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