Should medical humanities lie in an instrumental relation to medicine, assisting healthcare practitioners to conduct their work in more humane ways? Or should it understand itself as an independent research discipline that can critique medicine without the burden of instrumentality to the aims of medical practice? Medical humanities scholarship has offered a lively debate on this issue, which continues to this day. This article examines a recent contribution to this debate: Critical Medical Humanities. This approach is sceptical of the paradigm of instrumentality, proposing instead to reinvigorate radical strands from the history of medical humanities towards a truly independent transdisciplinary approach. However, Critical Medical Humanities faces a range of epistemological, political, and methodological problems that arise from a lack of sufficient constraint by the point of view of agents engaged in the medical pathway (such as doctors and patients). This renders the Critical Medical Humanities analysis epistemologically incomplete and ethically/politically problematic, the latter since it can constitute misrecognition of the agents' points of view. Towards a solution, the article offers a methodology, a dialectics of change, that can engage radical medical humanities analysis while negotiating recognition and influencing practice.

Debates on the distinction between religious experience and mental disorder tend to assume, rather than argue for, the existence of unique types of experience: the religious and the psychopathological. This paper interrogates this approach to the problem. It deconstructs the distinction by examining what the distinction is about beyond the terms in which it is presented and whether it matters who is trying to make it. A key idea is that one’s standpoint in the debate—that is, whether one adopts a religious or a secular standpoint—determines what they can say about the distinction. This leads to the central argument of the first part of the paper: The distinction between religious experience and mental disorder can only be invoked from a secular standpoint but can only be clarified from a religious standpoint. In other words, if you have the grounds to invoke it, you cannot have the tools to clarify it; and if you have the tools to clarify it, you do not have the grounds to invoke it. In the second part, the paper follows through the implications, from a secular standpoint, of accepting this argument. It appeals to the politics of difference and to mental health activism to argue against the binary view whereby mental distress is either illness and incapacity or a path to purpose and identity.

Are Mental Health "Peer Support Workers" Experts by Experience? The author reports no conflict of interests. In this well-argued paper, Dr. Abdi Sanati asks whether a person's experience of mental illness could be the basis for professional expertise and concludes that, "on its own," it cannot be. Elsewhere he states that "the different forms of knowledge that are required for expertise … could not be produced solely on the basis of personal experience" (Sanati, 2024, 107). The qualifications "on its own" and "solely" suggest that personal experience of mental illness could be the basis for professional expertise if other conditions are also met. What are these conditions, and can they be met? Gratefully, Sanati provides an excellent exposition of a concept of expertise and the conditions that are required for satisfying it. Expertise needs to be thought of as a "form of life" that requires more than the accumulation of knowledge and cannot happen in isolation. To become an expert, you need to be part of a community through which you can acquire factual knowledge (knowledge-that) and acquire the practical capacities and dispositions (knowledge-how) that enable you to conduct actions related to your area of expertise. With training over time, experts develop tacit knowledge that enables them to "ap ply background theories to new cases," which is why an expert is able to deal with a multitude of cases that appear different from each other. Experts should be able to hold a relatively cohesive view of their subject matter and see how it all 'holds together'. The importance of community for the possibility of becoming an expert is further emphasized by Sanati's appeal to Wittgenstein's Private-Language Argument. A 'private language,' if such a thing were to exist, is a language that enables the person to express mental states with reference only to what is occurring in the speaker's mind and known through introspection. This language, in being private, makes sense only to the speaker and is not comprehensible to others. Introspection allows privileged access to my mental states, which thus become a unique source of knowledge available only to me. And the argument against such a private language is that it is impossible, for in being unintelligible to others, it becomes nonsensical as such. The reasons behind this have to do with the nature of language as a rule-based activity that requires intersubjective agreement, engaging in which is to partake in a form-of-life. [End Page 113] Putting aside the details of the Private-Language Argument, I am interested in the conclusion that Sanati draws from it. He starts by pointing out that what is taken as the basis for expertise-by-experience is the supposed privileged access to one's mental states that leads to a unique form of knowledge. It is this knowledge that underlies the claim to expertise. Sanati's view is that one cannot acquire a kind of knowledge completely inaccessible to others yet expressed in language as this would amount to use of a private language, which is impossible. And so, the person is either expressing nonsense or is merely using shared language. If the latter, then the alleged uniqueness of the experience is lost as it has been brought under a rule-based form of life. Sanati seems to imply that experience can only constitute a unique form of knowledge if it arises from a single mind through introspection and use of a private language. Given that this is not possible, the experience can no longer be unique. But I do not see why it cannot be a form of knowledge which, while not being unique to a single individual, is still an expression of human experience that only a proportion of the population go through, the proportion who are diagnosed with a certain mental health condition. In other words, a form of knowledge does not to have to be unique to be distinct, and if it is distinct then perhaps it can constitute the basis for expertise if other conditions are also met. In fact, this is suggested by Sanati's conclusion when he writes: "for the community of experts to exist there...

AbstractAmong the different approaches in mental health activism, there is an ongoing concern with the concepts and meanings that should be brought to bear upon mental health phenomena. Aspects of Mad Pride activism resist the medicalisation of madness, and seek to introduce new, non-pathologizing narratives of psychological, emotional, and experiential states. This essay proposes a view of Mad Pride activism as engaged in no less than the creation of a new culture of madness. The revisioning and revaluing of madness requires transformations in the basic concepts constitutive of current mental health narratives. This process is illustrated with the concept of self and its relation to passivity phenomena (thought insertion). The essay concludes with some of the challenges facing Mad Pride's ambition to enrich the cultural repertoire.

The 'Power Threat Meaning Framework'Yet Another Master Narrative? Mohammed Abouelleil Rashed, PhD (bio) Proposing narratives that reflect our values and address what we believe to be, and what in fact in this case are, valid concerns is no doubt an attractive venture. But good intentions are not enough, and often it is careful analysis that shows why this is the case. Alastair Morgan's (2023) essay Power, Threat, Meaning Framework: A Philosophical Critique is a bright example of philosophy-in-action; it demonstrates, to use a popular expression, that the road to hell is paved with good intentions. In this commentary I argue that while the concerns of the authors of the Power Threat Meaning Framework (PTMF) are valid, their proposed solutions lead us to yet another master narrative. The PTMF presents itself as an alternative to psychiatric diagnosis (Johnstone & Boyle, 2018). The conceptual, scientific, and anthropological limitations of psychiatric diagnoses have been identified and debated for several decades. Conceptually, there remain difficulties in drawing clear boundaries that separate mental disorder from its absence. Scientifically, the search for discrete biomarkers for particular conditions has proved elusive, with continuing reliance on phenomeno logical classifications, and ongoing complaints that psychiatric categories lack validity. Anthropologically, while mental distress and related forms of experience occur in all communities around the world, existing classifications reflect the cultural psychologies and conceptions of the person of their societies of origin in North Europe and North America. Authors of the PTMF document discuss and cite aspects of these critiques in their document. They intend for the PTMF to address some of these shortcomings and in this way to provide a better way of understanding and managing mental health difficulties. In this commentary, I shall focus on one aspect of the PTMF, which is the narrative aspect, i.e., the PTMF as a story we can tell about mental health difficulties. Authors of the document foreground this narrative aspect and dedicate ample space to it. The authors, and rightly so, take issue with the implications of diagnostic narratives on the meaning and intelligibility of mental health phenomena: psychiatric diagnoses change what people feel and do into something they have (e.g., 'schizophrenia') or are (e.g., a damaged or defective kind of personality.) Diagnosis can also remove meaning [End Page 69] and intelligibility from thoughts, feelings and actions. (2018, p. 29) Further on in the document the authors point out, again correctly, that diagnosis is itself a kind of meaning, although an exclusionary one: Diagnosis is not a description on which a range of narratives can easily be built. Rather, diagnosis itself incorporates a powerful narrative about the nature and causes of troubling experiences and behavior, about the kinds of patterns to be found amongst them. (2018, p. 90) So, the concern is not that diagnosis removes meaning entirely but that it offers one specific and rather narrow perspective grounded in ideas such as incapacity, illness, and psychological and biological dysfunction. This perspective can result in loss of agency and diminished possibilities for self-understanding and so can be both disempowering and reductive (ibid.). Accordingly, diagnosis cannot always do justice either to the phenomenon itself or to how people experience it and the sort of meanings they are inclined to draw from it. It cannot do justice, that is, to people's own constructions of what they are going through, a point most acutely felt with the conditions known as 'schizophrenia' and 'bipolar disorder.' Now, of course, in some cases people find agency and self-understanding through diagnosis, something we see today through the ascription of ADHD and Autism-spectrum diagnoses, among others. But in many cases diagnosis can be a hindrance to agency and self-understanding, a point repeatedly made by activists and service-users (see Rashed, 2019, Chapter 1, for a review). The PTMF critique of diagnostic narratives, in so far as meaning-making is concerned, can therefore be parsed out along two lines: 1) A critique of the content of diagnostic narratives. 2) A critique of the extent to which diagnostic narratives are open to modifications of their content to offer a reasonably flexible blueprint for people's experiences with the minimum amount of...

Recognition and Identity:Abstract Concepts, Concrete Struggles Mohammed Abouelleil Rashed (bio) What Is Meant by "The Scope of Recognition"? Political activity on the basis of a shared identity has been with us for several decades. Race, sexual orientation, gender, and myriad other categories form the center-of-gravity around which social groups demand recognition of the validity and value of their self-understandings. How should social and political institutions respond to these demands? In contemporary social and political philosophy much of the weight of answering this question has fallen on developing a theory of recognition. That theory would then perform several functions: It could provide an explanation as to the emergence and subsequent contestation of shared social norms; it could offer an account of the motivation that drives people to struggle for recognition; and it could provide normative resources for the justification and adjudication of demands for recognition. With such a theory at hand, we would possess a foundation from where we could deliberate as to the appropriate social or political response to a particular demand. But to engage in the sort of deliberations by which an identity claim can be offered an appropriate social or political response (whatever these turn out to be) is to presuppose that the claim can be considered in that way, that is, can be considered within the scope of recognition. In the original essay (Rashed, 2021), I theorize the limit (scope) of social recognition as it arises from consideration of the capacities presupposed by a theory of recognition: The capacity to determine the nature of the relation between one's subjective conviction and the social category with which one identifies; the capacity for diachronic unity of selfconception; and the capacity for synchronic unity of self-conception. A demand for recognition that satisfies these capacities can then be considered for questions such as: Should the meaning and range of [social identity] be modified to include this person/group within its boundaries? Is the social identity good/valuable as asserted by the recognizees? In my essay, the focus is not on these questions, but on what can be considered at all in their light. For this reason, the aim of the essay is at once modest and ambitious. It is modest in that it does not attempt an intervention in ongoing debates as to what social identities should (or should not) be recognized as valid and valuable. Yet it is ambitious precisely because it tries to establish some key distinctions in the boundary conditions of these debates. Every normative theory presupposes an [End Page 323] addressee, and this applies to Kantian theory and its derivatives, to neo-Aristotelianism (including the ethics of care), and—as I demonstrate in the essay—to the theory of recognition. These presuppositions exclude a wide range of phenomena of madness. In this context, Audra Goodnight's (2021, p. 319) formulation of the key proposal of my essay requires a slight, though crucial, adjustment; she writes: "[Rashed] proposes an alternative approach to the boundary problem by focusing on the identity claims that should be excluded from the scope of recognition". If I rewrite this, I would replace the "should be" with "are". We identify the boundary conditions that exclude madness from the scope of recognition not in order to fix them as normative gold standards to be applied to the world; we identify the boundary conditions in order to know just how we can go about modifying them toward a broader inclusivity of mental health phenomena. The 'Engine' for Social Change The foregoing philosophical and theoretical considerations aside, there are questions about recognition 'on the ground' highlighted by Goodnight's commentary. She asks how we can determine "the authoritative social group" that can bestow recognition upon the recognizees. In my essay I leave this determination intentionally obscure for two reasons: First, my focus is not on struggles for recognition as such but on the limits imposed by a particular theoretical version of recognition. Second, the nature of recognition, and of struggles toward it, belie the possibility of identifying relevant social groups from the comfort of our armchair, so to speak. Why...

Social deviance refers to actions or behaviours that violate social norms. Since the declassification of homosexuality and development of DSM-III, one of the aims of a definition of mental disorder has been to make explicit the distinction between mental disorder and social deviance. It is well-recognized that psychiatric disorders frequently manifest as violations of social norms, and the validity of the distinction between disorder and deviance has been of great interest to philosophers of psychiatry. This article provides an overview of some of the major conceptual strategies that have been discussed as a means of discriminating between mental disorder and social deviance, and the extent to which these strategies can be said to be philosophically successful. Specifically, we review DSM's definition of mental disorder, notions of dysfunctions (commonsensical, clinical, naturalist), intrinsic and socially constituted distress, disability, 3E perspectives and functional norms, and ethical and political approaches to this question. Current philosophical strategies don't offer a distinct dividing line between disorder and deviance, but they help illuminate the relevant considerations involved. It may be concluded that the distinction between disorder and deviance is not simply discovered but also negotiated between competing values.

Asking the Right Questions on Psychosis and Intelligibility Mohammed Abouelleil Rashed The challenge of understanding psychotic phenomena is one of the enduring problems in the philosophy of psychiatry. The first to formulate the problem in its philosophical dimension was Karl Jaspers in General Psycho-pathology (first edition, 1913). Jasper’s solution was rather pessimistic, for he argued that we cannot extend empathic understanding to certain phenomena, such as primary delusions. His work was followed by a long period of philosophical silence on the issue, and it was only three decades ago that philosophy began to engage once again with the problem of understanding. Today there is a rich literature that explores this problem: from philosophy of language to European phenomenology, and from theories of rationality to philosophy of action, researchers have left few philosophical stones unturned in their attempts to illuminate psychosis. Sofia Jeppsson’s eloquent essay Psychosis and Intelligibility belongs to this tradition of theorizing about psychosis. She guides us gently along the challenge of understanding unusual experiences and beliefs and, along the way, provides helpful definitions of the notion of intelligibility and convincing arguments for ‘intelligibility duties’: “we ought to try to understand others and try to see them as intelligible, as far as we can.” With a philosophical style that is at once conversational and precise, Jeppsson demonstrates how she made sense of her own lived experience through some of the philosophical concepts and theories that have been developed to render psychotic phenomena intelligible. From empiricist and rationalist accounts of delusions, from the concept of the bedrock, and from the reasoning traits amplified in psychosis, Jeppsson outlines an account of psychosis. The psychotic journey often involves a quest for understanding significant, yet strange, perceptual experiences amid severely challenged certainties. This quest, Jeppsson tell us, can end in the arrival to “the feeling of finally understanding what is going on … a theory that perfectly explains everything that was going on” When this occurs, “all the pieces of the puzzle slide into place,” no matter how idiosyncratic the finished picture might appear to others. This arrival is powerful and, indeed, personal. Jeppsson, a philosopher, found meaning in a range of philosophical concepts that afforded a meta-account of psychosis. That is how she rendered her experiences of psychosis intelligible to herself. And here we have the first question on psychosis and intelligibility and two possible ways of answering it: [End Page 255] Q1: How can I render my own psychotic experiences intelligible to me? a. Arrive at a ‘feeling of understanding’ (e.g., I finally understand that I am at the center of a global conspiracy—“it all makes sense now”). b. Arrive at a meta-account of psychosis (using concepts like the bedrock, feelings of significance, etc.). Question 1b—which is one of the questions that Jeppsson implicitly addresses in her essay—is not so much a personal account of the meaning of psychosis, as we find in Q1a, but a meta-account that moves away from individual meanings for the sake of a general interpretation. As a stance, Q1b is probably only possible with a degree of hindsight, perhaps when one is not in the immediate grips of psychosis. The second question that we could ask about psychosis and intelligibility goes like this: Q2: How can psychotic experiences be rendered intelligible to others who have not had them? How we go about answering this question depends on what exactly we are trying to render intelligible: a. What needs to be rendered intelligible is the psychotic worldview itself (as articulated in Q1a) b. What needs to be rendered intelligible is not the psychotic content, but the meta-account, or theory, of psychosis (as articulated in Q1b) Q2b is the second question that Jeppsson addresses in her essay—she is keen to illuminate theoretical constructs such as the ‘bedrock’ and ‘feelings of significance’ through psychotic and non-psychotic experiences. Jeppsson is therefore concerned with two things: with developing a meta-account of psychosis that accommodates her own experiences (Q1b), and with rendering this account intelligible to people who have not experienced psychosis (Q2b). But if we define intelligibility, following Jeppsson, as “grasping what it was like for the...

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.

Critical psychiatry takes the position that 'mental illness' should not be reduced to 'brain disease'. Here I consider whether this particular stance is outdated in light of more recent exchanges on reductionism, which consider questions raised by new mental health sciences that seek truly integrative and specific biopsychosocial models of illness.

AbstractThis Chapter presents the case of a Qur’anic healer in the Dakhla Oasis of Egypt. It identifies the values that the healer is seeking to promote and the cultural influences on his beliefs and practices. The Chapter demonstrates the interplay of traditional practices and scientific concepts and methods, and concludes by considering implications for the development of mental health services in communities such as the Dakhla Oasis.

Central to the identity of modern medical specialities, including psychiatry, is the notion of hypostatic abstraction: doctors treat conditions or disorders, which are conceived of as "things" that people "have." Mad activism rejects this notion and hence challenges psychiatry's identity as a medical specialty. This article elaborates the challenge of Mad activism and develops the hypostatic abstraction as applied to medicine. For psychiatry to maintain its identity as a medical speciality while accommodating the challenge of Mad activism, it must develop an additional conception of the clinical encounter. Toward elaborating this conception, this article raises two basic framing questions: For what kind of understanding of the situation should the clinical encounter aim? What is the therapeutic aim of the encounter as a whole? It proposes that the concepts of "secondary insight" (as the aim of understanding) and of "identity-making" (as a therapeutic aim) can allow the clinical encounter to proceed in a way that accommodates the challenge of Mad activism.

Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism is the first comprehensive philosophical examination of the claims and demands of Mad Pride and mad-positive activism (Mad activism). Contemporary developments in mental health activism pose a radical challenge to psychiatric and societal understandings of madness. Mad activism rejects the language of mental illness and mental disorder, reclaims the term “mad,” and reverses 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 culture or 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? 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 begins with Georg Hegel and Immanuel Kant, and continues into 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. It charts a pathway for reconciling opponents and supporters of Mad activism and, ultimately, for reconciling madness and society.

'Public Mental Health Across Cultures' examines the ethical issues raised by the prevention of depression across cultural contexts. It contrasts two approaches: a public mental health approach such as would be adopted by the movement for Global Mental Health, and a local approach that can be found in the Dakhla Oasis of Egypt. Each approach has different views on the categorisation of distress, its causes, risk factors, and the preventive strategies that would reduce the incidence of the conditions. Given these differences in worldview, the chapter considers the ethical principles that ought to regulate the interaction between the public health team and the community, where prevention of depression is at stake. These principles are examined in the case of two levels of intervention: family and social relationships, and individual interventions. It is argued that the complexities involved in the interaction suggest that it ought to be approached with the ethical mindset of an intercultural encounter not of a public health intervention.

Spirit possession is a common phenomenon around the world in which a non-corporeal agent is involved with a human host. This manifests in a range of maladies or in displacement of the host's agency and identity. Prompted by engagement with the phenomenon in Egypt, this paper draws connections between spirit possession and the concepts of personhood and intentionality. It employs these concepts to articulate spirit possession, while also developing the intentional stance as formulated by Daniel Dennett. It argues for an understanding of spirit possession as the spirit stance: an intentional strategy that aims at predicting and explaining behaviour by ascribing to an agent (the spirit) beliefs and desires but is only deployed once the mental states and activity of the subject (the person) fail specific normative distinctions. Applied to behaviours that are generally taken to signal mental disorder, the spirit stance preserves a peculiar form of intentionality where behaviour would otherwise be explained as a consequence of a malfunctioning physical mechanism. Centuries before the modern disciplines of psychoanalysis and phenomenological-psychopathology endeavoured to restore meaning to 'madness,' the social institution of spirit possession had been preserving the intentionality of socially deviant behaviour.

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 judgments, and the second arises 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.

The centenary of Karl Jaspers' General Psychopathology was recognised in 2013 with the publication of a volume of essays dedicated to his work (edited by Stanghellini and Fuchs). Leading phenomenological-psychopathologists and philosophers of psychiatry examined Jaspers notion of empathic understanding and his declaration that certain schizophrenic phenomena are 'un-understandable'. The consensus reached by the authors was that Jaspers operated with a narrow conception of phenomenology and empathy and that schizophrenic phenomena can be understood through what they variously called second-order and radical empathy. This article offers a critical examination of the second-order empathic stance along phenomenological and ethical lines. It asks: (1) Is second-order empathy (phenomenologically) possible? (2) Is the second-order empathic stance an ethically acceptable attitude towards persons diagnosed with schizophrenia? I argue that second-order empathy is an incoherent method that cannot be realised. Further, the attitude promoted by this method is ethically problematic insofar as the emphasis placed on radical otherness disinvests persons diagnosed with schizophrenia from a fair chance to participate in the public construction of their identity and, hence, to redress traditional symbolic injustices.

Beyond Dysfunction:Distress and the Distinction Between Deviance and Disorder Rachel Bingham (bio) and Mohammed Abouelleil Rashed (bio) Keywords Social deviance, mental disorder, critical psychiatry, DSM-5 Johanna Moncrieff’s and Dan Stein’s commentaries illuminate the complexity inherent in the question we pose in the original paper ‘Can Psychiatry Distinguish Social Deviance from Mental Disorder?’ So much difficulty abounds in addressing such a question: on one hand, there are the difficulties in defining mental disorder that many readers of this journal are familiar with. On the other, there is the critical stance held by some writers to the effect that psychiatry medicalizes human suffering, thus obscuring its moral, social, and political underpinnings (e.g., Rapley, Moncrieff, and Dillon 2011). Adherents of the seminal critique of Thomas Szasz question the very distinction between mental disorder and social deviance, and for them the question of how to delineate the proper domain of psychiatry is nonstarter. An essential discussion, before dismissing psychiatry outright, would consider what to say about those large swathes of humanity voluntarily seeking psychiatric help for their distress. But this is not the central concern of our paper, which does not commit to any strong claim about what or whom should be treated by psychiatrists. Rather, we are concerned to develop one recognized criterion for when people should not be treated by psychiatrists: namely, when their distress is solely the result of social deviance or conflict with society. Given the complexity of this topic which the commentaries highlight—and the potential for misunderstanding, which may explain some of our disagreement with Moncrieff in particular—our response partly clarifies our approach and thesis, and partly takes issue with specific points made by the commentators. 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, 257). [End Page 267] 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, XX) 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...