One approach that has tried to define mental disorder is called "natural function objectivism." According to natural function objectivism, it is possible to base the demarcation between normal and pathological mental states using a theory of natural normal function. Although promising, this approach has faced decisive criticisms forcing the search for alternative theories. In this article, I want to argue that there is still hope for a definition of mental disorder based on the criterion of dysfunction if we rethink the value-freedom ideal usually associated with this notion. One theory of function that has received little attention in the debate about the definition of mental disorder is the causal role approach to function (CR), initially developed by Robert Cummins. CR has usually been rejected as the right theory of function to define mental disorder using a "dysfunction clause." This is because it was considered too dependent on human interests. In this article, I want to defend that CR should be amended rather than rejected. More precisely, my claim is that CR's relativity to human interests should be constrained rather than the whole theory dropped. My aim is to provide a framework for thinking about a notion of dysfunction that is both value-laden and sufficiently objective to provide a basis for distinguishing between healthy and pathological mental conditions, using Alexandrova's account of "social objectivity."
For several decades, philosophers of medicine and psychiatry sought to clarify the boundaries of illness by defining a scientific concept of disorder. This project, which has come to be known as naturalism, has met with considerable difficulties that cast doubt on its approach and presuppositions. The difficulties met in arriving at a naturalistic definition of disorder suggest the need for an alternative approach to the boundary problem. Prompted by engagement with the philosophy of social recognition and with recent developments in mental health activism this article provides a new approach to the boundary problem. This approach does not operate with the customary concepts of disorder, disease, distress, and dysfunction but with a different set of concepts that bring forth their own boundary conditions and judgments: The concepts of social recognition, social and individual identity, and unity and continuity of self. On the basis of the proposed approach, clarifying the boundary problem is not to be achieved by getting a handle on the definition and limits of the concept of mental disorder, but on understanding the addressees and normative limits of recognition and what this means for a wide range of mental health phenomena.
A Universal Definition of Mental Disorder:Neither Necessary nor Desirable G. Scott Waterman (bio) Psychiatry's relation to the rest of medicine is ambivalent. Its legitimacy as a specialty is often conceived as being closely linked to its fidelity to the fundamental paradigms of medicine, especially the centrality of diagnosis and the association of diagnosis with treatment indications. However, as Gagné-Julien notes, a major impetus behind the quest for a solution to the demarcation (i.e., disorder vs. not-disorder) problem in psychiatry is "growing concerns regarding over-medicalization" (Gagné-Julien, 2021, p. 353). Although it could appear that these two considerations point in opposite directions, both arguably would be served by what Gagné-Julien labels "a satisfying definition" of mental disorder. Such a definition would, the conventional thinking goes, rely on the notion of function/dysfunction while minimizing, if not eliminating, the role of values in distinguishing disorder from normality. It would, thereby, purportedly be more like diagnosis in the rest of medicine and reduce the risk of labeling as pathological phenomena that are merely socially disvalued. Gagné-Julien reviews the two most prominent representatives of what Varga has dubbed "natural function objectivism" (Varga, 2011): Boorse's biostatistical theory and Wakefield's harmful dysfunction analysis (HDA). Agreeing with several previous commentators, she finds biostatistical theory wanting with respect to the traditional desideratum of being value-free, while HDA presents different shortcomings related to its apparent reliance on greater knowledge of human evolutionary history than is available to us. She nevertheless maintains optimism that a definition of mental disorder that relies on functional language can be salvaged. The road she travels to an account of mental disorder as dysfunction that is sufficiently objective, albeit still value-laden, is serpentine but well worth taking with her. It traverses Cummins' "causal role" theory of function in biology, which circumvents the primary objection to HDA. She concedes its inability to distinguish function from dysfunction in a way that is independent of human interests, but argues that augmentation of causal role theory with explicit acknowledgement of the values-dependent nature of all of science might yield a suitable framework within which to develop a satisfying definition of mental disorder. The details of how that can be accomplished are beyond the scope of her paper, but perhaps the most intriguing element of Gagné-Julien's prescription [End Page 377] for formulation of such a definition is her invocation of Alexandrova's work on "social objectivity," which, as a systematic and democratized approach to identifying and scrutinizing normative assumptions that might otherwise remain implicit and/or parochial, resonates with recent work in critical psychiatry (e.g., Lewis, 2008). As much as I agree with much of Gagné-Julien's argument, in the remainder of this commentary I wish to challenge a couple categories of assumptions that seem to underlie and motivate the development (and belief in the feasibility) of a definition of mental disorder founded on the notion of function/dysfunction. I will then use Gagné-Julien's recommendation of democratization of the process of definition formulation as a point of departure to suggest what might appear to be a radical solution, but one I believe to be conceptually defensible and pragmatically desirable. In the introduction to the article in which he coins the expression "natural function objectivism," Varga recites—as one of the motivations behind the effort, begun in the 1970s, of the American Psychiatric Association to define mental disorder—the Szaszian argument that the "problems in living" that constitute the subject matter of psychiatry are "really non-medical in nature" (Varga, 2011). The implied presupposition of an essentialist account of what distinguishes a medical disorder from a problem in living is Szasz's, not Varga's. More to the point, it is false—both with respect to the somatic vs. mental distinction with which Szasz was primarily concerned and with the disorder vs. not-disorder one that is the focus of the present discussion. Readers in my age bracket will attest that advertisers on the broadcast television shows we watch know their demographic, as evidenced by the high proportion of commercials for treatments of a range of maladies. In one of them...
Osborne P. Wiggins, Jr., PhD, 1943–2021 John Z. Sadler Click for larger view View full resolution Friends, family, and the Association of the Advancement of Philosophy and Psychiatry (AAPP) community mourn the death of Osborne "Ozzie" Wiggins this past May 18. In many ways, his story contributes a large portion to the founding of the AAPP, this journal, and the philosophy/psychiatry community worldwide. I met Professor Wiggins as a sophomore at Southern Methodist University in Dallas in 1974. I was a student in his twentieth-century humanities class. I didn't know at the time that he was in his early years as an academic, having recently obtained his PhD in philosophy from the New School for Social Research in New York. Moreover, I hadn't yet encountered a teacher who was so audacious as to tell his students on the first day of class: "This class will change the way you see the world." It didn't happen that day. However, I did view the world differently by the time the semester was over. In retrospect, Wiggins inculcated his students, and me, into what I later learned was the "phenomenological attitude" (Natanson, 1973). At the time, I would have described this change as the suspension of the impulse to judge my experiences, and instead, cultivate an attitude of ongoing openness to experience. I moved away from my adolescent critical attitude, and toward one informed by continuous curiosity, a contemplative stance where appraisals required no hurry, and the unfolding of experience was not just a way to knowledge and wisdom, but a source of joy and renewal. He was one of those professors you read about but seldom encounter, ones who "touch lives." I was a kid who knew his vocational path, however naively, from my teens. I sought out Wiggins because of his apparent interest in psychology and mental illness. He welcomed me into his office and I shared, tentatively, my belief that people with mental illness had "philosophical problems" and that philosophy was a way for people with mental illness to "figure out how to live." Rather [End Page 291] than the bemusement that I had feared, Professor Wiggins told me this made a lot of sense, and told me about his dissertation research at the New School, a phenomenological examination of the developmental psychology of Jean Piaget under his mentor's guidance, Aron Gurwitsch. Thus began a lifetime of mentorship, friendship, collaboration, and collegiality with me. In my meetings with Wiggins over my remaining years at SMU, he told me about his undergraduate years at Lamar State College where he initially majored in music performance. He was a promising bassist and jazz arranger/composer. However, he realized early that he did not have the "stuff" to succeed in the art/music world; he was already chagrined at Charles Mingus' extraordinary music, the brilliant corners of Thelonious Monk's compositions, and this new player with Chick Corea's band, Stanley Clarke, who had seemingly impossible technique on the double bass. Instead of music, Wiggins turned to philosophy. However, his aesthetic sense and skills were always sharp, and much of what I have learned about jazz I learned from Ozzie. We have shared this joy in music in general, and jazz in particular, over both our lifetimes. Years passed, and the next time Wiggins changed my life was when I was a freshly trained psychiatrist starting out my career in academic medicine. The year was 1986, and I was busy earning my keep as an medical educator, a consultation–liaison psychiatrist, and maintaining a small outpatient practice. Since college, my academic dream had been to explore the relationships between philosophy and psychiatry, but in the hurly-burly of my new career, I was discouraged. I had no colleagues, no community, and few prospects. Then that October, the cover article of the "green journal," The American Journal of Psychiatry, was an article by Michael Alan Schwartz and Osborne P. Wiggins, with a convoluted but intriguing title (Schwartz & Wiggins, 1986a). The bald fact that the top journal in American psychiatry was publishing a philosophical article hit me like a bucketful of cold water. I remember telling myself "it...
There is still a good deal of disagreement about which conditions should be viewed as psychiatric disorders. In the third and fourth editions of the Diagnostic and Statistical Manual of Mental Disorders, the "bereavement exclusion" distinguished symptoms of non-disordered grief from major depressive disorder, because treating "normal" grief medically was considered inappropriate. In DSM-5, this "bereavement exclusion" was removed, on the grounds that symptoms of grief reaching the intensity and duration of symptoms of major depressive disorder should be treated as "complicated" grief in order to alleviate suffering. This removal was controversial. What was at stake in this change was whether it is better to err in the direction of undertreating or overtreating those with distressing grief. A widespread underlying assumption-on all sides of the controversy-is that normal reactions to major losses should not be classified as psychiatric disorders. I challenge this assumption. This article proposes including a new concept of psychological injury in the broader concept of psychiatric disorder. Psychological injury, like physical injury, can evoke a normal response that calls for clinical attention. When major losses (such as bereavement) are conceptualized as psychological injuries, treatment eligibility can be assured without classifying the patient's reactions to loss as pathological or abnormal. The word "pathological," with its evocations of nineteenth century microscopy, is unhelpful in this psychiatric context. The word "abnormal" is also best avoided here because of its associations with normative judgments. The word "disorder" serves a useful and less stigmatizing role that should not be identified with the terms "pathology" or "abnormality."
