Philosophy, Psychiatry, & Psychology

In "On the Concept of 'Psychiatric Disorder,'" Miriam Solomon strives to resolve the tension between thinking of bereavement as a normal reaction to loss, and recognizing that its most extreme forms look very much like major depressive episodes and benefit from psychiatric treatment. To do this, she introduces the idea that a condition can be both normal and a mental disorder, or in other words, that some mental disorders are normal. Although I very much like the idea that some mental are predictable responses to stressors, I have trouble making sense of the argument Solomon provides. I am going to focus on two reasons why.

First, the concept of psychological injury is not new and does not do the work Solomon needs it to do for her. "Psychological injury" is a legal term used in forensic psychology and psychiatry that includes not bereavement, but physical and psychological conditions that can result from harms done by responsible others, such as suffering, exacerbation of a preexisting condition, posttraumatic stress, traumatic brain injury, phobias, adjustment disorders, chronic pain, and depression, depending on the jurisdiction. "Psychological injury" as it already exists does not discriminate the physical from the psychological, whereas Solomon wants to restrict the meaning to "conditions in which brain mechanisms are not disrupted," even though typical psychological functioning may be. What the existing forensic concept of psychological injury and Solomon's version share is the idea that certain harms can be expected to result from specific life stressors. However, to insist on this language would confuse two very different conceptions of psychological injury, which typically is not the goal of analytic philosophy. Second, Solomon fails to engage with the extensive literature on what it is to be a disorder—specifically, a mental disorder—and how the "disordered" relates to "the normal." She says in her abstract, though not in the body of her paper, "The word 'abnormal' is … best avoided [in speaking of the pathological] because of its associations with normative judgments." She does not say why this is, nor does she argue the point. In section 2, she refers to Horwitz and Wakefield's (primarily Wakefield's) position that a mental disorder is a "harmful dysfunction," without acknowledging any conceptual problems with that formulation and the biological unclarity of "dysfunction" on which it relies (Faucher & Forest, 2021). Later, in section 3, Solomon seems to uncritically accept some pre-established and preferred conception of disorder by contrasting it with pathology, "which evokes nineteenth century abnormal microscopic findings" (pp. 334), although psychiatry refers to psychopathology regularly. Again, there is a hint that using the word "disorder" avoids some of the value-ladenness of "pathology" and "pathologizing," [End Page 347] which to Solomon evokes stigma (against mental disorders? the people who have them?). However, Solomon does not explore how the various terms are value laden, and she never addresses how much the conceptions of anomaly, abnormality, or disvalue inhere in the concept of disorder.

But, of course, Solomon needs the concept "disorder" to be free of any implicit reference to departures from "the normal" in order to make the crucial distinction she wants to make: to say that in fact, some mental disorders are normal. In the end, she rejects defining "mental disorder" as "harmful dysfunction," but only to make room for her concept of psychological injury as partly constitutive of mental disorder. But she still wants to say that her version of psychological injury (in which brain mechanisms are not interrupted) is normal, without saying how she is defining "normal," and how it avoids the problems of normativity she recognizes but declines to address. In some of her discussion, "normal" seems to mean "appropriate to the circumstances," such as when she compares grief with a bone fracture from a motor vehicle accident. At other times, "normal" seems to mean "predictable," such as the grief response to loss of a loved one.

I am left wondering why she limits herself in the way she does. If the goal is to make treatment available to bereaved persons who seek treatment, she need not worry: no mental health professional would ever code for...