Philosophy, Psychiatry, & Psychology

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.

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