The Journal of Mind and Behaviour
Spring 2001, Volume 22, Number 2
The Concept of Mental Illness: An Analysis of Four Pivotal Issues
The concept of mental illness is explored through an examination of four key foundational issues. These are (1) the notion of the "mental" as it relates to psychopathology; (2) the concept of illness; (3) the relationship of mental illness to concepts of function and malfunction; and (4) sociocultural dimensions of psychopathology. The problematic status of the concept of mental illness is investigated through locating it within the various discourses of biomedicine, psychology, law, and sociology and by explicating and relating the philosophical underpinnings of those discourses.
In mid-1999 the President of the United States ordered the Federal Employee Health Benefit Plan to provide federal employees with insurance that established "full parity" between mental illnesses and those more accepted maladies that are the physician's stock and trade (Causey, 1999). The President urged private insurers nationwide to end their favoured practice of maintaining special restrictions on payments for the treatment of mental disorders. Yet while mental patients and those professionals who care for them undoubtedly rejoiced, what can only be termed philosophical rumblings occurred in the popular media. Various journalists described to their lay readership many of the issues that, over the last few decades, have confounded philosophers (Moldover, 1999; Rowan, 1999).
Defining and delimiting illness, especially when the illness is the kind treated by psychiatrists and psychologists, is not straightforward. What properly is encompassed by the category "mental illness" turns out to be a matter on which consensus is not easily reached. Standing at the intersection of various conflicting cultural contexts, the concept of mental illness seems to possess an inevitable nebulousness. The competing biomedical, psychological, sociological, and legal perspectives on mental illness assign to it distinctive and often incompatible properties. The conceptual ambiguity of mental illness, as it turns out, derives from many perennial philosophical quandaries that are at the foundations of the disciplines that seek to conceptualise it. An inquiry into the nature of mental illness entangles us unavoidably with perennial philosophical issues: mind and body, freedom and responsibility, fact and value.
What follows is an exploration of issues that are basic to the philosophy of psychiatry, a discipline whose origin owes much to Szasz's (1974) seminal critiques of the mental illness concept. Through an exploration of these issues I shall attempt to delineate some philosophical assumptions that underlie various discourses addressing mental illness and begin to adumbrate the intellectual and cultural space that the concept of mental illness occupies.
The "Mental" in Mental Illness
Our inquiry into the concept of mental illness begins with a focus upon the mental. Using the adjective "mental" to modify the noun "illness" indicates that the illness is of or about the mind. Historically, in both psychiatry and law, this adjectival relation has signified either that the primary symptoms of an illness were mental or that the causes of an illness were believed to reside in the mind. Yet, as we shall see, neither the presence of mental symptoms nor mental causes is either necessary or sufficient for a malady to be designated a mental illness.
Psychopathology's most spectacular manifestations are its cognitive and emotional aberrations. The delusions and hallucinations of psychosis and the intense affect found in the mood and anxiety disorders are prototypical of mental disorder. But many, if not most, of the classic psychological symptoms of mental disorder are present in conditions that fall outside the boundaries of mental illness. Hallucination, for example, can be a symptom of starvation, high fever, sensory deprivation, religious ecstasy, or drug action. And the varieties of mental anguish characteristic of many psychiatric disorders can be generated by all kinds of circumstances.
In fact, the current version of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV; American Psychiatric Association, 1994) specifically excludes from its purview symptomatology that is. "expectable and culturally sanctioned," e.g., grief immediately following the death of a spouse. When mental symptoms result from a "general medical condition" (read physical illness), this circumstance is exclusionary for a diagnosis of most paradigmatic mental disorders contained in DSM-IV.
DSM-IV distinguishes between primary mental disorders and those stemming from either a general medical condition or a disorder that is "substance induced." The distinction drawn here is essentially that formerly labelled as functional versus organic: old diagnostic wine in a new nosological bottle (American Psychiatric Association, 1994, p. 165). DSM-IV's authors claim that the distinction between primary mental disorders and those stemming from a general medical condition should not be taken to imply that there are fundamental differences between mental disorders and general medical conditions. The terminological dichotomy, however, introduces some circularity, in that a general medical condition is defined as a medical condition that is not a mental disorder, and a primary mental disorder is defined as a disorder that is not a component of a general medical condition. In addition, primary mental disorders are described as having "no specified aetiology" (American Psychiatric Association, 1994, p. 165). With this language DSM-IV stipulates as a kind of axiom the historical role of psychiatry as a processor of aberrations within the category of illness. Mental illnesses are enigmatic, poorly understood maladies that normal physicians do not treat.
Unless we assume that all human conduct is a kind of Diltheyian expression of mind, many symptoms of psychopathology are not mental at all, but behavioural or social. Mentally ill people frequently play the social roles assigned to them either incompetently or with great distress, and their actions often are objectionable to others. They may behave in a bizarre, ineffective, unattractive, or even dangerous manner. Social deviance theories of mental illness, favoured by sociologists, behaviourists, and such opponents of mainstream psychiatry as Szasz (1974) and Foucault (1964/1965), regard the labelling of any conduct as mental illness to be a political act and view conduct so labelled as simple social deviancy that has been medical zed and proscribed by the culture. The social deviance perspective on mental illness tends to blur the boundaries between mental illness, on the one hand, and criminality, social ineffectiveness, or cultural variation, on the other.
Clear cases of universally recognized mental illnesses where mental symptoms may be absent are the somatoform disorders, those conditions that in different eras have fallen under various rubrics: hysteria, psychosomatic illness, and, currently, the favoured and highly descriptive "unexplained physical complaints" (American Psychiatric Association, 1994, p. 469). These disorders frequently involve no emotional or cognitive abnormalities, simply the presence of somatic symptoms, e.g., blindness, that cannot be explained via a known physical mechanism.
Sometimes the "mental" in mental illness refers to the kind of cause that is assumed to underlie pathology. A common approach to conceptualising psychopathology is to assume that mental illnesses are underlain by a class of dysfunctions of the mind, or brain, that cause the symptoms of an illness. A number of authors (Boorse, 1997; Kendell, 1975) have followed this line, which leads to a kind of naturalism about psychopathology, one that often is predicated on a kind of medical mind-body dualism.
Historically in psychiatry, a dysfunction of the mind has been posited in one of two instances. The first of these occurs when there exists a theory of psychogenesis, such as psychoanalysis, that hypothesizes mental entities to be the underlying causes of the symptoms of a disorder. The second instance involves the presence of symptoms in the absence of a physicalistic explanation. Psychogenic aetiology may be inferred solely from the absence of a known underlying physical mechanism, thus revealing a premise that originated even before Paracelsus and has governed Western medicine for the past century. Disease entities, whether they be causes or symptoms, belong to one and only one of two categories - either the physical or the mental - these two categories being mutually exclusive (Robinson, 1996). Patients whose distress, whatever its variety, cannot be linked to a scientifically explained physical pathology are assumed to be suffering from a psychogenic disorder. Individuals afflicted with multiple sclerosis, Wilson's disease, temporal lobe epilepsy, and numerous other maladies currently within the purview of somatic medicine were once regarded as mentally ill. Through the course of medical progress mental illness has served as a residual category in which poorly understood or refractory illness has been placed, only to exit when medical science caught up with the disorder (Grob, 1991).
Medical dualism was never more pronounced than at the middle of the twentieth century when there was a clear division of theory types between the mentalistic psychodynamics of Freudian theory and the biological idiom of the rest of medicine. Recent trends within Western medicine, however, suggest a move away from mind-body partitioning. The advent of such disciplines as psychoneuroimmunology and behavioural medicine has brought us evidence, in many domains of medicine, of the close connections and complex concurrent interactions among mental, behavioural, and somatic variables. When we examine many somatic illnesses (e.g., hypertension) from the various stand- points of aetiology, symptomatology, and treatment, they emerge as complex entities with multifaceted interacting components, with both mental and physical causes (Baum and Posluszny, 1999; Cohen and Herbert, 1996).
Oddly enough, the categorical wholism that is emerging from contemporary Western medical research bears some resemblance to indigenous, non-Western constructions of illness within which human suffering is conceived non-dualistically. The traditional division between psyche and soma in Euro American medicine is not reflected in the conceptions of illness held by “the great majority of the world's people, including many in North America, [who] experience human suffering in an integrated, somatopsychological mode: as simultaneous mind and body distress”. (Lewis-Fernandez and Kleinman, 1994, p. 67)
The courts, on various occasions, have been called upon to address the concept of mental illness, as distinct from insanity. In such cases, for the most part, jurists have been content to defer to psychiatric authority. Illustrating this trend the United States Supreme Court has assumed that "the term [mental illness] can be given a reasonably precise content and that the 'mentally ill' can be identified with reasonable accuracy" (O'Connor v. Donaldson, 1975, p. 575). When there is no clear psychiatric consensus on whether a condition qualifies as a mental illness, the Supreme Court has deferred to state legislatures in matters of definition, suggesting that these bodies are the appropriate cultural mechanisms to clear the turbid waters of professional disagreement (Kansas v. Hendricks, 1997).
In one set of circumstances the courts have been called upon to analyse the concept of mental illness in detail. In the United States, policies written by private health insurance companies often place limits on mental health care benefits. Frequently, these limitations are predicated upon the dualistic mind/body categorizations described earlier. The question before the court in such cases is whether a particular malady is subject to mental illness limitations, a matter that is usually reduced to the question "Is the condition at issue a mental illness or a physical illness!"
Three distinct juridical approaches to discriminating mental and physical illnesses have resulted (Cook, 1995). Two of these are predicated on the criteria described earlier, either symptoms or underlying causes, respectively. When courts employ a symptom-based analysis, they tend to rely not on standard diagnostic manuals nor on expert testimony but rather upon ordinary vernacular distinctions between mind and body. Under this rule, a patient suffering from delusions would be considered mentally ill because a lay understanding classifies such symptoms as "mental" and persons manifesting such symptoms as mentally ill. Although irrelevant in symptom-based juridical analyses, expert testimony is crucial when courts adopt a causation-based model. In this approach expert opinion as to aetiology is the determining factor. If symptoms are ruled to be somatic in origin, the illness is considered physical, no matter what the symptoms might be. A third, treatment-based approach, sidesteps analysis of the symptomatology or aetiology of the disorder to focus entirely upon the kind of treatment medical authorities deem appropriate. In this approach mental illness tacitly is conceptualised as the kind of disorder that mental health professionals treat, whether the treatments employed are psychosocial or psychopharmacological in nature.
The use, in science or law, of causation-based criteria for categorizing illness as mental or physical is challenged by the concept of ‘supervenience’, taken from the philosophy of mind. The majority of contemporary philosophers of mind believe that mental events supervene on physical events, i.e., biological events in the brain (Chalmers, 1996; Kim, 1993). The supervenience of the mind on the brain does not mean that every mental event is reducible to a brain event. It implies that for human beings (as opposed to conceivable silicon creatures or human-like residents of a twin earth), mental events do not occur in the absence of an underlying biology and that, ultimately, mental processes are caused by physical processes. Supervenience would suggest that for any causal story involving mental entities, there is a potential parallel account involving physical entities. All illnesses with mental causes, therefore, also would have causes that could be described in physical terms. What could discriminate mental illnesses from somatic illnesses would be not the presence or absence of a biological underpinning, since, within a supervenience-based account, everything mental is grounded in the biology of the human organism.
Perhaps an illness might be categorized as mental if a mental causal explanation were the best available account. This might be the case if the mental explanation were more parsimonious, elegant, heuristically powerful, or simply conceived at a more suitable level of analysis. For example, a theory hypothesizing depression to result from cognitions about the self might be more scientifically or therapeutically valuable than a parallel physicalistic theory that accounted for the same events through a translation of cognition into biology. This could be simply because the parallel biological account turned out to be too complex, not as easily tested with extant research methods, nor as helpful for clinicians.
Whether we focus on causes or symptoms, deciding upon the essential features of mental illness is not straightforward. Nor is distinguishing mental illness from physical illness. In the following section we will see that some of the imprecision in our ideas about mental illness results from nebulousness in the cluster of concepts that includes "illness," "disease," and "disorder."
The Concept of Illness
"Illness" is a concept that is related to other concepts such as "disease," "disorder," "medical condition," "malady," "defect," and "disability." Various distinctions can be drawn among these. For example, in somatic medicine, infectious diseases are distinguished from traumatic injuries, and understood to be fundamentally different kinds.
One such distinction, that appeared in the early writings of the philosopher Christopher Boorse (1975) and later was taken up by the medical anthropologist Arthur Kleinman (1986), is that between disease and illness. This distinction is between theoretical and practical concepts of sickness, respectively. Disease is conceived in naturalistic terms, as a malfunction of an organismic mechanism, and is thought to be a value-free concept. Illness, on the other hand, is regarded as a value-laden cultural category that is contextualised within a complex web of formal and informal social practices. A recent influential account of mental disorder, that of Wakefield (1992), also holds that the theoretical and practical dimensions of psychopathology can be separated into a value-free component (a mind/brain malfunction) and a symptom set that is socially disvalued. Various assumptions that underlie these accounts turn out to be questionable, as I shall show in the next section.
The Sick Role
Sociological concepts related to illness are medicalisation and the sick role. As the purview of medicine and its allied disciplines is extended into more and more of social life, i.e., society becomes medicalised (Conrad, 1992), illness becomes a metaphor for a greater segment of human experience. Individuals and groups are categorized as sick, dysfunctional, addicted, compulsive, traumatized, and so on. The sick role, as described by Parsons (1975), comprises two interrelated kinds of requirements and exemptions. The sick person is not considered responsible for being in the grip of an illness, the amelioration of which also is deemed to be out of the patient's control. Capacities to perform a variety of everyday roles are viewed as impaired and the sick person is relieved of some obligations to function normally. In exchange for exoneration from various forms of responsibility, the patient is expected to accept the "illness" label and to cooperate with treatment by authorized healers.
Since Parson's classic formulation, the sick role seems to have evolved somewhat in the direction of greater responsibility being assigned to the patient. As the aetiology and course of medical conditions are illuminated and greater variance in many illnesses is attributed to behavioural factors, individuals can be held accountable for contracting or aggravating illness. In contemporary morally pluralistic and relativistic societies, maintaining a salubrious lifestyle may emerge as one of the few values on which a broad consensus can be reached (Brandt and Rozin, 1997).
The sick role is notoriously exculpatory on those occasions when criminal defendants are adjudged not guilty by reason of insanity (Reznek, 1997). The courts have developed various definitions of legal insanity. The most important of these involve (1) the cognitive defence: mental illness rendered the defendant ignorant of the nature of his or her act; and (2) the volitional defence: mental illness rendered defendant unable to control his or her impulses. The American Law Institute's Model Penal Code incorporates both theories, allowing either to be sufficient, in stating that a person is not responsible for criminal conduct if that person, as a result of a mental illness lacks “substantial capacity either to appreciate the criminality of his conduct or to conform his conduct to the requirements of the law.” (American Law Institute, 1985, Section 4.01)
On the whole, courts and legislatures, as well as legal and psychiatric professional associations, have accepted the cognitive defence but have had greater misgivings about absolving individuals who claimed to be unable to resist criminal impulses. Determining what a defendant knows has been regarded as a scientifically defensible endeavour. Assessing the power of destructive impulses or the efforts and capacities of defendants to resist them, however, has been thought a dubious undertaking by many legal scholars (English, 1988). Among these, the English jurist, Lord Parker, argued that there exists no evidence that could compel the decision between "he did not resist his impulse" and "he could not resist his impulse" (Reznek, 1997). In a similar vein the American Psychiatric Association's Insanity Defence Work Group concluded that the line between "an irresistible impulse and an impulse not resisted is probably no sharper than that between twilight and dusk" (American Psychiatric Association, 1983, p. 685). The APA Work Group suggested that expert testimony might simply confuse jurors, a plausible suggestion given how much philosophical confusion has resulted from the underlying issues. The volitional defence often requires juries to pit the intentional idiom of folk psychology against the causal language of psychiatry in describing and explaining a single action, and then to decide which is preferable. Parallel conflicts between deterministic and volitional paradigms now are commonplace in many spheres of society as the terminology and explanatory models of psychological science exert great influence over everyday discourse and decision making (Woolfolk, 1998).
When deviant conduct is of the sort we think should not be deemed "freely chosen" and if we also believe that a certain kind of humane attitude toward the conduct is appropriate, then we will be inclined to apply an illness label to it. One attempt to clarify the boundaries of illness has emanated from philosophical work on functions. Much of this effort has involved the attempt to describe mental disorders as biological malfunctions.
Mental Illness and Malfunction
Some writers have contended that mental illness involves a departure from the normal and proper functioning of the mind/brain (Klein, 1978). This view takes an objectivist, naturalist position on mental illness, in that the malfunction of a mental mechanism, a component of our species design, is held to be necessary for psychopathology. It is further assumed that the putative malfunctioning underlying mental illness can be discriminated from proper functioning, or functioning according to design, by a value-neutral empirical analysis. This naturalist picture of mental illness as malfunction is at variance with normativist or social constructionist accounts.
The concept of malfunction, which is pivotal to this view, is intelligible only in relation to a conceptualisation of proper or normal functioning. And normal functioning is intelligible only in relation to the concept of a function. Three concepts of function have been discussed extensively in the philosophical literature. They are etiological functions, propensity functions, and Cummins functions. For each of these, there are corresponding analyses of proper functions and malfunctions, each with various implications for the concept of mental illness.
An etiological function is conceived as the effect of a trait or organ that was favoured by natural selection due to its enhancement of inclusive fitness. In the etiological sense an organ is performing its function properly when doing what caused it to become part of our equipment through natural selection (Millikan, 1989; Neander, 1991; Wright, 1976).
The malfunction of an etiological function is, simply, the failure or deficiency of an organ in doing that which caused it to evolve to its present form. Etiological functions and their related malfunctions can be determined objectively, at least in principle, by evolutionary biology. In practice, however, ascertaining the relation of current traits to fitness in times past is, at best, an uncertain enterprise, given the rather primitive state of evolutionary science.
If we choose to define malfunction etiologically, many human capacities and proclivities, and some psychopathology, may lie outside the function/malfunction dimension. In order to malfunction, an organ must have been selected for at a time when it enhanced fitness. Some of our current mind/brain apparatus may have no etiological function whatsoever because it was never selected for. It is probable that some features of the mind/brain are what Gould and Lewontin (1979) term "spandrels," features not in themselves fitness-enhancing but that arise as by-products of other correlated developments that are fitness-enhancing and, hence, favoured by natural selection. The mammalian navel, the white colour of bones, and the human chin frequently are classified as spandrels. If there are numerous mental spandrels, as Gould (1997) has suggested, then we are replete with mental mechanisms that are indirect products of evolution but have not been selected for. They, therefore, possess no etiological function. Because spandrels have no etiological function, they cannot, in the etiological sense, malfunction.
Much theory in evolutionary psychiatry has proposed that mental illness may result from the mind/brain functioning properly in the etiological sense, albeit in an environment for which it was not designed (Murphy and Woolfolk, in press). The social competition theory of depression, for example, hypothesizes that within the small, cohesive tribal groups of the Pleistocene an episode of depression might have been an adaptive response to a fall in status or the loss of resource holding power. In response to such vicissitudes, depression enables the unfortunate individual to conserve energy, reduce costly behaviour, and elicit aid from others, thereby providing the opportunity to develop new and potentially more effective tactics for gaining status (Nesse, 2000; Price, Sloman, Gardner, Gilbert, and Rohde, 1994). The theory has it that depression-eliciting events were relatively rare in the lives of early humans, but that in the contemporary world one is bombarded with stimuli that are continuous reminders of those who are richer, prettier, smarter, etc. Thus overloaded relative to their designed capacities, our status detection mechanisms send us spiralling down into dysphoria. Whether this story about depression turns out to be true is less important than its possibility and potential testability. Not only depression, but also the anxiety disorders and several personality disorders have been theorized to be not malfunctions but responses consonant with the species design, albeit in circumstances where "proper" functioning results in psychopathology (McGuire and Triosi, 1998).
Thus behaviour that qualifies for a DSM-IV diagnosis could occur in the absence of any mechanism that is, in the etiological sense, malfunctioning. In one case, spandrels, there may be no adaptive function involved at all, hence, no malfunction. In the other case, mechanisms selected by evolution, when functioning as designed, may bring about patterns of behaviour that, for various reasons, we would choose to classify as pathological.
A propensity function is defined in relation to its tendency to enhance fitness in a present or future environment (Bigelow and Pargetter, 1987). When contrasted with etiological functions that are defined historically, propensity functions are said to be "forward-looking" in their import, in that they refer to probable future selective success rather than to a history of selection. Propensity functions take into account that a previously adaptive trait may no longer function to enhance fitness in its current environment, e.g., the predatory equipment of domesticated animals that no longer hunt for food. Or traits that originally conferred either no adaptive advantage or disadvantage, subsequently, could become fitness enhancing in a novel environment. Indeed, almost any trait, in some environment, might enhance the chances of survival or procreation either of individuals or the kinship groups to which they belong.
If our concept of malfunction is predicated upon propensity functions rather than etiological functions, a somewhat less restrictive picture of malfunction emerges. Because propensity functions are environment-relative, their malfunction can result from a mismatch between environment and evolutionary design. For example, the propensity concept of function, unlike the etiological concept, would allow us to view our antediluvian limbic systems as malfunctioning in response to stress, even though all features might be operating in accordance with the evolutionary blueprint.
Propensity functions have in common with historical functions that they make fitness (survival and procreation) the test. The fitness criterion is appropriate in the case of etiological functions since selection due to fitness caused the feature to be there in the first place. But how do we export the propensity model of malfunction to societies where people's chances to survive and procreate are not systematically biased by their psychological traits? The propensity perspective suggests that no psychopathology (at least that requiring malfunction) would be present there. We, of course, easily can imagine a society where the brightest and the best (and the "healthiest") choose not to procreate or to procreate less than other groups. Fitness seems an odd criterion to apply in these cases, but any alternative standard would surely derive from cultural values and related concepts of human flourishing.
A third kind of function, named after the philosopher who proposed it (Cummins, 1975), makes no reference whatsoever to the enhancement of fitness. A Cummins function refers solely to cause and effect within a system specified by an analytic inquiry, characterizing the present causal relations between the system and its component parts. In this sense it is the function of the heart to pump blood, not because of its history of natural selection, but because the heart is a component of a larger system, the circulatory, within which it plays a vital causal role.
Cummins functions are termed "interest relative," meaning that the function of a component is always relative to a given analysis of a system that comprises the component. The designation of the system may be the result of an arbitrary explanatory interest. No background context of inquiry need be privileged over any other, as is the case with the privileging of an evolutionary account by etiological functional analysis.
Cummins functions allow great latitude with regard to the designation of function and malfunction. Many different kinds of outcomes are associated with living systems. Such systems subsist and procreate, but they also become diseased and die. And if our interest is in the explanation of the processes of disease and death, we may construct functional analyses that illustrate the contributions of our organs to such baneful outcomes. In this kind of endeavour various containing systems with interacting components can be described. In such analyses we can speak properly, in the Cummins sense, of the coronary arteries functioning to accumulate plaque, the lungs to host pneumococci, and of cancer cells functioning to interfere with cellular nutrition.
There is universal acceptance of the proposition that a heart that cannot not pump blood is a malfunctioning heart and is, therefore, pathological. But the consensus on such judgments of malfunction does not depend upon an evolutionary account of why hearts exist, but rather unanimity of opinion on the question of what hearts are for. We all want the heart to circulate the blood, whether it evolved to do so or not. What we wish to explain and why those explananda are important to us, the relations between knowledge and human interests, seem crucial here in making the functional analyses of somatic medicine appear to be evaluatively neutral. The "proper functioning" or "normality" of the body is uncontroversial to the extent that there is consensus on what constitutes health and infirmity. Human beings universally disvalue death, discomfort, and incapacity. Therefore, to the extent that somatic structures and processes are relatively invariant and reliably related to universally desired health outcomes, Cummins functional systems, and their corresponding malfunctions, can be constructed within a common background of explanatory and valuational interests.
Malfunction as a Problematic Criterion
The belief that many mental illnesses originate in mental modules that are not performing according to the design of evolution is at the foundation of various naturalist views that posit a realm of function and malfunction that is independent of human interests. The assumption that etiological malfunction underlies psychopathology has led to some promising empirical work on autism and psychopathy conducted within a cognitive science/evolutionary psychology framework (Blair, 1995; Leslie, 1987).
To the degree that we attempt to make etiological malfunction a necessary condition, for psychopathology, however, we negate a postulate of writers as diverse as Freud, Cannon, and Selye. This view, that has guided psychiatry and clinical psychology for a century, is that our species is in many respects not cut out for the contemporary world and that many of our emotional difficulties stem from the stresses placed by modem society upon a "stone age psyche" reacting exactly as it was designed to.
When malfunction is defined in relation to either propensity functions or to Cummins functions, a distinction between theoretical and practical concepts of illness becomes difficult to sustain. Since propensity malfunctions imply lack of success within a given environment, they seem to resuscitate, as a criterion for psychopathology, that shibboleth, "adjustment to society." In the case of Cummins functions, we require background assumptions concerning biological or psychological normality or desirability to impute malfunction to a component within a system. These assumptions likely will emanate from the practical arena of clinical medicine or from the culture at large.
The Social Construction of Mental Illness
There is little doubt that categories of psychopathology historically have been intertwined with structures of power and with cultural norms. Drapetomania, the desire of slaves to escape captivity, was in the early nineteenth century considered a mental illness (Cartwright, 1851/1981; Szasz, 1971). Victorian physicians regularly performed "therapeutic" clitoridectomies on masturbators, who also were thought to be pathological. As recently as 1938, listed among the forty psychiatric disorders in a leading textbook (Rosanoff, 1938), were moral deficiency, masturbation, misanthropy, and vagabondage. Homosexuality, which had been universally regarded as a manifestation of mental illness by Western psychiatry, was "officially" depathologised in 1973, after a contentious political struggle, by a vote of the board of trustees of the American Psychiatric Association (Kutchins and Kirk, 1997). Other conditions commonly regarded as pathologies by many clinicians and researchers, e.g., Premenstrual Dysphoric Disorder and Masochistic Personality Disorder, were denied official status as mental illnesses after highly polemical and acrimonious conflicts among the parties who influenced the fashioning of DSM-IV. Not so long ago psychiatrists in the former Soviet Union performed an Orwellian manoeuvre of medicalising opposition to the state when they employed the diagnosis "sluggish schizophrenia" to effect the incarceration of many political dissidents (Bloch and Reddaway, 1977).
Writers of a social constructionist bent (Gergen and McNamee, 2000; Sarbin and Mancuso, 1972) are inclined to conclude from the long lamentable catalogue of psychiatric folly that psychopathology is pretty much a matter of what conduct and states of mind are fashionable across history and culture. They hold that mental illness is fundamentally about what a society values, as with musical tastes or standards of proper attire. This position is often contrasted with the naturalist/biomedical view that mental illnesses are universals, natural kinds (each of which is underpinned by an identical biological deep structure) that are constant across culture and history. If the normativism/cultural relativism espoused by social constructionist writers were true, we might expect, through historical or cultural research, to find societies where it was the norm to be what we would today term pathological. This turns out not to be the case for the major psychiatric disorders: the psychoses or the mood disorders. The prototypical mental illness, schizophrenia, comes close to being universal and uniform across diverse societies, although such incidentals as delusional content (e.g., thinking oneself to be Bill Gates rather than Napoleon), of course, are variable. We unfailingly recognize one of the first depressions to occur in Western literature, that of Sophocles' Ajax. His symptoms: loss of appetite, anhedonia, sadness, and suicidality, still define the disorder, which also is described in the Bible and other ancient sources.
It is not surprising that severe mental illness is not valued as a universal modus vivendi in any known society. Psychotics and depressives cannot serve as the cornerstones of any society in which energy, ingenuity, and cooperation are necessary for that society's survival. This is not to say that within complex societies with excess resources there cannot be subgroups where psychopathology is the norm. Nor is it the case that societies cannot prosper if many or all of their members engage in conduct or have experiences that contemporary Western psychiatry would regard to be indicative of mental illness, e.g., hearing voices that do not emanate from living persons (Jaynes, 1976; Mezzich, Kleinman, Fabrega, and Parron, 1996).
Culture accounts for significant variance in mental illness, just enough to refute the biomedical view. There are many specific syndromes, such a koro (the delusion that one's penis is retracting into the abdominal cavity and that death will ensue) that are unique to particular cultural contexts. Symptoms that indicate pathology in one society, e.g., regularly hearing the voice of a dead relative, are normal and customary in others. The epidemics of anorexia nervosa and bulimia in the contemporary West are unprecedented, but are spreading to upper classes around the world, along with Westernisation and its current aesthetic ideal of a slender female body (Ung and Lee, 1999). Writers such as Ian Hacking (1995, 1999) have argued persuasively that some mental disorders, e.g., multiple personality disorder, are roles that are created by the theories and practices of the mental health professions and subsequently enacted by patients. The articulation and dissemination of information about psychopathology through professional activities and by the media provide a symptom set and patient profile that can be assimilated by disturbed individuals with sufficient psychic malleability. On this view clinical theory and practice are not only mirrors of cultural norms but shapers of those norms as well (Woolfolk, 1998).
If we count as mental illnesses those disorders that represent the extremes of various personality types, e.g., narcissistic personality disorder, as DSM-IV does, the cultural case becomes much stronger. Factors highly influenced by socialization; attitudes toward self, intimacy, and authority, as well as patterns of emotional expression and interpersonal relations, are the constituents of personality and also constitute the dimensions of those highly variable cultural norms that are the diagnostic criteria in this controversial region of psychopathology, the personality disorders.
Although mental illnesses supervene on biological processes, these processes are complex and poorly understood. Despite the public relations clout of an effective biomedical lobby bankrolled by an affluent multinational pharmaceutical industry, the claim that mental illnesses have been shown to result from straightforward metabolic imbalances has not been substantiated. There is no biological laboratory test for any mental illness that confirms or disconfirms a diagnosis derived from a clinical interview. The clinical interview continues to be the diagnostic "gold standard." No biological theory of aetiology for any of the major disorders has been confirmed by empirical research. For a given disorder, effective somatic treatments, invariably, are motley sets with heterogeneous mechanisms of actions and frequent unwelcome, harmful effects (Breggin, 1997; Frank, 1997; Valenstein, 1998). Nor is specificity found when treatments, rather than disorders, are examined. Most psychotropic medications have broad-spectrum effects. When a drug is therapeutically efficacious, it often diminishes symptoms in a variety of ostensibly dissimilar disorders (Healy, 1998).
The naturalistic conception of mental illness given by biological psychiatry inevitably fails to take into account that psychiatry is not only a branch of knowledge but also a social institution that fashions and adjusts what the sociologist Benjamin Nelson (1981) termed directive structures, cognitive frameworks that channel and motivate behaviour through the articulation of what is "valued" and "normal." Directive structures are analogous to Parson's (1977) normative order: the norms and values instantiated in and disseminated by social institutions and that maintain social solidarity, regulate social action, and control social deviance. Contemporary Western societies have tended to medicalise, as opposed to criminalize, social deviance. The more societies choose to medicalise social deviance, the more psychiatric disorders they will recognize and the greater numbers of their citizens will be subject to the ministrations of mental health professionals. Once in the mental health care system, individuals are conceptualised as victims or sufferers, not as malefactors. Where to draw boundary between responsible volition and irresistible impulse, this is an ancient question for which neither science nor philosophy generates certain answers. Thus intertwined with human interests, psychiatry must reflect its social context, as surely as it is one of the forces shaping that context, sometimes in its own image.
Mental illness has been conceptualised within a number of intellectual frameworks: psychiatric, legal, sociocultural, and evolutionary. These various perspectives often diverge in their articulations of mental illness, furnishing to society and policy makers a concept that is ambiguous and controversial. The various discourses addressing mental illness are predicated on perennial philosophical issues of mind and body, freedom and responsibility, fact and value. When the philosophical underpinnings of these discourses are analysed, the conclusion is reached that the concept of mental illness cannot be completely naturalized. It is both descriptive and normative, possessing no sufficient condition and no necessary feature, save that of being disvalued by some relevant decision maker: a patient, a member of a patient's family, or an agent of society.
The intellectual functions of the notion of mental illness often seem to be those of other biopsychosocial concepts occurring at similar levels of abstraction, e.g., stress, trauma, and addiction, that of organizing objects of scientific research conveniently, but without straightforward theoretical implications. An unpacking of the mental illness concept perhaps provides less scientific guidance than it does a kind of interdisciplinary appreciation of our past and present views of what it means to be a human being and to flourish or founder as such.
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