In this paper, I argue for a new way to understand the integration of facts and values in the concept of mental disorder that has the potential to avoid the flaws of previous hybrid approaches. I import conceptual tools from the account of procedural objectivity defended by Helen Longino to resolve the controversy over the definition of mental disorder. My argument is threefold: I first sketch the history of the debate opposing objectivists and constructivists and focus on the criticisms that led to the emergence of the debate. Second, I offer a reconstruction of the “Natural Function Approach” (NFO) argument to make explicit an unsound assumption underlying this approach. The reconstruction will allow me to show that the NFO’s argument depends on the ideal of value-free science that I will criticize. Then I propose an alternative ideal for psychiatry: social objectivity. I argue that the concept of mental health should be seen as “socially objective” rather than value-free, moving the debate towards the social procedures by which the definition is produced rather than the normative and factual content of its definition.
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Another way to address the issue of the definition can be called the «ostensible approach» (see Rounsaville et al. 2002, p. 6 for the appellation). This approach has been defended by Lilienfeld and Marino (1995). They argue that we classify mental conditions as mental disorders if they are similar enough to prototypical cases of mental disorders, such as schizophrenia or depression. Finding an operational definition of mental disorder that would encompass all cases of mental disorders is then seen as doomed to fail. However, this approach leaves aside the question of values in the definition of mental disorder, which is the main interest of this paper.
Regarding the presence or absence of value in the definition of mental disorder, note that Wakefield can also be classified as the proponent of what has been called the “hybrid approach”, because he adopts a “two layers approach” to defining mental disorder. He identifies value-laden and a value-free constituents in the definition: harm and dysfunction. However, since both Wakefield and Boorse argue for the existence of a pure value-free notion of dysfunction in the definition of mental disorder, I believe it is legitimate to classify them in the same approach: the natural function objectivist approach (NFO), being part of the naturalist approach about the places and roles of values in the definition of mental disorder. By this, I want to emphasize the opposition between one side that argues for the sole presence of social and cultural values in the definition of mental disorder, the normativists, and the other side for which at least the dysfunction component in the definition of mental disorder is value-free, the NFO.
One could argue that some specifications such as the potentiality of appropriate treatment in Cooper’s account could overcome this criticism. Since there is no potential treatment for lack of humor, but potential treatment for depression, we could demarcate between healthy and disordered states, even if both are socially disvalued. However, it is not clear that the same kind of demarcation can be drawn for every contentious case. For instance, psychological treatments (unfortunately) exist for homosexuality (and some societies consider this condition bad), but it doesn’t mean that homosexuality should be considered as a mental or somatic disorder. Someone could claim that this treatment is non-effective (then not appropriate, as the definition requires), but that doesn’t show that it can’t potentially become effective in the future. Suppose that in a society S, homosexuality is seen as a bad thing to have and that an appropriate and effective “treatment” exists, then in S homosexuality becomes a disorder. The same goes for ugliness: plastic surgery exists, is practiced by doctors and is in most cases efficient, but this doesn’t mean that ugliness should be conceived as a disorder.
An exception here might be another type of constructivism. The neo-Aristotelian approach has defended the existence of objective values that could guide the demarcation between mental health and disorder, based on the idea of vital goals (e.g., Megone 1998a, b, 2000; Nordenfelt 1995). For instance, Megone’s approach is grounded in Aristotle’s account of dysfunction, in which normal functions are processes and states that allow human beings to live as good human beings. A good human being is to be understood as someone who lives her life according to norms of rationality typical of the human species. Normal functions are those that help humans live a fully rational life (Megone 2000). While this account is innovative, it encounters big enough problems trying to look for alternative options. The main limit of this approach is the controversial nature of “a good human life”, and the claim that this conception can be universal (See e.g., Cooper 2017a, p. 280 for this type of criticism. See also Bolton 2000 and Hobbs 1998 for other lines of criticism). As I show later, it might be better to argue that the type of values at play in the definition of mental disorder be intersubjectively and critically examined rather than found in a neo-Aristotelian account.
It should be noted that the distinction between epistemic and non-epistemic values has been challenged, see e.g., Rooney (2017).
More fine-grained distinctions about the meaning of objectivity could be made (like those made by Douglas 2004 or Lloyd 1995). However, for my purposes here, I am more interested in the distinction made by Longino because I believe it relates the debate over the possibility of an «objective» definition of mental disorder as it took place in the philosophy of psychiatry.
See e.g., Jukola (2015) for a more detailed discussion of Longino’s social objectivity and commercial biomedical research in general, and how major funding from the pharmaceutical industry can partly explain the adoption of “the biological psychiatry approach,” according to which mental disorders have to be understood as neurophysiological failures. As Jukola argues, some proposals have been made to address this specific way that commercial interests affect science, such as the enhancement of public funding (Elliott 2011, see also Haque et al. 2014), but this solution lies outside of the social objectivity model as operationalized it in this paper.
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I wish to thank Anke Bueter, Luc Faucher, Maël Lemoine and Sophia Rousseau-Mermans for their help with previous versions of this paper, as well as three anonymous reviewers for Synthese for their critique, questions and suggestions. Thanks to Eric Muszynski for linguistic revisions and helpful comments. I would also like to thank audiences of the workshops “Philosophy of Medicine Meets Social Epistemology” (Hanover, Germany) and “Issues in Medical Knowledge” (Cologne, Germany) where I gave earlier versions of this paper. This work was supported by the Social Sciences and Humanities Research Council (SSHRC) (Grant No. 767-2014-1733).
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Gagné-Julien, AM. Towards a socially constructed and objective concept of mental disorder. Synthese 198, 9401–9426 (2021). https://doi.org/10.1007/s11229-020-02647-7
- Definition of mental disorder
- Social objectivity
- Naturalism and normativism
- Values in science
- Social epistemology