There’s a perennial debate about the psychiatric concept of
mental disorder. Is that concept being abused? Are normal behaviours being
pathologized to sell pharmaceuticals? But the truth of mental health and insanity
seems far removed from this controversy.
Mental Disorder as Dysfunction
The latest psychiatric manual of disorders, the DSM-5,
defines “mental disorder” as “a syndrome characterized by clinically
significant disturbance in an individual's cognition, emotion regulation, or
behavior that reflects a dysfunction in the psychological, biological, or
developmental processes underlying mental functioning. Mental disorders are
usually associated with significant distress in social, occupational, or other
important activities. An expectable or culturally approved response to a common
stressor or loss, such as the death of a loved one, is not a mental disorder.
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,
as described above.”
The key to understanding this definition is the notion of a
“function.” The psychiatrist wants to distinguish between normality and
pathology, the latter being a deviation from a norm that calls for psychiatric
action; more precisely, she wants to cater to cultural presumptions about
psychological normality, which is why the definition adds that “An expectable
or culturally approved response to a
common stressor or loss, such as the death of a loved one, is not a mental
disorder” (my emphasis). If a culture sanctions some behaviour, the behaviour
cannot be abnormal or dysfunctional—unless the whole culture is backward and
deranged from a modern, Western viewpoint. What, then, does “dysfunction” add
to the concept of mere statistical abnormality, that is, to the concept of something’s
rarity? Here the psychiatrist walks a fine line between calculating the
difference between common and uncommon psychological and social patterns, on
the one hand, and moralizing on the other. The latter is forbidden to the contemporary
psychiatrist who seeks to align her discipline more with the hard sciences than
with philosophy, theology, and the arts. In the past, psychiatrists did
rationalize theological prejudices regarding the alleged evil of certain
dispositions such as homosexuality and femininity. Jews and Christians read in
their scriptures that women are inferior to men, and early modern, Western
psychiatrists deferred to that unscientific, moralistic judgment, prescribing
patronizing means for women to adapt to their alleged inferiority and lack of
full personhood. But after R.D. Laing, Foucault, and others showed in the 1960s
and ‘70s that the prevailing psychiatric criteria for mental health were subjective,
psychiatrists developed objective tests in the form of checklists, thus preserving
the scientific image of their discipline. (For a stirring presentation of this recent
history, see Part 1 of Adam Curtis’ documentary, The Trap.)
The notion of dysfunction, then, is crucial to this larger psychiatric
project. On the one hand, a dysfunction is an inability to carry out some
process, to complete some expected relation between cause and effect. The fact
that there’s a causal relationship at issue provides the generality to account
for the norm which is being violated, since causality is the paramount
scientific concept for understanding natural order. Psychiatrists see
themselves as scientists exploring the mind and so they posit an order in the
mental domain. The order investigated by scientists in general is explained with an instrumental agenda in mind, the goal being not just to understand but to
control phenomena. Thus, scientists are minimalists and conservative in their
theorizing: they objectify, explaining regularities in terms of force, mass,
and other such relatively value-neutral properties. Real patterns are understood in terms of
physical necessity—not as happening, for example, by free choice, since that would be
a form of magic, a miracle that couldn’t be controlled and therefore couldn’t
be scientifically (instrumentally and objectively) understood.
So a dysfunction is a deviation from, or a blockage in the
furtherance of, a function, where a function is at least a causal relationship.
However, because the psychiatrist sees herself as a medical scientist, she thinks she does well in the world,
and so a mental function must be more than a regularity that merely happens
regardless of any normative context. Functions are deemed to be good from some
perspective, namely by a culture at large. Psychiatrists thus still kowtow to social presumptions, but they do so
under the cover of scientific (instrumentalist, objectifying) rhetoric.
Mental dysfunctions are, therefore, relatively
bad irregularities: violations of
social norms, causing suffering which is commonly assumed to be unwanted, and
preventing the individual from carrying out her “important activities.” The
goodness of mental health depends on a social evaluation, which the
psychiatrist merely presupposes, but she’s quick to point out that not every
conflict with society is pathological. Political, religious, or sexual rebels
aren’t mentally unwell unless their behaviour is brought on by a dysfunction,
as the DSM definition says. This means the rebel must suffer because of her
inability to function, that is, because of a syndrome reflecting a disturbance
in her thought processes.