I have been fascinated by the problem of distinguishing between “mental disorder” and “social deviance” since the early days of my psychiatric training. My exposure to the antipsychiatry philosophical literature had left me with a lingering, nagging doubt that unless there was some valid way of making this distinction, the legitimacy of psychiatry as a profession would stand on precarious and perilous ground.
Social deviance refers to actions or behaviors that violate social norms. The declassification of homosexuality brought the issue of differentiation between disorder and deviance to the forefront in the 1970s. When DSM-III was published, Spitzer sought to formalize a definition of mental disorder that would make explicit this distinction.
In the article, Rashed and I provide 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. We begin by reviewing the DSM's definition of mental disorder, which relies on “dysfunction in the individual” as the primary demarcating criterion.
|Mohammed Abouelleil Rashed|
However, given that “dysfunction” is left undefined, it offers little guidance, forcing us to explore specific notions of dysfunction as they exist within the context of commonsensical, clinical, and naturalist approaches. The commonsensical approach ends up relying on “folk” judgments, the naturalist approach (exemplified by Wakefield’s harmful dysfunction analysis) puts us in an epistemic bind since our knowledge of the mechanisms of psychological functioning is limited, and their evolutionary history is largely speculative.
The clinical approach, on the other hand, blurs the distinction between dysfunction and distress/disability since the presence of distress/disability is seen as an indicator of dysfunction. This leads us to discuss how distress (conceptualized in our discussion as intrinsic vs socially constituted) and disability (which is always in the context of a particular social environment) fare in this regard. While both are promising and practically more helpful than dysfunction, neither offers a perfect or straightforward way of making this distinction.
3E enactive approaches offer a promising theoretical strategy which relies on “functional norms” of an individual that support continued self-maintenance and adaptation, however, the notions of self-maintenance and adaptation are not currently operationalized in a manner that would allow us to resolve controversial cases with any degree of consensus.
Finally, the application of ethical and political approaches transforms this issue into a complex negotiation of values which requires us to consider, for instance, balancing of harms and benefits of disorder designation, the need for “rational moral justification” vs reliance on relativistic societal value judgments, and higher-level arguments based upon a theory of the good society or eudaimonia. Other approaches such as such as Mad Pride and neurodiversity question the very distinction between social deviance and mental disorder in the first place.
Our review of all these strategies suggests that no single approach satisfactorily accounts for all possible cases and that a distinct dividing line between disorder and deviance remains elusive. However, these various philosophical strategies help illuminate the relevant considerations involved and suggest that the distinction between disorder and deviance is not simply a natural fact to be discovered but a complex judgment that requires negotiation between competing values.
Perhaps you may be wondering: how does this conclusion impact my lingering, nagging doubts about the legitimacy of psychiatry that I mentioned in the beginning? The process of philosophical reflection over the years has disabused me of the notion that a simple reliance of naturalism is what is needed for psychiatry to be legitimate. Psychiatry may be value-laden through and through, and there may be no easy demarcations, but that is a problem only if we continue to naively insist that nature be carved at its joints when no such joints exist.