What is Mental Disorder?: An essay in philosophy, science, and values

410 Pages·2008·2.03 MB·English

by  Derek Bolton

What is a mental disorder?
An essay in philosophy, science, and values
Derek Bolton
OUP 2008

9780198565925
Epigraphs
What health and illness mean in general are matters which concern the
physician least of all. He deals scientifically with life processes and with
particular illnesses. What is ‘ill’ in general depends less on the judgement
of the doctor than on the judgment of the patient and on the dominant views
in any given cultural circle.
Karl Jaspers The fact is that any definition of disease which boils down to
‘what people complain of’, or ‘what doctors treat’, or some combination of
the two, is almost worse than no definition at all. It is free to expand or
contract with changes in social attitudes and therapeutic optimism and is at
the mercy of idiosyncratic decisions by doctors or patients. If one wished to
compare the incidence of disease in two different cultures, or in a single
population at two different times, whose criteria of suffering or therapeutic
concern would one use? And if the incidence of disease turned out to be
different in the two, would this be because one was healthier than the other,
or simply because their attitudes to illness were different?
Robert Kendell
Preface
The question of mental disorder is a curious one. On the one hand, the main
groups involved have other problems to solve.
Psychiatrists focus on their main task – the diagnosis and treatment of the
problems people bring to the clinic – and they can get on with this without
worrying too much about what ‘mental disorder’ really is; it is just assumed or
known that the problems are mental disorders, and there is no need to be held up.
Researchers in the sciences basic to psychiatry are clear about their main task of
constructing causal models of the conditions of interest, but they do not need to
assume that what they are studying are mental disorders in one sense or another,
or that they are mental disorders at all. A particular kind of condition may turn
out to involve, for example, brain disease, or expressions of normal traits in
problematic environments, or perhaps normal at a particular age – but these
options are a matter for the science and not assumption from the start. The other
potential stakeholders in this problem are the people who at some time or
another use mental health services and therefore receive a diagnosis of some
mental disorder, and their parents, brothers, sisters, partners and children, who
all together make up probably half the population, but their immediate concerns
are managing and getting help, and this is not what this essay is about.
In this way to spend time with the question of mental disorder is idling, off main
task. – On the other hand, the question matters much. Psychiatrists and other
mental health professionals in some social and clinical contexts have to be clear
about why some conditions are considered to be mental disorders and others not,
about what the distinction is meant to be, and about related questions such as
why psychiatric treatments are appropriate for some conditions and not for
others. These same questions involve the users or potential users of mental
health services. In constructing causal models of the conditions of interest, the
basic sciences become involved with constructs that are essentially involved in
the notion of mental disorder, such as what is normal or abnormal in the
population, typical or atypical, the effects of lesions and disease processes and
adverse environments, and the meaningfulness or otherwise of people's
responses to them. The public interest is in the way psychiatry carries out the
task of demarcating mental disorder from mental order, and in the fact that
society assigns it this task, even though psychiatry for its main purposes hardly
needs to worry about its meaning. Some way along in the development
of the manuals for diagnosis of mental disorders – the American
Psychiatric Association's DSM and the World Health Organisation's ICD – there
was a need for a definition of what mental disorder is, for the purpose, among
other things, of being clear why certain conditions should be included in them
and others should excluded. Much hung on this, questions of whether difference
or disadvantage or life-style choice was being pathologised and disqualified,
questions of provision of services and funding for treatment – large scale social
and economic questions, matters of public policy.
So the topic of this essay has a curious status, barely visible yet of widespread
importance, many-sided and immensely complex.
This I say partly by way of apology that my attempt to address it in this essay
and the conclusions reached are not as clear as I would have liked. The place the
essay has ended up can be described as sceptical – a scepticism of the gentle
variety. Having considered the ways in which mental disorder is understood in
psychiatric practice, the explicit definitions in the diagnostic manuals, and
bearing in mind the clinical problems that they characterise, and having
examined the more elaborate, rigorous definitions in the surrounding literature,
the most
influential of which is due to Jerry Wakefield, and the sociological approaches,
and the paradigms and general findings of the current science – there ends up
being, so far as I can see, no stable reality or concept of mental disorder; it
breaks up into many, quite different kinds, some reminiscent of an old idea of
madness or mental illness, others nothing like this at all. This instability and
fragmentation corresponds to diversity in the phenomena, in current clinical
services, and in current terminology. I would have settled for one clear proposal
as to what mental disorder really is, but couldn't find one.
That said, the scepticism is just about whether there is something stable, fixed
and distinctive here, for which ‘mental disorder’ is a suitable name. It does not
include doubts about the reality of the phenomena: the distress and disabilities
that people bring to the clinic, and the need for psychiatric, or more generally
mental health professional care. The domain of healthcare as a response to
personal distress and disability seems to me permanent, only mistakenly seen as
something to be deconstructed away. There may be no clear basis for
distinguishing between mental health problems and social problems, or between
mental health problems and ‘normal – more or less normal – problems of living’,
but what distinguishes healthcare is the response to the person involved. The
response is care for the
individual, based on professional training, science and expertise, distinct from
social or political action, or religious judgement, or demands for self-reliance.
By all means there is then a debate to be had as to the pros and cons of one kind
of response as opposed to another, a debate involving many stakeholders, with
some clear cases, and many controversial boundary issues, but healthcare has a
permanent seat in the debating chamber.
I have brought to this essay various parts of my life. I read philosophy at
Cambridge and went on to doctoral and post-doctoral work on Wittgenstein,
following which I read psychology and trained in clinical psychology at the
Institute of Psychiatry and Maudsley Hospital in London. Subsequently I have
worked there as a clinician for many years in various settings, mostly in child
and adolescent services, mainly in-patient and more recently out-patient. My
research interests have been mainly in obsessive compulsive disorder and other
anxiety disorders, including recently behavioural genetic modelling and
treatment studies. The Institute of Psychiatry and Maudsley Hospital have been
great places to work and to learn, full of people with enquiring minds with a
wide variety of clinical and research ideas and expertise – without this
educational environment I never could have attempted such an essay, and I hope
the result does it some justice. The same applies for my experience in the clinic
over many years working with the children, adolescents, parents and families
with many kinds of problems – my gratitude is to them for teaching me about the
reality and the details of these conditions and how they can be managed. At a
personal level I have suffered from a stammer life-long, speech-long, one of the
conditions in the psychiatric manuals of mental disorders, which figure large in
this essay. A stammer produces characteristic communication difficulties and
associated emotional problems which I have had to live with and for which I had
many kinds of speech-and psycho-therapy at various periods, all of which
helped, until finally several decades ago for some reason at that stage in my life I
stopped minding and have been better since. I learnt much from all this, about a
fraction of the great variety of mental health problems from the inside, and the
complications of internalised social exclusion, and the subtleties of change, in
and out of therapy.
Some years ago I began to teach a course the concept of mental disorder, part of
a Masters degree in the Philosophy of Mental Disorder run jointly by the
Institute of Psychiatry and the Philosophy Department of King's College
London. This essay is an outcome of teaching that course, and I have to thank
the postgraduates for many lively and instructive sessions on the topic. It became
ever more apparent to me during these recent years of teaching that the problem
of mental disorder criss-crosses many fields of enquiry: clinical, scientific,
philosophical, literary and socio-political. Sometimes I have made sense of this
by thinking that the subject of mental disorder covers all aspects of being human,
from a certain point of view, as one of the boundary conditions.
My debt to Foucault's broad, penetrating analysis of the modern western idea of
madness and mental illness is evident in the essay. My biggest intellectual
debt is to Jerry Wakefield's work on the concept of mental disorder. His work
has rightly dominated the field for nearly two decades; it draws together many
crucial themes in the medical model of psychiatry, the roles of social norms and
values, and the post-1960s idea that a proper understanding of mind and mental
disorder has to have an evolutionary theoretic basis. This essay ends up in a
quite different place, but it never would have got started without the stimulation
of Wakefield's work, and it never would have got hold of key problems without
having to wrestle with his well-argued, cogent proposals.
While writing the book I have benefited from many conversations on some of its
key problems and from comments on drafts of parts or the whole. I want to thank
particularly Jeremy Adler, Gwen Adshead, Matthew Bolton, Mary Douglas,
Jonathan Hill, Jeff Poland, Jennifer Radden, Nik Rose, and Jerry Wakefield. The
errors of all sorts are mine.
Derek Bolton, London, June 2007
Introduction
The effects of mental disorder are apparent and pervasive, in suffering, loss of
freedom and life opportunities, negative impacts on use of education, work
satisfaction and productivity, complications in law, institutions of healthcare,
intensive scientific research into causes and cures and so on. Suffering, loss of
functioning, and perceived threat are among the personal and social experiences
that can lead to mental health services. Once the problems are brought to the
attention of mental health services and mental disorder is diagnosed, a range of
possible outcomes is licensed, including offer of treatment, funding and perhaps,
depending on severity and other circumstances, paid leave from work due to
illness, possible shame and stigma, and in extreme cases compulsory admission
to hospital, or acceptance of no or diminished responsibility in the Courts.
Mental health professionals engage with the problems inside institutional
structures using manuals for diagnosis and providing treatments that are
increasingly required to be backed by scientific evidence of effectiveness. The
social and institutional outcomes of assigning a diagnosis are important topics
for social scientific theory and research. However, earlier in the chain of events
and consequences are the social manifestations of mental disorder, open for all
to see, and most importantly the personal and interpersonal effects, experienced
by the people with the problems, their families and friends.
Typically the experiences of the people with the problems are of anguish,
confusion, of being in some respects and in some degree unable to carry on with
their normal life. In other kinds of case, the problem is less for the person
themselves and more for others, in the form of threats to safety from behaviour
that deviates from fundamental standards of conduct. These are the kinds of
phenomena that trigger involvement of mental health services and diagnosis of
mental disorder.
Labelling by a diagnosis, but behind that the phenomena themselves, belong
with some positive responses, provision of care and treatment, but they equally
belong with some negative responses, associated with perception of falling
below the level of normal expectations. Add to this the fact that it is the person's
mind that is in question, and the risks of denigration and shame are evident. If
the person's behaviour is seen to present threat to others, then fear is also an
obvious consequence. The negative connotations of mental disorder probably
obvious consequence. The negative connotations of mental disorder probably
outweigh the positive, though the
positive, the provision of care and treatment, are the point of mental health
services. The same issues arise considering that ‘normal’ carries the implication
like us, and ‘abnormal’ not like us. To this extent attribution of mental disorder is
essentially socially excluding: it positions the speaker in the in-group and the
recipient of the label in the out-group. ‘Normal’ mental functioning signifies
belonging to a community of shared practices, emotions and beliefs, in which
one person makes sense to another and is included in ‘we’. By contrast
‘abnormal’ mental functioning signifies a break in perceived sense, a form of
practice, emotion or belief which does not make sense, and which so far
excludes the person from his position as an agent among us. Now in some cases
of mental disorder, such as advanced dementia, or an acute psychotic episode,
isolation from the group occurs regardless of any labelling process. However,
the term ‘mental disorder’ in current usage does not discriminate between these
kinds of case and others, between those and depression, say, or a debilitating
social anxiety, or between the person who was in an acute psychotic state, but is
now out-of-episode. The same term ‘mental disorder’ applies, and profoundly
disqualifying significance clings to it.
There are two main sets of questions to be addressed in this essay, and the first
set is alluded to above. 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 since the 1960s have been dominated by the contrast between norms
that are medical or 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?
There are social norms aplenty, familiar to us, and they can be applied to
personal functioning. In many religious frameworks the fundamental issue is
conformity or otherwise to divine law: piety and sin will be the fundamental
division, and other important distinctions including normal as opposed to
abnormal functioning may be interpreted in those terms, mental disorder then
appearing as sin or devilish influence. In systems of morality generally, being
good as opposed to bad is the main issue, and again other important distinctions
are liable to be regarded in this light. A specific moral value, especially high in
capitalist systems, is productive activity as opposed to uselessness and