disorder (Stein et al. 2010). These changes were intended to guide the development of the definition in the now published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5. The authors proposed the following criteria which develop those in the DSM-IV (APA 1994); a mental disorder is:
- A behavioural or psychological syndrome or pattern that occurs in an individual
- the consequences of which are clinically significant distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning).
- must not be merely an expectable response to common stressors and losses (for example, the loss of a loved one) or a culturally sanctioned response to a particular event (for example, trance states in religious rituals)
- that reflects an underlying psychobiological dysfunction
- that is not solely a result of social deviance or conflicts with society
In this article we consider criterion E, an exclusionary criterion intended to safeguard against pathologising social deviance and imparting diagnoses on the basis of discrimination. The importance of this safeguard cannot be overstated. The distant as well as recent history of psychiatry is replete with instances of the abuse of diagnosis and treatment for political purposes (van Voren 2010). And psychiatry tends to be susceptible to the claim that it functions as a tool for social control, disposing of ‘problematic’ individuals under the justification of a medical diagnosis (Szasz 1998). It has been argued for some time that abuses of psychiatry do not require mal-intent on the part of clinicians, but happen despite psychiatrists involved believing their diagnoses to be valid (van Voren 2002). Fulford, Smirnov and Snow (1993, 801) suggest that corruption, political pressures, poor clinical standards and a lack of safeguards “explain the ‘how’ but not the ‘why’ of abuse”. The authors argue that conceptual issues – in particular failure to recognise the value-laden nature of psychiatric diagnoses – explains the “why”, and leaves psychiatry particularly vulnerable to abuse. Elsewhere, the need to address past abuses of psychiatry was argued to require a satisfactory definition of ‘mental disorder’ (Wakefield 1992). Antipsychiatrists did not agree with this diagnosis. Following Thomas Szasz’s seminal argument that mental illness is a ‘myth’, the conceptual foundation of psychiatry has been strenuously disputed. Conceptual issues were not, for Szasz, the root of abuses, but rather legitimised them:
[W]hile de jure, the mental hospital system functions as an arm of the medical profession, de facto, it functions as an arm of the state’s law-enforcement system. The practices thus authorized do not represent the abuses of psychiatry; on the contrary, they represent the proper uses of psychiatry, sanctioned by tradition, science, medicine, law, custom, and common sense. (Szasz 2000, 11-12)
This is an articulation of the concern, or allegation, to which Criterion E responds. In the past, the scholarly defence has been to argue, in various ways, that psychiatry is in fact able to recognise and define its proper domain, thus the question of what is a mental disorder is central to the debate. Criterion E offers both an official recognition of the dangers of pathologisation and an apparent conceptual safeguard. This paper does not further rehearse the debate about the need for such a safeguard, but explores whether Criterion E is able to fulfil this role. Thus our contribution is to update the debate in the light of recent work on concepts of health and illness, to try to make the distinction between social deviance and mental disorder using DSM-5, and to provide an original analysis of the social origins of some forms of distress in the light of these considerations.[i]
In order to explore what criterion E entails we revert to the full definition provided in the now published DSM-5: “Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual” (emphasis added). [ii] This is almost identical to the definition provided in the DSM-IV. Thus formulated, as Stein and colleagues (2010, 1765) note in relation to the DSM-IV, criterion E is not “strictly necessary” as the prior specification (criterion ‘D’) that the condition or syndrome must be due to a dysfunction in the individual suffices. However, given the aforementioned importance of guarding against misuse of psychiatry for political or other discriminatory purposes and the difficulty in indicating appropriate use of the term ‘dysfunction’, Stein and colleagues chose to retain criterion E in simplified form. Conceptually, then, if a dysfunction can be identified then a mental disorder can be said to be present if the other criteria are also fulfilled. The safeguard against pathologising social deviance is accordingly the identification of dysfunction in the individual. Thus although presented as a criterion required by the conceptual and empirical difficulties inherent in defining and identifying dysfunction, to do any work criterion E in fact depends on the ability to define and identify dysfunction.
This article proceeds as follows: First, we identify some relevant meanings of ‘dysfunction’ with a particular focus on dysfunction understood in terms of the consequences of a syndrome: distress and disability. Second, we examine the implications for criterion E of understanding dysfunction in those terms. We argue that distinguishing social deviance from mental disorder now requires that a distinction is drawn between phenomena in which distress is an outcome of social conflict and discrimination and phenomena in which distress is intrinsic to the condition. Third, we explore different meanings of ‘intrinsic’ distress. We point out the difficulty in providing a positive definition and focus thus on what ‘intrinsic’ is not rather than on what it is. We propose that an alternative to distress being intrinsic to a condition is for such states to be constituted by social factors. What does it mean for distress to be constituted by social factors? To answer this question we explore the difference between factors that may cause a distressing state and factors that constitute that state. We argue that psychological states that are socially constituted – that is, are created and sustained by social factors – are excluded by criterion E from candidacy for mental disorder. Fourth, we provide an account of distress with the conditions of most relevance to the distinction between social deviance and mental disorder, pointing out in what ways distress may be understood as socially constituted. Fifth, and finally, we present some clarifications and outline some implications of this view. This article considers only Criterion E, and not the other criteria for a mental disorder as listed above. Thus, a condition that is argued to meet Criterion E may yet fail the other criteria and therefore not be considered a mental disorder under the DSM definition, despite meeting the final criterion.
As indicated in the introduction, to do any work criterion E depends on defining and identifying dysfunction. A reasonable starting point, then, would be to attempt to specify the meaning of the term ‘dysfunction’. One prominent strategy has been to seek a definition of dysfunction in naturalistic terms. The most widely debated and influential has been Jerome Wakefield’s evolutionary theoretic approach (1999, 1997). According to Wakefield, a dysfunction is a result of some mechanism failing to perform its natural function as designed (selected) by evolution (i.e. the function that can explain why the mechanism or organ exists and why it is designed the way it is). Wakefield’s account has been criticised as highly speculative and lacking in clinical utility. Further, it appears to rely on the questionable assumption “that there is a clear (enough) division between psychological functioning that is natural (evolved and innate), as opposed to social (cultivated)” (Bolton 2008, 124). In the absence of a clear division, Wakefield’s dysfunction cannot tag exclusively onto a fact of nature, precisely because psychological function is the product of “several interweaving” natural, social, and individual factors which are not separable through the science we currently possess (Bolton 2010, 329-331).
Problems with Wakefield’s account and with naturalism more generally have prompted alternative strategies to understand dysfunction.[iii] Thus, Bolton argues, if we abandon naturalism about illness, “if we give up trying to conceptually locate a natural fact of the matter that underlies illness attribution – then we are left trying to make the whole story run on the basis of something like ‘distress and impairment of functioning’” (2010, 332). Stein and colleagues note that an alternative to naturalism is to understand ‘dysfunction’ in terms of the “consequences of the syndrome, specifically that it leads to or is associated with distress and disability” (2010, 1763, emphasis added). The move from ‘naturalism about illness’ to ‘distress and disability as the mark of illness’ is a reversal of the priority of dysfunction from being antecedent to the syndrome to being a manifestation, or consequence, of it. For example, what marks out a syndrome like depression as illness is not some underlying and invariant psychological or biological mechanism(s) but the subjective experience of distress and the extent of impairment of the person’s day to day functioning. This is consistent with the syndrome being caused or constituted by biological factors: this reversal does not entail the denial of biology. What it indicates is that illness attributions, conceptually, cannot be made on the basis of an antecedent natural fact, but on the basis of the consequences of the syndrome as they manifest for the subject. This raises a further complexity in terms of which kinds of distress are to be conceived as illness as opposed to a normal response to the vicissitudes of life. We leave this complexity aside and stay with the original point: to do any work criterion E depends on defining and identifying dysfunction. Now that ‘dysfunction’ is understood in terms of the consequences of the syndrome, viz. distress and disability, could it be claimed that the identification of distress and disability is sufficient ground to diagnose mental disorder irrespective of social deviance or conflict? The answer to this question clearly is no. The reason is that distress and disability may be an outcome of social deviance and conflict, while they also may not. If we wish to ensure that diagnosis is not inappropriately applied to individuals whose suffering can, in some relevant and significant sense, be understood as a consequence or expression of conflict with society, then it becomes necessary to draw this distinction.
[i] A reviewer for this paper had made the important point that the distinction between mental disorder and social deviance is itself a cultural construction with a long history. This suggests that there is scope to deconstruct the distinction. While clearly an interesting project in its own right, our concerns here are more limited to exploring whether – through criterion E – the distinction can be made. We thus assume that there is something called mental disorder or mental health problem (definitions of which are subject to much debate), and something called social deviance (which has nothing directly to do with mental disorder). We further assume that this is an important distinction to make. [ii] DSM-5. The definition of Criterion E in the DSM-IV: “neither deviant behaviour (e.g. political, religious or sexual) nor conﬂicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual” (APA 2000, p. xxxi). [iii] See Bolton (2008, 2013) and Kingma (2013) for review and critical assessment of the various attempts to define dysfunction in naturalistic terms.