Mental disorder is an urgent and growing public health problem.1 Scientific investigation of this problem has the pragmatic goals of identifying the causes of mental disorders and developing strategies to effectively treat them. Philosophers of psychiatry have participated in the inquiry into the empirical examination of mental disorders, predominantly by debating whether psychopathology is a legitimate target of scientific inquiry and, if so, how mental disorders should be explained, predicted, and intervened on. However, as I (...) show in this paper, these philosophical discussions have mostly neglected the actual state of inquiry in psychiatry and relevant disciplines, as well as the first-person experiences... (shrink)

What mental disorder means is controversial. I attempt to solve that controversy by applying the method of defining a phenomenon in terms of the goals we have for demarcating that phenomenon from other phenomena to the case of mental disorder. I thus address the question about the nature of mental disorder by paying attention to the goals we have for demarcating mental disorder. I maintain that these goals, which embody the reasons why (...) we consider mental disorder a significant phenomenon for us, have a common denominator: they refer to psychological capacity for autonomy. I present a conceptual foundation for defining mental disorder on the basis of that psychological capacity and argue that this way of understanding the nature of mental disorder avoids the main problems of the central contemporary theories of mental disorder. Then I explain why this conception of the nature of mental disorder is not undermined by anti-psychiatric criticisms to the effect that mental illness does not exist, that the mentally ill should not be treated differently from others, and that seeing problems of the mentally disordered as psychiatric problems is unjustified medicalization. I conclude by suggesting that the presented conceptual foundation for defining mental disorder would benefit from being complemented by results of empirical psychology. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Intentional OrderRichard Gipps (bio)Bengt Brülde and Filip Radovic inform the reader that they will assume "there is such a thing as a general category of disorder, of which mental and somatic disorders can be regarded as subcategories" (2006, 100). With this assumption in place, they take up a fascinating discussion of what warrants our categorizations of certain disorders as mental as (...) opposed to physical. The answers they then canvass include the possibilities that it is the mentality of the internal causes, or of the symptomatic effects, of these disorders which renders them mental, or that there is no single answer, or that there is no valid distinction to be drawn.In what follows I wish to question the initial assumption, and then offer an understanding of the nature of mentality that I hope will lead to a different way of answering the question, what is mental about mental disorder? It worries me that the views I develop here may share too little by way of common framework assumptions with the views developed in Brülde and Radovic's paper. I hope that this does not render dialogue impossible, or make the thoughts that were inspired by their thoughtful paper appear just too off field to be seriously entertained.The Concept of DisorderBrülde and Radovic assume that "mental disorders" and "physical disorders" are subtypes of a general category of disorder. (In what follows I describe this as the assumption.) They also distinguish between two questions: (1) What is mental about mental disorder? (in what follows I describe this as the question) and (2) What does it take for a condition to be a disorder? This latter question is, they acknowledge, certainly important, but is set aside for the time being.Mental disorder, physical disorder, and we might perhaps also add social disorder, are then subcategories of disorder. They are perhaps not natural kinds, but nevertheless they are subcategories within a general category. With their assumption in place it makes good sense to reject accounts of the mentality of mental disorders that seem to simply presuppose the concepts of mind and body when they address the question.There is of course a trivial sense in which everyone must agree that mental disorders and physical disorders are to be considered subcategories of disorder. There is what could be described as a logical sense of category and subcategory, in which any noun is said to designate a category and any adjectival qualification of it to introduce a subcategory. However, we can also distinguish what I call a "semantic" sense, in which talk of categories and subcategories is more restricted. Here we rely on there being a unitary sense to the putative category if we are to talk meaningfully of subcategories of this single category. [End Page 117]The philosophy of the individuation of senses is not within my expertise, but I am relying on an intuitive notion spelled out by the following. First, that a good dictionary would elaborate these senses by providing different definitions of the putative category rather than a single definition followed by examples. Second, that when we do not have to do with categories in the semantic sense, we would find ourselves more in want of true understanding of what was being said, and not so much in want of mere further knowledge, if we are offered a description that included the noun (disorder) without the qualifier (mental). Third, that we are less likely to be dealing with subcategories within a general semantic category if we easily can turn the adjective–noun pair (e.g., mental disorder) around to provide two nouns in a short phrase (e.g., disorder of the mind), or if there are verbal and adjectival forms of the second noun that can also be used in conjunction with the first noun (e.g., disordered mind).An example serves to make things clearer. Consider a chemist who has a reaction in her laboratory. What is referred to may be an emotional reaction (to her sudden scientific breakthrough), or a chemical reaction. In this case, I suggest, we do not have to do with a semantic category of "reaction," which... (shrink)

Worries about the potential medicalization of social and moral problems has propelled the debate on the nature of mental disorder, with normativists insisting that psychiatric classification is inherently value-laden and naturalists maintaining that a purely descriptive account of disease is possible. In recent work, some authors take a different path, accepting that the concepts of disease and mental disorder are value-laden but maintaining that this does not prevent objective truths regarding mental disorder attribution. This (...) paper explores two such accounts and the important steps they provide toward rethinking the nature and metaphysical status of mental disorder. The challenges raised in this paper are meant to contribute to the further development of this stimulating work. (shrink)

Authenticity has recently emerged as an important issue in discussions of mental disorder. We show, on the basis of personal accounts and empirical studies, that many people with psychological disorders are preoccupied with questions of authenticity. Most of the data considered in this paper are from studies of people with bipolar disorder and anorexia nervosa. We distinguish the various ways in which these people view the relationship between the disorder and their sense of their authentic self. (...) We discuss the principal modern ac-counts of authenticity within the analytic philosophical tradition. We argue that accounts based on autonomous, or wholehearted, endorsement of personal characteris-tics fail to provide an adequate analysis of authenticity in the context of mental disorder. Significant elements of true self accounts of authenticity are required. The concept of authenticity is a basic one that can be of particular value, in the context of self-development, to people with mental disorder and to others experiencing substantial inner conflict. (shrink)

Mental disorder (earlier entitled “illness” or “disease”) is ascribed to deviations from normal thoughts, reasoning, feelings, attitudes, and actions that are considered socially or personally dysfunctional and apt for treatment. Schizophrenia, depression, and bipolar disorder are core examples. The concept of mental disorder plays a role in many domains, including medicine, social sciences such as psychology and anthropology, and the humanities, including literature and philosophy. Philosophical discussions are the primary focus of the present entry, which (...) differs from the entry on Philosophy of Psychiatry in noting several different approaches—not only those of the philosophy of science and mind, but also those arising from phenomenology and social theory. -/- Mental disorder is a widely contested concept and there are longstanding debates on whether disorders are biological or social in nature. Even uncontroversial disorders, such as those listed above, were not always regarded as disorders in the past (Porter 2002). Moreover, the status of mental disorder has frequently indicated ethical, as much as other deficiency (Irwin 2013). Such reminders direct our attention to contemporary medical psychiatry’s sometimes uncompromisingly neurobiological, and avowedly value-free “medical model”, with its incumbent analogies and assumptions, and to the general question of how the taxa of psychiatric classifications are to be viewed as objects of natural science. This model has received intensive philosophical scrutiny, including arguments that deny these conditions are deficiencies at all. Along with issues arising from cognitive psychology and the neurosciences, such foundational matters make up much of the following entry. Because of their focus on issues central to the philosophy of mind and ethics (e.g., the mind-body problem, moral responsibility, agency and identity), analyses of mental disorder have extensive implications for those fields. As clinical phenomena, they also reflect an inescapable, everyday, social reality, giving theoretical inquiries additionally urgent practical, moral, and legal implications. (shrink)

In this dissertation, I examine our mental health concepts to see what work they are currently doing as well as what work they could be doing. In 1976, Christopher Boorse stated that the mental health literature is a “web of obscurities” (p. 51). To resolve some of this confusion, I argue that we need to consider the goals we should have for our mental health concepts and then give accounts of those concepts that meet our stated goals. (...) I argue that our goals for our mental health concepts should be twofold: first, we need concepts that will work to alleviate the stigmatization of mental disorder as this stigmatization gets in the way of providing and receiving medical help, and second, we need concepts that will be useful tools for medical practitioners to use in their diagnosis and treatment practices. -/- I begin by arguing that our mental disorder concept is not currently a useful tool for medical practitioners. Moreover, I argue that our mental disorder concept is confused in such a way that it is unlikely that it could ever be a useful tool for medical practitioners. If we cannot give an account of the mental disorder concept that is a useful tool for medical practitioners, then perhaps we can give an account of the mental disorder concept that can be used toward our goal of alleviating the stigmatization of mental disorder. Before we can do that, however, we need an account of the stigmatization concept so that we can understand what our mental disorder concept needs to be alleviating. -/- I argue that stigmatization is a process whereby some entity becomes marked as disgraceful or shameful. This stigmatization process includes (1) an attitude against the entity for reasons found in the social ideology, and (2) acts against the entity. I then argue that acts of stigmatization take two forms: direct stigmatization (where stigmatizors take acts against the stigmatized entity) and indirect stigmatization (where potential victims of stigmatization take acts to avoid becoming victims of stigmatization). With that in mind, we learn that if we are to alleviate the stigmatization of mental disorder, we need to work on alleviating both direct and indirect stigmatization. It is at this point that I argue for a new account of our mental disorder concept that can be utilized to alleviate the direct and indirect stigmatization of mental disorder. With our mental disorder concept redesigned to achieve that goal, I turn to the goal of providing medical help for persons that need that help. I argue that we need to reconceptualize what it means to be a ‘diagnosable condition’ so that we can develop a new framework for diagnosis and treatment that will be more efficacious than our current system. In conclusion, I suggest that we can untangle the current confusion that is the mental health literature by imbuing our mental health concepts with specific purposes and then utilizing them to achieve those purposes as I outline in this dissertation. (shrink)

According to the Argument for Autonomous Mental Disorder, mental disorder can occur in the absence of brain disorder, just as software problems can occur in the absence of hardware problems in a computer. This article argues that the AAMD is unsound. I begin by introducing the “natural dysfunction analysis” of disorder, before outlining the AAMD. I then analyze the necessary conditions for realizer autonomous dysfunction. Building on this, I show that software functions disassociate from (...) hardware functions in a way that mental functions do not disassociate from brain functions. It follows that mental disorders are brain disorders necessarily. (shrink)

The question of whether mental disorders are disorders of the brain has led to a long- running and controversial dispute within psychiatry, psychology and philosophy of mind and psychology. While recent work in neuroscience frequently tries to identify underlying brain dysfunction in mental disorders, detractors argue that labelling mental disorders as brain disorders is reductive and can result in harmful social effects. This book brings a much- needed philosophical perspective to bear on this important question.

Mental disorder (earlier entitled “illness” or “disease”) is ascribed to deviations from normal thoughts, reasoning, feelings, attitudes, and actions that are considered socially or personally dysfunctional and apt for treatment. Schizophrenia, depression, and bipolar disorder are core examples. The concept of mental disorder plays a role in many domains, including medicine, social sciences such as psychology and anthropology, and the humanities, including literature and philosophy. Philosophical discussions are the primary focus of the present entry, which (...) differs from the entry on Philosophy of Psychiatry in noting several different approaches—not only those of the philosophy of science and mind, but also those arising from phenomenology and social theory. -/- Mental disorder is a widely contested concept and there are longstanding debates on whether disorders are biological or social in nature. Even uncontroversial disorders, such as those listed above, were not always regarded as disorders in the past (Porter 2002). Moreover, the status of mental disorder has frequently indicated ethical, as much as other deficiency (Irwin 2013). Such reminders direct our attention to contemporary medical psychiatry’s sometimes uncompromisingly neurobiological, and avowedly value-free “medical model”, with its incumbent analogies and assumptions, and to the general question of how the taxa of psychiatric classifications are to be viewed as objects of natural science. This model has received intensive philosophical scrutiny, including arguments that deny these conditions are deficiencies at all. Along with issues arising from cognitive psychology and the neurosciences, such foundational matters make up much of the following entry. Because of their focus on issues central to the philosophy of mind and ethics (e.g., the mind-body problem, moral responsibility, agency and identity), analyses of mental disorder have extensive implications for those fields. As clinical phenomena, they also reflect an inescapable, everyday, social reality, giving theoretical inquiries additionally urgent practical, moral, and legal implications. (shrink)

I stipulate and motivate the overlooked problem of demarcating radical skeptics (perceptual and moral) from mentally disordered persons, given that both deny that they know ordinary Moorean propositions (e.g., that they have hands or that killing for fun is morally wrong). Call this ‘the demarcation problem’. In response to the demarcation problem, I develop a novel way to demarcate between mentally disordered persons and radical skeptics in an extensionally adequate way that saves the appearance that radical skeptics are not mentally (...) disordered persons (at least not typically). Finally, I examine how a Moorean, non-skeptical epistemologist would compare radical skeptics with the mentally disordered in terms of what Plantinga calls internal and external rationality. Perhaps surprisingly, by Moorean lights, the mentally disordered fare better than the radical skeptic in terms of (internal) rationality. The upshot is that for Mooreans skeptical philosophy is more of an epistemic evil than mental disorder. (shrink)

Meaning-making plays a central role in how we deal with experiences of suffering, including those due to mental disorder. And for many, religious beliefs, experiences, and practices (hereafter, religious engagement) play a central role in informing this meaning-making. However, a crucial facet of the relationship between experiences of mental disorder and religious engagement remains underexplored—namely the potentially positive effects of mental disorder on religious engagement (e.g. experiences of bipolar disorder increasing sense of God’s (...) presence). In what follows, I will present empirical findings from two recent studies of mine which shed light on the extent to which participants experienced these positive effects, specific components of these effects, and how they fit into their understanding of their mental disorder and its relationship to their religious identity. In doing so, I will draw on and expand Tasia Scrutton’s Potentially Transformative view (2015a, 2015b, 2020) according to which mental disorders may provide opportunities for spiritual growth. My empirical results align with and help deepen an account according to which mental disorders are potentially spiritually transformative by providing further insight into such instances: specifically, which symptoms and internal and external factors are often involved, as well as which religious beliefs, experiences, and/or practices are often affected. After presenting these results and articulating their relevance for a potentially transformative view of mental disorder, I will then address some potential objections to the theoretical account as well as some limitations of the empirical work, before sketching possible promising directions for future research. (shrink)

I hope to show that mental disorders are not analogous to physiological diseases. I hope to show that a mental disorder like bipolar disorder cannot be located in the brain in the way a physiological disease like cirrhosis can be located in the liver. Mental disorders, unlike physiological diseases, lack a locatable corporeal basis to serve as a visible fulcrum on which to be based. However, I hope to also demonstrate that it is a mistake (...) to infer the inexistence of disorders from such an absence of a locatable corporeal basis. There are countless phenomena including the force fields pointed out by physics that lack such a basis but whose reality isn’t doubted; by the fact of such absence alone, we have no reason to doubt the existence of mental disorders, nor, for that matter, the existence of the minds thatexperience them. (shrink)

Due to several socio-political factors, to many psychiatrists only a strictly objective definition of mental disorder, free of value components, seems really acceptable. In this paper, I will explore a variant of such an objectivist approach to defining metal disorder, natural function objectivism. Proponents of this approach make recourse to the notion of natural function in order to reach a value-free definition of mental disorder. The exploration of Christopher Boorse's 'biostatistical' account of natural function (1) (...) will be followed an investigation of the 'hybrid naturalism' approach to natural functions by Jerome Wakefield (2). In the third part, I will explore two proposals that call into question the whole attempt to define mental disorder (3). I will conclude that while 'natural function objectivism' accounts fail to provide the backdrop for a reliable definition of mental disorder, there is no compelling reason to conclude that a definition cannot be achieved. (shrink)

In order to judge how behavior caused by the positivity effect should be considered, comparisons were made between the positivity effect and two mental disorders. These disorders, Tourette’s syndrome and psychopathy, were selected due to their extreme differences in what Strawsonian attitudes they inspire and how they are perceived relative to disordered patients’ will. Disorder-affected behavior of Tourette’s patients inspires the objective attitude and is seen as a condition affecting an individual’s will, while disorder-affected behavior of psychopaths (...) inspires the interpersonal attitude and is seen as a character trait. Relevant distinctions between psychopathy and Tourette’s syndrome were found to include their neurological causes, the obviousness of the suffering they caused, and how easily their disorder-affected behavior could be mapped onto goal-seeking behavior. These considerations suggest the positivity effect should be viewed similarly to psychopathy in terms of responsibility, although this is complicated by its time of development and other factors. (shrink)

Understanding Mental Disorders aims to help current and future psychiatrists, and those who work with them, to think critically about the ethical, conceptual, and methodological questions that are raised by the theory and practice of psychiatry. It considers questions that concern the mind’s relationship to the brain, the origins of our norms for thinking and behavior, and the place of psychiatry in medicine, and in society more generally. With a focus on the current debates around psychiatry’s diagnostic categories, the (...) authors ask where these categories come from, if psychiatry should be looking to find new categories that are based more immediately on observations of the brain, and whether psychiatrists need to employ any diagnostic categories at all. (shrink)

Many individuals who have mental disorders often report negative experiences of a distinctively epistemic sort, such as not being listened to, not being taken seriously, or not being considered credible because of their psychiatric conditions. In an attempt to articulate and interpret these reports we present Fricker’s concepts of epistemic injustice (Fricker, 2007, p. 1) and then focus on testimonial injustice and hermeneutic injustice as it applies to individuals with mental disorders. The clinical impact of these concepts on (...) quality of care is discussed. Within the clinical domain, we contrast epistemic injustice with epistemic privilege and authority. We then argue that testimonial and hermeneutic injustices also affect individuals with mental disorders not only when communicating with their caregivers but also in the social context as they attempt to reintegrate into the general society and assume responsibilities as productive citizens. Following the trend of the movement of mental health care to the community, the testimonies of people with mental disorders should not be restricted to issues involving their own personal mental states. (shrink)

In this chapter I investigate the kinds of changes that psychiatric kinds undergo when they become explanatory targets of areas of sciences that are not “mature” and are in the early stages of discovering mechanisms. The two areas of science that are the targets of my analysis are cognitive neuroscience and cognitive neurobiology.

"Grapples with the legacy of Jerome Wakefield, one of the most influential critics of modern psychiatry and the use of the DSM for psychiatric diagnosis"--.

In this paper I argue that thinking in terms of process metaphysics and seeing the mind and mental disorders as processual in nature allows for a more complete understanding of mental disorders than is allowed by non-processual frameworks, while it also allows us to incorporate what we currently know about them. In addition, it can address problems in psychiatry that arise when we ask the wrong kinds of questions that naturally arise within a non-processual metaphysical framework. In this (...) paper I address the problems of reductionism, essentialism and dualism. -/- . (shrink)

The publication of DSM-5 has been accompanied by a fair amount of controversy. Amongst DSM’s most vocal ‘insider’ critics has been Thomas Insel, Director of the US National Institute of Mental Health. Insel has publicly criticised DSM’s adherence to a symptom-based classification of mental disorder, and used the weight of the NIMH to back a rival research strategy aimed at a more biology-based diagnostic classification. This strategy is part of Insel’s vision of a future, more preventative psychiatry (...) in which mental disorders are not only understood as biological disorders of the brain, but also as neurodevelopmental disorders. This paper examines the interest and merit of Insel’s views of mental and neurodevelopmental disorder for the philosophy of psychopathology, with a special focus of his neurodevelopmental model of schizophrenia. Pitman’s ‘moderate materialism’ will be used both as a philosophical lens through which to examine Insel’s position, as well as an example of a philosophical framework that may require updating and revision in the light of moves towards a neurodevelopmental conception of mental disorder. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Religious ExperienceThe Need for a Humble, Pragmatic PluralismWarren Kinghorn, MD (bio)Mohammed Abouelleil Rashed follows Charles Taylor’s argument that in the “therapeutic turn” of modernity, “certain human struggles, questions, issues, difficulties, problems are moved from a moral/spiritual to a therapeutic register,... from a hermeneutic of sin, evil or spiritual misdirection, to one of sickness” (Taylor, 2007, pp. 619–620). While the project of construing mental (...) disorder in naturalistic, non-religious terms carries the risk of subsuming “the rest of life” into the realm of the medical, it is nonetheless needed in order “to protect a region of illness and incapacity from the reach and excesses of the hermeneutic disciplines with their tendency to over-interpretation, and from cultural traditions, including religious discourse, that can implicate the person in narratives of evil, sin, faithlessness, spiritual misdirection, and moral deviance.” Rashed notes, however, that this medical narrative is challenged not only by religious communities but also by various forms of identity-based activism including the Mad Pride and Neurodiversity movements. He argues that strict illness/purpose, deficit/value, mechanism/meaning dichotomies have become “unstable” and encourages scholars to focus their attention on resolving the apparently contradictory realities that people sometimes demand and require medical forms of care while investing significance in the sociocultural and existential context of their distress and refusing reductionistic constructions of their distress as illness.I agree wholeheartedly with Rashed’s conclusion that clinicians and scholars must move beyond a strict mechanism/meaning dichotomy with respect to unwanted and/or disvalued experience and behavior, and must remain open to the social and contextual interpretations that particular cultural communities—including religious communities—offer. But as a psychiatrist who is also [End Page 215] a Christian theological ethicist, I suggest that this sensible conclusion can be reached more straightforwardly by adopting a more flexible approach to “religious experience” and by abandoning the assumptions that mental disorder is “a fully areligious type of suffering” and that religious experience and mental disorder are “fundamentally separate apprehensions of our experience.”Although Rashed never defines religious experience, he posits a distinction between “psychological distress or anomalous experience that has a religious origin, content, or end (purpose)” and “psychological distress or anomalous experience that has no religious origin, content, or end (purpose).” He then helpfully describes how Islamic tradition narrates psychological suffering as deviation from fitrah and as God’s trial, arguing that in Islamic perspective “mental disorder cannot be disentangled from the person’s religious situation and from the religious origin, content, or end (purpose) of his distress.” I make no claim about Rashed’s interpretation of Islam, but would observe that many voices within Christian tradition resist both the equation of psychological suffering with wrongdoing and the assertion that God is the direct cause of psychological suffering (see, for example, John Paul II, 1984). Suffering may instead have to do with being sinned against (as in the case of war, assault, or oppression), or the experience of living in a fallen world that God will one day make right. When the psalmist cries, “Save me, O God, for the waters have come up to my neck” (Psalm 69:1, NRSVue), many Christians observe that it is the psalmist’s enemies, not God, who are the proximate cause of the psalmist’s distress. That is to say, Christian tradition allows for a broad range of interpretations about the cause of distress, including distress resulting from injury, physical illness, and oppression. Christians are encouraged to regard all of their lives as in some way related to God as the creator, sustainer, and orienting end of life—and so in that sense all experience is “religious” in nature. But at least for Christians this does not preclude more naturalistic or sociological interpretations of distress and suffering.Rashed is right that a “fully areligious type of suffering” with “no religious origin, content, or end (purpose)” can only be invoked from a secular standpoint—if “secularity” is taken in Charles Taylor’s first sense of “public spaces... [that] have been allegedly emptied of God, or of any reference to ultimate reality” (Taylor, 2007, p. 2). This is not because... (shrink)

While the UK Home Office’s proposals to preventively detain people with what it has called dangerous severe personality disorder have been subjected to debate and criticism the deeply troubling jurisprudential issues in these proposals have not yet entered into public debate in a way that their seriousness deserves.1 It is good that a commentator as well known as Professor Szasz is speaking out on this issue.Professor Szasz focuses upon a crucial question by calling into question the medicalisation of terms (...) like dangerousness and mental illness.2 There is a great temptation for legislators and the public to treat these terms as if they are purely scientific terms and to think of risk assessment as a precise science. I don’t share Professor’s Szasz’s worry about how psychiatry is using these terms but I think there are some important questions about how these concepts function in the public sphere.This issue is important enough to justify the use of some rhetorical claims because such claims can serve to bring out what are neglected and important issues. In raising the following objections I am not attempting to refute the message that is in Szasz’s article or to say that he is not making an important point but rather to attempt to sharpen the issues and to suggest ways that we can respond to Professor Szasz’s challenge.Psychiatry has progressed in a number of ways since Professor Szasz wrote The Myth of Mental Illness.3 The science is much better, we have much better medications, and psychiatrists are acutely aware of the tension between treating their patient and their obligations to the public interest.So when Professor Szasz says: “Psychiatrists offer to relieve the disturbed person of the burden of coping …. (shrink)

I shall begin with the "anti-psychiatry" view that the lack of a physical basis excludes many familiar mental disorders from the category of "illness". My response to this argument will be that anti-psychiatrists are probably right to hold that most mental disorders do not involve any physical disorder, but that they are wrong to conclude from this that these mental disorders are not illnesses.

The effects of mental disorder are apparent and pervasive, in suffering, loss of freedom and life opportunities, negative impacts on education, work satisfaction and productivity, complications in law, institutions of healthcare, and more. With a new edition of the 'bible' of psychiatric diagnosis - the DSM - under developmental, it is timely to take a step back and re-evalutate exactly how we diagnose and define mental disorder. This new book by Derek Bolton tackles the problems involved (...) in the definition and boundaries of mental disorder. It addresses two main questions regarding mental illness. Firstly, what is the basis of the standards or norms by which we judge that a person has a mental disorder - that the person's mind is not working as it should, that their mental functioning is abnormal? Controversies about these questions have been dominated by the contrast between norms that are medical, scientific or natural, on the one hand, and social norms on the other. The norms that define mental disorder seem to belong to psychiatry, to be medical and scientific, but are they really social norms, hijacked and disguised by the medical profession? Secondly, what is the validity of the distinction between mental disorder and order, between abnormal and normal mental functioning? To what extent, notwithstanding appearances, does mental disorder involve meaningful reactions and problem-solving? These responses may be to normal problems of living, or to not so normal problems - to severe psycho-social challenges. Is there after all order in mental disorder? With the closing of asylums and the appearance of care in the community, mental disorder is now in our midst. While attempts have been made to define clearly a concept of mental disorder that is truly medical as opposed to social, there is increasing evidence that such a distinction is unviable - there is no clear line between what is normal in the population and what is abnormal. 'What is Mental Disorder?' reviews these various crucial developments and their profound impact for the concept and its boundaries in a provocative and timely book. (shrink)

People hold wildly opposing and very strong views on the question whether mental disorders are brain disorders, and the disagreement is primarily a conceptual one, not one about whether there are,...

This paper offers a philosophical analysis of the connection between mental disorder and suicide risk. In contemporary psychiatry, it is commonly suggested that this connection is a causal connection that has been established through empirical discovery. Herein, I examine the extent to which this claim can be sustained. I argue that the connection between mental disorder and increased suicide risk is not wholly causal but is partly conceptual. This in part relates to the way suicidality is (...) built into the definitions of some psychiatric diagnoses. It also relates to the broader normative assumption that suicidal behavior is by definition mentally disordered behavior. The above has significant epistemological implications, which I explore. I propose that the claim that suicide is connected with mental disorder cannot be justified solely by appealing to empirical evidence but also warrants a justification on conceptual and normative grounds. (shrink)

Mental disorders are often thought to be harmful dysfunctions. Jerome Wakefield has argued that such dysfunctions should be understood as failures of naturally selected functions. This suggests, implicitly, that evolutionary biology and other Darwinian disciplines hold important information for anyone working on answering the philosophical question, 'what is a mental disorder?'. In this article, the author argues that Darwinian theory is not only relevant to the understanding of the disrupted functions, but it also sheds light on the (...) disruption itself, as well as on the harm that attends the disruption. The arguments advanced here are partially based on the view that a core feature of Darwinism is that it stresses the environmental relativity of functions and dysfunctions. These arguments show a very close empirical connection between social judgments and dysfunctions, which is of interest for psychiatric theory. Philosophically, they lead to the conclusion that the concept of mental disorder is identical to the concept of mental dysfunction. Consequently, it is both misleading and redundant to conceptualize mental disorders as 'harmful dysfunctions', and not simply as 'mental dysfunctions'. (shrink)

First, I want to thank PPP for the privilege of having my work read and commented on by esteemed colleagues. In this response, I briefly review some of the key issues that they have raised. These issues include 1) the usefulness of a definition of mental disorder for North American psychiatry, 2) the absence of a concrete criterion to address the demarcation problem, 3) the place and role of values in such a demarcation, and 4) the worries of (...) over-inclusiveness, problematic values and imposition of values.The first question that needs to be clarified is raised by Waterman's commentary : Is it really necessary to define mental disorder and mental health? Here I feel I should clarify a background assumption of... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an (...) article on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy... (shrink)

Autonomy is a fundamental though contested concept both in philosophy and the broader intellectual culture of today’s liberal societies. For instance, most of us place great value on the opportunity to make our own decisions and to lead a life of our own choosing. Yet, there is stark disagreement on what is involved in being able to decide autonomously, as well as how important this is compared to other commitments. For example, the success of every group project requires that group (...) members make decisions about the project collectively rather than each on their own. This disagreement notwithstanding, mental disorder is routinely assumed to put a strain on autonomy; however, it is unclear whether this is effectively the case and, if so, whether this is due to the nature of mental disorder or the social stigma that often attaches to it. This book is the first exploration of the nature and value of autonomy with reference to mental disorder. By reflecting on instances of mental disorder where autonomy is apparently compromised, it offers a systematic discussion of the underlying presuppositions of the present autonomy debates in philosophy and psychiatry. In so doing, it helps address different kinds of emerging scepticism questioning either the appeal of autonomy as a concept or its relevance to specific areas of normative ethics, including psychiatric ethics. (shrink)

This is a reply to Gipps' commentary on my 'The Concept of Mental Disorder'.

It is now generally agreed that we have to rely on value judgments to distinguish mental disorders from other conditions, but it is not quite clear how. To clarify this, we need to know more than to what extent attributions of disorder are dependent on values. We also have to know (1) what kind of evaluations we have to rely on to identify the class of mental disorder; (2) whether attributions of disorder contain any implicit (...) reference to some specific evaluative standard; and (3) whether the concept of mental disorder is value laden in the definitional or in the epistemic sense. I will argue that the evaluations we have to rely on are mainly considerations of harm, but that we also need to rely on other evaluations; that there should be no references to specific evaluative standards; and that even though mental disorders are necessarily undesirable, "mental disorder" may well be a descriptive phrase. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Vice, Mental Disorder, and the Role of Underlying Pathological ProcessesNancy Nyquist Potter (bio) and Peter Zachar (bio)Keywordsresponsibility, virtue theory, cultural norms, psychopathologyThe issues discussed by John Sadler are among the most complicated in the philosophy of psychiatry, if for no other reason than that they highlight an area where disciplinary fault lines between clinical psychiatry/ psychology and philosophy seem most evident. We spent a year writing an (...) article on the relationship between the assessment of personality disorders and moral evaluations, and these fault lines became manifest not only between ourselves, but also when discussing our ideas with members of the various disciplines.Many practicing psychiatrists acknowledge that moral attributions (such as manipulativity) might be made about people with certain disorders (such as borderline personality disorder), but also find the argument that psychiatric diagnoses are moral rather than medical conditions to be a ludicrous bit of antipsychiatry in the Szaszian tradition. Philosophers, on the other hand, are less involved with these diagnostic categories in their day-to-day work and are more willing to be skeptical. Whether they are doing philosophy of psychiatry, moral theory, or sociopolitical philosophy, they are interested in digging a little bit deeper and are not impressed by arguments to the effect that—it’s obvious that these are really disorders. Being “obvious” is not a persuasive philosophical argument.The metaphysical task of determining what belongs in the category of criminality compared with other ways of sorting behavior has parallels in moral philosophy: Why is fraud, or theft, criminalized whereas (most) lying is not? Why is one set of moral norms enforceable, whereas a second set is aspirational? Does the difference involve property, where infractions of property are thought to be more serious wrongs than lying, which is “only” psychological rather than material? Are the “most serious” wrongs the ones we mark as crimes? Why is sodomy still criminalized in some areas but betraying one’s lifelong love is viewed as morally reprehensible but not criminal? Both actions are private, and only one seems to do harm—unfaithfulness—yet that is the one that is not criminalized. The point here is that, regardless of domain, our classification systems need to be justifiable, yet justification is most often mystifying. [End Page 27]The same is true for classifying mental disorders. The class of mental disorders appears to be a somewhat inconsistent collection of heterogeneous conditions and does not form a natural kind (Zachar 2000). At the most, the class of mental disorders names a family of loosely related conditions and the reasons for inclusion can shift from disorder to disorder.If the class of mental disorders does not specify an internally coherent kind akin to gold, deciding on the scope of psychiatric practice becomes an important problem. As Sadler asks, for what reasons do we classify pedophilia with schizophrenia—both as disorders—but omit sadism? This is an important question of disciplinary scope.This question of scope is itself ethically charged because, on the one hand, bringing a condition under the purview of psychiatry offers the possibility for treatment, and at least establishes the goal of improving the lives of people with specific kinds of problems. Making lives better is one of the humanistic justifications for science itself; clearly it is a raison d’être of psychiatry. On the other hand, medicalization sets up the conditions for a certain kind of social control. Hospitalization, educational services, day treatment, and disability payments are all contingent upon psychiatric diagnostic practices. These programs and the institutions that manage them are both socially available and socially prescribed. The diagnosed behaviors can now be considered to be entities, and explanations of them can be developed. New technologies for altering them will also be introduced. Such practices have been associated with dehumanization (Phillips 2009).Two important questions also need to be distinguished. The first is a question for moral philosophy—What degree of responsibility do people with putative mental disorders have for their behaviors? For example, should people with psychotic disorders or personality disorders be held responsible for crimes they commit? If so, under what conditions? Should responsibility for certain behavior be mitigated? If so, under what conditions? Moral philosophy... (shrink)

According to the predominant view within contemporary philosophy of psychiatry, mental disorders involve essentially personal and societal values, and thus, the concept of mental disorder cannot, even in principle, be elucidated in a thoroughly objective manner. Several arguments have been adduced in support of this impossibility thesis. My critical examination of two master arguments advanced to this effect by Derek Bolton and Jerome Wakefield, respectively, raises serious doubts about their soundness. Furthermore, I articulate an alternative, thoroughly objective, (...) though in part normative, framework for the elucidation of the concept of mental disorder. The concepts of mental dysfunction and impairment of basic psychological capacities to satisfy one’s basic needs are the building blocks of this framework. I provide an argument for the objective harmfulness of genuine mental disorders as patterns of mental dysfunctions with objectively negative biotic values, as well as a formally correct definition of the concept of mental disorder. Contrary to the received view, this objective framework allows for the possibility of genuine mental disorders due to adverse social conditions, as well as for quasi-universal mental disorders. I conclude that overall, the project of providing an objective account of the concept of mental disorder is far from impossible, and moreover, that it is, at least in principle, feasible. (shrink)

The aim of this chapter is to argue against the idea that there needs to be a polar opposition between "biological" and "humanistic" psychiatry. The basis for this idea lies in the philosophical tradition-the view that "mind" and "brain" must be conceived either as two separate "substances" or as one and the same. It is argued that this ontological conception of the problem should be replaced with a phenomenological description of what is actually meant by talk of human mental (...) life. In particular, Merleau-Ponty's account of human beings as "body-subjects" enables us to explain some aspects of some mental disorders as manifestations of neurological dysfunction, others as human responses to traumatic situations, and others as both. (shrink)

This contribution focuses on what type of question “Are mental disorders brain disorders?” is and what task Anneli Jefferson performs in her book with the same title. I distinguish between conceptual engineering and conceptual choice, the former involving the individuation of an adequate concept for a specific goal, and the latter involving the normative problem of whether we should employ the concept at hand. I contend that Anneli Jefferson’s book is a work of conceptual engineering, which is valuable in (...) and of itself, but that this is insufficient to answer an equally essential version of the question, “Are mental disorders brain disorders?”, namely, whether we should adopt the newly engineered concept or not, considering a broader range of goals for mental health research and practice. (shrink)

A link between mental disorder and freedom is clearly present in the introduction of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It mentions “an important loss of freedom” as one of the possible defining features of mental disorder. Meanwhile, it remains unclear how “an important loss of freedom” should be understood. In order to get a clearer view on the relationship between mental disorder and (a loss of) (...) freedom, in this article, I will explore the link between mental disorder and free will. I examine two domains in which a connection between mental disorder and free will is present: the philosophy of free will and forensic psychiatry. As it turns out, philosophers of free will frequently refer to mental disorders as conditions that compromise free will and reduce moral responsibility. In addition, in forensic psychiatry, the rationale for the assessment of criminal responsibility is often explained by referring to the fact that mental disorders can compromise free will. Yet, in both domains, it remains unclear in what way free will is compromised by mental disorders. Based on the philosophical debate, I discuss three senses of free will and explore their relevance to mental disorders. I conclude that in order to further clarify the relationship between free will and mental disorder, the accounts of people who have actually experienced the impact of a mental disorder should be included in future research. (shrink)

The Philosophy of Psychiatry is a unique area of research because the nature of the subject matter leads to quite distinct methodological issues. Naturalism, Interpretation, and Mental Disorder is an original new work focusing on the challenges we face when trying to interpret and understand mental illness. The book integrates a hermeneutical perspective, and shows how such an approach can reveal important facts about historical sources in psychiatry and the nature of dialogue in the therapeutic encounter. In (...) addition, the book demonstrates how such an approach can be valuable for understanding the concept of mental disorder itself. Naturalism, Interpretation, and Mental Disorder brings fresh thinking to the philosophy of psychiatry, and will be of interest to students and scholars in the fields of Mental Health and Philosophy. (shrink)

Meaning-making plays a central role in how we deal with experiences of suffering, including those due to mental disorder. And for many, religious beliefs, experiences, and practices (hereafter, religious engagement) play a central role in informing this meaning-making. However, a crucial facet of the relationship between experiences of mental disorder and religious engagement remains underexplored—namely the potentially positive effects of mental disorder on religious engagement (e.g. experiences of bipolar disorder increasing sense of God’s (...) presence). In what follows, I will present empirical findings from two recent studies of mine which shed light on the extent to which participants experienced these positive effects, specific components of these effects, and how they fit into their understanding of their mental disorder and its relationship to their religious identity. In doing so, I will draw on and expand Tasia Scrutton’s Potentially Transformative view (2015a, 2015b, 2020) according to which mental disorders may provide opportunities for spiritual growth. My empirical results align with and help deepen an account according to which mental disorders are potentially spiritually transformative by providing further insight into such instances: specifically, which symptoms and internal and external factors are often involved, as well as which religious beliefs, experiences, and/or practices are often affected. After presenting these results and articulating their relevance for a potentially transformative view of mental disorder, I will then address some potential objections to the theoretical account as well as some limitations of the empirical work, before sketching possible promising directions for future research. (shrink)

The concept of mental disorder is often defined by reference to the notion of mental dysfunction, which is in line with how the concept of disease in somatic medicine is often defined. However, the notions of mental function and dysfunction seem to suffer from some problems that do not affect models of physiological function. Functions in general have a teleological structure; they are effects of traits that are supposed to have a particular purpose, such that, for (...) example, the heart serves the goal of pumping blood. But can we single out mental functions in the same way? Can we identify mental functions scientifically, for instance, by applying evolutionary theory? Or are models of mental functions necessarily value-laden? I want to identify several philosophical problems regarding the notion of mental function and dysfunction and point out some possible solutions. As long as these questions remain unanswered, definitions of mental disorder that rest upon the concept of mental dysfunction will lack a secure foundation. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Mental Disorder and Moral Responsibility:Disorders of Personhood as Harmful Dysfunctions, With Special Reference to AlcoholismJerome C. Wakefield (bio)Keywordsalcohol dependence, philosophy of psychiatry, mental disorder, harmful dysfunction, psychiatric diagnosis, person, moral responsibilityIn his paper, Ethical Decisions in the Classification of Mental Conditions as Mental Illness, Craig Edwards grapples with a profound problem: why is it that when we classify a mental condition as (...) a mental disorder, that tends to take the condition out of the sphere of moral responsibility or virtuousness of character? For example, it is not uncommon when someone commits suicide and the question is raised as to why he or she did it, that instead of a reason or character trait that would place the act within a moral calculus, one is offered the explanation "she was clinically depressed" or "he was bipolar," and this tends to terminate discussion and make reasons and moral evaluation superfluous. Why does such a comment have that effect?As Edwards notes, this can get complicated as the moral and the disordered interact. Certainly people are sometimes morally responsible for acting on their disordered impulses (as in pedophilia), and they are responsible for putting themselves in the way of disorder, as when someone imbibes in a way likely to lead to alcoholism. But at the normal/disorder divide, there seems to be a consistent lifting of some responsibility, reflecting the application of the sick role. For example, the rough equivalent of our current category of post-traumatic stress disorder (PTSD) was recognized as a disorder in earlier wars ("shell shock," "war neurosis"), but often considered an expression of cowardice; the cowardice was morally evaluable as a failure of virtue (even if, like many personality traits, being a coward is not within the person's direct voluntary control) and led to contempt for those with PTSD, but nonetheless—except in cases thought to be malingering—the PTSD that resulted constituted a disorder for which the individual was [End Page 91] not in the same direct sense blameworthy. This moral shift requires explanation.This topic also has important social ramifications. Relief from responsibility may sound like a good thing, and it is trumpeted by mental health advocates as a reason for supporting the classification of many conditions as disorders. But as Edwards is aware, it is a two-edged sword. Disordered status may allow escape from censure and offer the protections of the sick role, but it also changes the relationship of the agent to his or her own actions and imposes the responsibility of the sick role on the individual to attempt to change ("get better"). The sick role allows for no defense of an idiosyncrasy based on normal variation ("It takes all kinds…") or the individual's eccentric vision or steadfast integrity, for that vision or sense of integrity are now seen as pathological and not morally legitimate. The individual is subjected to endless entreaties to seek help and it is implied that not to do so is irresponsible, so that a decision to embrace one's nature and remain as one is becomes illegitimate. Moreover, the sick role allows for no explanation in terms of the individual's normal defensive response to unjust, deprived, or challenging social or environmental circumstances, thus weakening the motives for social change rather than individual intervention.In sum, there is an inevitable sense in which being placed in the sick role inherently stigmatizes the "sick" condition in virtue of the special moral attitudes extended to the disordered. Cultures can thus easily exploit the sick role and its much-touted relief from responsibility to extend the reach of social control processes. This is one reason why the distinction between disorder and non-disorder is so important, and why it is crucial to identify when non-disordered conditions are mislabeled as disorders—as when, for example, psychiatry gets it wrong about the distinction between normal and disordered sadness (Horwitz and Wakefield, 2007). Such overpathologization can redefine the boundaries of our moral universe on mistaken grounds.Edwards offers two provocative answers—not entirely at ease with each other—to the question of why mental disorders relieve the patient from moral responsibility: (1) mental disorders are... (shrink)

There are different ways of responding to the absence of a shared physical causal core among the range of mental disorders currently recognized by the International Statistical Classification of Diseases and Related Health Problems and the Diagnostic and Statistical Manual of Mental Disorders. Obviously enough, some of the listed disorders are not physically explicable in principle, while others are merely likely to be biological in origin. Only a minority of disorders can be explained as the outcomes of impaired (...) biological function, and in some of those cases biological explanations capture their phenomena little more than partially. Psychiatry nevertheless is perceived as and understands itself... (shrink)

In this chapter, I explore moral competence as a central condition on moral responsibility. I distinguish two main conceptions. On the first, a morally competent agent is someone who knows right from wrong. On the second, a morally competent agent is someone who responds aptly to reasons. These two conceptions merit separate treatment as they offer different insights on how and why moral competence might be compromised. This distinction is of particular relevance since the chapter critically examines a standard assumption (...) stating that whenever a mental disorder impacts moral competence, it decreases its scope (on the first conception) or precision (on the second). In close conversation with the memoir literatures on bipolar disorder, autism and schizophrenia, I argue that moral competence may also be affected by what looks like increases in scope or precision; moreover, neither impact – decrease or increase – necessarily undermines moral competence in and of itself; oftentimes, either could enhance it in a reliable way. Finally, by critically revisiting the ecological or scaffolding approach to moral responsibility, I show that moral competence is best understood as a practical way of knowing right from wrong embedded in daily routines and habits, and irreducible to propositional understanding or intellectual skills. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Makes a Mental Disorder Mental?Jerome C. Wakefield (bio)Keywordsharmful dysfunction, mental disorder, intentionality, mental dysfunction, mental functioning, phenomenality, somatic disorderWhat makes a medical disorder mental rather than (exclusively) somatic or physical? Psychiatry to some extent depends for its existence as a medical specialty on the distinction between mental and somatic disorders, yet the history of this distinction presents a (...) bewildering array of puzzling judgments, radical shifts, and seemingly arbitrary distinctions. The historical observation that putative mental disorders are often reclassified as physical disorders as soon as their physiologic basis is understood further confuses matters. Moreover, recent debates about such classifications often seem to reflect desires to protect professional turf or obtain optimal reimbursement for treatment more than they do the application of a coherent conceptual distinction. No wonder that Brülde and Radovic (2006) disarmingly admit at the outset of their exploration of this question that there is a case to be made that their topic is relatively unimportant or even meaningless intellectually, a rare way to start an inquiry!Could there nonetheless be a cogent conceptual distinction lurking here? Brülde and Radovic usefully invite us to reframe the question, in effect as follows: Suppose we pay attention to professional and lay judgments as evidence but at the same time try to avoid being ensnared by the distortions resulting from turf issues and other pragmatic motives and constraints. Can we then identify some principled distinction in this domain that is worth making and that interestingly corresponds to the distinction generally made between mental disorders and strictly somatic disorders? Brülde and Radovic do not come to any confident or compelling conclusion about this.My answer, based on my harmful dysfunction analysis of disorder (Wakefield, 1992a, 1992b, 1999a, 1999b), is that a mental disorder is a harmful mental dysfunction, where a mental dysfunction is a failure of the capacity of some mental mechanism to perform a function for which it was biologically designed. I argue that, owing to a series of logical missteps, Brülde and Radovic needlessly reject this view. After some preliminary comments and clarifications, I defend the internal dysfunction approach from the objections posed by Brülde and Radovic, and then conclude by elaborating this view in some new ways. Note that Brülde and Radovic critique something they call the "internal cause view" of what makes a disorder mental, and they name others who hold that view. However, my work figures prominently in their discussion, and for expository simplicity, I will presume to simply construe their arguments as aimed at the harmful dysfunction analysis. [End Page 123]Clarifying the QuestionIt is easy to misconstrue the question "What makes a mental disorder mental" as demanding a precise account of the mental, an error to which Brülde and Radovic succumb in their repeated complaints that various writers do not present principled accounts of the mental but rely on lists of prototypical mental states or tentative guidelines to fix the reference of mental. We would need a precise definition of mental if the problem were how to classify cases in which it is ambiguous whether some phenomenon is mental or physical. We might imagine, for example, someone being genuinely puzzled as to whether inability to sleep is failure of a mental function or process. But this sort of puzzle about the boundaries of the mental is not the problem with which Brülde and Radovic are concerned; anyway, ambiguous cases may just be inherently ambiguous. The problem, which a crisp definition of mental will not resolve, is what relation mental states or mechanisms must have to a disorder to make it a mental disorder; must there be mental symptoms, or mental dysfunctions, or either one, and so on? But, even if a precise resolution of the nature of the mental is not needed, some notion of the mental domain is essential in pursuing this discussion. We can pick out the mental ostensively, by pointing to lots of examples (e.g., perception, motivation, emotion, thought, and sensation) much more confidently than we can define it in a principled way. But because Brülde and Radovic find fault in such ostensive reference fixing, let me... (shrink)

A person suffering a mental illness or disorder may differ dramatically from his or her previous well self. Family and close friends who knew the person before the onset of illness tend to regard the illness as obscuring their loved one's true self and see the goal of treatment as the restoration of that self. ‘He is not really like this,’ they will say with increasing desperation. Treatment teams and others, who have no acquaintance with the person when (...) well, respond to what they see in front of them and do sometimes make harmful judgments of character based on the person's presentation when ill. (shrink)