The Identity of Psychiatry in the Aftermath of Mad Activism

[Introduction to an essay I am working on for a special issue of the Journal of Medicine & Philosophy with the title ‘The Crisis in Psychiatric Science’]

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THE IDENTITY OF PSYCHIATRY IN THE AFTERMATH OF MAD ACTIVISM

  1. INTRODUCTION

 Psychiatry has an identity in the sense that it is constituted by certain understandings of what it is and what it is for. The key element in this identity, and the element from where other features arise, is that psychiatry is a medical speciality. Upon completion of their medical education and during the early years of their training, medical students – now budding doctors – make a choice about the speciality they want to pursue. Psychiatry is one of them, and so is ophthalmology, cardiology, gynaecology, and paediatrics. Modern medical specialities share some fundamental features: they treat conditions, disorders, or diseases; they aspire to be evidence-based in the care and treatments they offer; they are grounded in basic sciences such as physiology, anatomy, histology, and biochemistry; and they employ technology in investigations, research, and development of treatments. All of this ought to occur (and in the best of cases does occur) in a holistic manner, taking account of the whole person and not just of an isolated organ or a system; i.e. person-centred medicine (e.g. Cox, Campbell, and Fulford 2007). In addition, it is increasingly recognised that the arts and humanities have a role to play in medical education, training, and practice. Literature, theatre, film, history, and the various arts, it is argued, can help develop the capacity for good judgement, and can broaden the ability of clinicians to understand and empathise with patients (e.g. Cook 2010, McManus 1995). None of the above, I will assume in this essay, is particularly controversial.

Even though psychiatry is a medical speciality, it is a special medical speciality. This arises from its subject matter, ordinarily conceived of as mental health conditions or disorders, to be contrasted with physical health conditions or disorders. Psychiatry deals with the mind not working as it should while ophthalmology, for example, deals with the ophthalmic system not working as it should. The nature of its subject matter raises certain complexities for psychiatry that, in extreme, are sometimes taken to suggest that psychiatry’s positioning as a medical speciality is suspect; these include the normative nature of psychiatric judgements, the explanatory limitations of psychiatric theories, and the classificatory inaccuracies that beset the discipline.[1] Another challenge to psychiatry’s identity as a medical speciality comes from particular approaches in mental health activism. Mad Pride and mad-positive activism (henceforth Mad activism) rejects the language of ‘mental illness’ and ‘mental disorder’, and rejects the assumption that people have a ‘condition’ that is the subject of treatment. The idea that medicine treats ‘things’ that people ‘have’ is fundamental to medical practice and theory and hence is fundamental to psychiatry in so far as it wishes to continue understanding itself as a branch of medicine. Mad activism, therefore, challenges psychiatry’s identity as a medical speciality.

In this essay, I argue that among these four challenges, only the fourth requires of psychiatry to rethink its identity. By contrast, as I demonstrate in section 2, neither the normative, nor the explanatory, or the classificatory complexities undermine psychiatry’s identity as a medical speciality. This is primarily for the reason that the aforementioned complexities obtain in medicine as a whole, and are not unique to psychiatry even if they are more common and intractable. On the other hand, the challenge of Mad activism is a serious problem. In order to understand what the challenge amounts to, I develop in section 3 the notion of the hypostatic abstraction, a logical and semantic operation which I consider to lie at the heart of medical practice and theory. It distinguishes medicine from other social institutions concerned with human suffering such as religious and some therapeutic institutions. In section 4 I demonstrate how Mad activism challenges the hypostatic abstraction. And in section 5 I discuss a range of ways in which psychiatry can respond to this challenge, and the modifications to its identity that may be necessary.

[1] These are not the only complexities; there are, for example, well-known difficulties and controversies surrounding the efficacy and risks of anti-depressant and anti-psychotic medication. In addition, psychiatry faces distinctive ethical complexities arising from the fact that mental health patients can be particularly vulnerable which raises questions of capacity not ordinarily raised in other medical specialities (see Radden and Sadler 2010).

 

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Madness & the Demand for Recognition

After more than three and a half years of (almost) continuous work, I have finally completed my book Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism.

You can find the table of contents, foreword, preface, and introduction: HERE

 

Contemporary developments in mental health activism pose a radical challenge to psychiatric and societal understandings of madness. Mad Pride and mad-positive activism reject the language of mental illness and mental disorder, reclaim the term ‘mad’, and reverse its negative connotations. Not content with reform of psychiatry, activists seek cultural change in the way madness is viewed, and demand recognition of madness as grounds for identity. But can madness constitute such grounds? Is it possible to reconcile delusions, passivity phenomena, and the discontinuity of self often seen in certain mental health conditions with the requirements for identity formation presupposed by the theory of recognition? And, in any case, why does recognition matter, and how should society respond to such demands? Guided by these questions, this book is the first comprehensive philosophical examination of the claims and demands of Mad activism. Locating itself in the philosophy of psychiatry, Mad studies, and activist literatures, and in the tradition of philosophical thought on recognition, freedom, and identity that finds its sources in the work of Georg Hegel and Immanuel Kant, and continues in the present day through the work of Charles Taylor, Axel Honneth, Nancy Fraser, Kwame Appiah, and Richard Rorty, the book develops a rich theoretical framework for understanding, justifying, and responding to Mad activism’s demand for recognition.

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The Meaning of Madness

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Excerpt from Chapter 1 of my book “Madness and the Demand for Recognition”. Forthcoming with Oxford University Press, 2018

Mad with a capital m refers to one way in which an individual can identify, and in this respect it stands similar to other social identities such as Maori, African-Caribbean, or Deaf. If someone asks why a person identifies as Mad or as Maori, the simplest answer that can be offered is to state that he identifies so because he is mad or Maori. And if this answer is to be anything more than a tautology – he identifies as Mad because he identifies as Mad – the is must refer to something over and above that person’s identification; i.e. to that person’s ‘madness’ or ‘Maoriness’. Such an answer has the implication that if one is considered to be Maori yet identifies as Anglo-Saxon – or white and identifies as Black – they would be wrong in a fundamental way about their own nature. And this final word – nature – is precisely the difficulty with this way of talking, and underpins the criticism that such a take on identity is ‘essentialist’.

Essentialism, in philosophy, is the idea that some objects may have essential properties, which are properties without which the object would not be what it is; for example, it is an essential property of a planet that it orbits around a star. In social and political discussions, essentialism means something somewhat wider: it is invoked as a criticism of the claim that one’s identity falls back on immutable, given, ‘natural’ features that incline one – and the group with which one shares those features – to behave in certain ways, and to have certain predispositions. The critique of certain discourses as essentialist has been made in several domains including race and queer studies, and in feminist theory; as Heyes (2000, p. 21) points out, contemporary North American feminist theory now takes it as a given that to refer to “women’s experience” is merely to engage in an essentialist generalisation from what is actually the experience of “middle-class white feminists”. The problem seems to be the construction of a category – ‘women’ or ‘black’ or ‘mad’ – all members of which supposedly share something deep that is part of their nature: being female, being a certain race, being mad. In terms of the categories, there appears to be no basis for supposing either gender essentialism (the claim that women, in virtue of being women, have a shared and distinctive experience of the world: see Stone (2004) for an overview), or the existence of discrete races (e.g. Appiah 1994a, pp. 98-101), or a discrete category of experience and behaviour that we can refer to as ‘madness’ (or ‘schizophrenia’ or any other psychiatric condition for this purpose). Evidence for the latter claim is growing rapidly as the following overview indicates.

There is a body of literature in philosophy and psychiatry that critiques essentialist thinking about ‘mental disorder’, usually by rebutting the claim that psychiatric categories can be natural kinds (see Zachar 2015, 2000; Haslam 2002; Cooper 2013 is more optimistic). A ‘natural kind’ is a philosophical concept which refers to entities that exist in nature and are categorically distinct from each other. The observable features of a natural kind arise from its internal structure which also is the condition for membership of the kind. For example, any compound that has two molecules of hydrogen and one molecule of oxygen is water, irrespective of its observable features (which in the case of H2O can be ice, liquid, or gas). Natural kind thinking informs typical scientific and medical approaches to mental disorder, evident in the following assumptions (see Haslam 2000, pp. 1033-1034): (1) different disorders are categorically distinct from each other (schizophrenia is one thing, bipolar disorder another); (2) you either have a disorder or not – a disorder is a discrete category; (3) the observable features of a disorder (symptoms and signs) are causally produced by its internal structure (underlying abnormalities); (4) diagnosis is a determination of the kind (the disorder) which the individual instantiates.

If this picture of strong essentialism appears as a straw-man it is because thinking about mental disorder has moved on or is in the process of doing so. All of the assumptions listed here have been challenged (see Zachar 2015): in many cases it’s not possible to draw categorical distinctions between one disorder and another, and between disorder and its absence; fuzzy boundaries predominate. Symptoms of schizophrenia and of bipolar disorder overlap, necessitating awkward constructions such as schizoaffective disorder or mania with psychotic symptoms. Similarly, the boundary between clinical depression and intense grief has been critiqued as indeterminate. In addition, the reductive causal picture implied by the natural kind view seems naive in the case of mental disorder: it is now a truism that what we call psychiatric symptoms are the product of multiple interacting factors (biological, social, cultural, psychological). And diagnosis is not a process of matching the patient’s report with an existing category, but a complicated interaction between two parties in which one side – the clinician – constantly reinterprets what the patient is saying in the language of psychiatry, a process which the activist literature has repeatedly pointed out permits the exercise of power over the patient.

The difficulties in demarcating health from disorder and disorders from each other have been debated recently under the concept of ‘vagueness’; the idea that psychiatric concepts and classifications are imprecise with no sharp distinctions possible between those phenomena to which they apply and those to which they do not (Keil, Keuck, and Hauswald 2017). Vagueness in psychiatry does not automatically eliminate the quest for more precision – it may be the case, for example, that we need to improve our science – but it does strongly suggest a formulation of states of health and forms of experience in terms of degrees rather than categorically, i.e. a gradualist approach to mental health. Gradualism is one possible implication of vagueness, and there is good evidence to support it as a thesis. For example, Sullivan-Bissett and colleagues (2017) have convincingly argued that delusional and non-delusional beliefs differ in degree, not kind: non-delusional beliefs exhibit the same epistemic short-comings attributed to delusions: resistance to counterevidence, resistance to abandoning the belief, and the influence of biases and motivational factors on belief formation. Similarly, as pointed out earlier, the distinction between normal sadness and clinical depression is difficult to make on principled grounds, and relies on an arbitrary specification of the number of weeks during which a person can feel low in mood before a diagnosis can be given (see Horwitz and Wakefield 2007). Another related problem is the non-specificity of symptoms: auditory hallucinations, thought insertion, and other passivity phenomena which are considered pathognomonic of schizophrenia, can be found in the non-patient population as well as other conditions (e.g. Jackson 2007).

Vagueness in mental health concepts and gradualism with regards to psychological phenomena undermine the idea that there are discrete categories underpinned by an underlying essence and that go with labels such as schizophrenia, bipolar disorder, or madness. But people continue to identify as Women, African-American, Maori, Gay, and Mad. Are they wrong to do so? To say they are wrong is to mistake the nature of social identities. To prefigure a discussion that will occupy a major part of Chapters 4 and 5, identity is a person’s understanding of who he or she is, and that understanding always appeals to existing collective categories: to identify is to place oneself in some sort of relation to those categories. To identify as Mad is to place oneself in some sort of relation to madness; to identify as Maori is to place oneself in some sort of relation to Maori culture. Now those categories may not be essential in the sense of falling back on some immutable principle, but they are nevertheless out there in the social world and their meaning and continued existence does not depend on one person rejecting them (nor can one person alone maintain a social category even if he or she can play a major role in conceiving it). Being social in nature they are open to redefinition, hence collective activism to reclaim certain categories and redefine them in positive ways. In fact, the argument that a particular category has fuzzy boundaries and is not underpinned by an essence may enter into its redefinition. But demonstrating this cannot be expected to eliminate people’s identification with that category: the inessentiality of race, to give an example, is not going to be sufficient by itself to end people’s identification as White or Black.

In the context of activism, to identify as Mad is to have a stake in how madness is defined, and the key issue becomes the meaning of madness. To illustrate the range of ways in which madness has been defined, I appeal to some key views that have been voiced in a recent, important anthology: Mad Matters: A Critical Reader in Canadian Mad Studies (2013). A key point to begin with is that Mad identity tends to be anchored in experiences of mistreatment and labelling by others. By Mad, Poole and Ward (2013, p. 96) write, “we are referring to a term reclaimed by those who have been pathologised/ psychiatrised as ‘mentally ill,'”. Similarly, Fabris (2013, p. 139) proposes Mad “to mean the group of us considered crazy or deemed ill by sanists … and are politically conscious of this”. These definitions remind us that a group frequently comes into being when certain individuals experience discrimination or oppression that is then attributed by them as arising from some features that they share, no matter how loosely. Those features have come to define the social category of madness. Menzies, LeFrancois, and Reaume (2013, p. 10) write:

Once a reviled term that signalled the worst kinds of bigotry and abuse, madness has come to represent a critical alternative to ‘mental illness’ or ‘disorder’ as a way of naming and responding to emotional, spiritual, and neuro-diversity. … Following other social movements including queer, black, and fat activism, madness talk and text invert the language of oppression, reclaiming disparaged identities and restoring dignity and pride to difference.

In a similar fashion, Liegghio (2013, p. 122) writes:

madness refers to a range of experiences – thoughts, moods, behaviours – that are different from and challenge, resist, or do not conform to dominant, psychiatric constructions of ‘normal’ versus ‘disordered’ or ‘ill’ mental health. Rather than adopting dominant psy constructions of mental health as a negative condition to alter, control, or repair, I view madness as a social category among other categories like race, class, gender, sexuality, age, or ability that define our identities and experiences.

Mad activism may start with shared experiences of oppression, stigma and mistreatment, it continues with the rejection of biomedical language and reclamation of the term mad, and then proceeds by developing positive content to madness and hence to Mad identity. As Burstow (2013, p. 84) comments:

 What the community is doing is essentially turning these words around, using them to connote, alternately, cultural difference, alternate ways of thinking and processing, wisdom that speaks a truth not recognised …, the creative subterranean that figures in all of our minds. In reclaiming them, the community is affirming psychic diversity and repositioning ‘madness’ as a quality to embrace; hence the frequency with which the word ‘Mad’ and ‘pride’ are associated.

In Defence of Madness: The Problem of Disability

My essay, about to be published in the Journal of Medicine & Philosophy.

I write defending mad positive approaches against the tendency to adopt a medical view of the limitations associated with madness. Unlike most debates that deal with similar issues – for example the debate between critical psychiatrists and biological psychiatrists, or between proponents of the social model of disability versus those who endorse the medical model of disability – my essay is not a polemical adoption of one or other side, but a philosophical examination of how we can talk about disability in general, and madness in particular.

You can read the essay here: IN DEFENCE OF MADNESS

And here is the abstract: At a time when different groups in society are achieving notable gains in respect and rights, activists in mental health and proponents of mad positive approaches, such as Mad Pride, are coming up against considerable challenges. A particular issue is the commonly held view that madness is inherently disabling and cannot form the grounds for identity or culture. This paper responds to the challenge by developing two bulwarks against the tendency to assume too readily the view that madness is inherently disabling: the first arises from the normative nature of disability judgements, and the second from the implications of political activism in terms of being a social subject. In the process of arguing for these two bulwarks, the paper explores the basic structure of the social model of disability in the context of debates on naturalism and normativism; the applicability of the social model to madness; and the difference between physical and mental disabilities in terms of the unintelligibility often attributed to the latter

Can Psychiatry Distinguish Social Deviance from Mental Disorder?

[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:

  1. A behavioural or psychological syndrome or pattern that occurs in an individual
  2. 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).
  3. 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)
  4. that reflects an underlying psychobiological dysfunction
  5. 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.

DYSFUNCTION

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.