Beyond Dysfunction: Distress and the Distinction Between Deviance and Disorder

Johanna Moncrieff’s and Dan Stein’s commentaries illuminate the complexity inherent in the question we pose in the original paper ‘Can Psychiatry Distinguish Social Deviance from Mental Disorder?’ So much difficulty abounds in addressing such a question: on one hand, there are the difficulties in defining mental disorder that many readers of this journal are familiar with. On the other, there is the critical stance held by some writers to the effect that psychiatry medicalizes human suffering, thus obscuring its moral, social, and political underpinnings (e.g., Rapley, Moncrieff, and Dillon 2011). Adherents of the seminal critique of Thomas Szasz question the very distinction between mental disorder and social deviance, and for them the question of how to delineate the proper domain of psychiatry is nonstarter. An essential discussion, before dismissing psychiatry outright, would consider what to say about those large swathes of humanity voluntarily seeking psychiatric help for their distress. But this is not the central concern of our paper, which does not commit to any strong claim about what or whom should be treated by psychiatrists. Rather, we are concerned to develop one recognized criterion for when people should not be treated by psychiatrists: namely, when their distress is solely the result of social deviance or conflict with society. Given the complexity of this topic which the commentaries highlight—and the potential for misunderstanding, which may explain some of our disagreement with Moncrieff in particular—our response partly clarifies our approach and thesis, and partly takes issue with specific points made by the commentators.

Mental Disorder: Separating Empirical From Conceptual Considerations

Let us begin by revisiting the conceptual basis of attributions of mental disorder. Criterion E is not, as we argued with Stein et al. (2010, 1765), conceptually necessary, but is of ethical and political importance given the historical context. Thus, notwithstanding the other criteria, a condition can only be considered for candidacy for mental disorder if “dysfunction” is present. What is a dysfunction? As Moncrieff puts it, there is a tautology in the definition of mental disorder where it is stated that a mental disorder reflects an “underlying psychobiological dysfunction” (Moncreiff 2014, 257). Moncrieff argues that this is flawed because underlying processes have not been established, which renders the definition tantamount to saying that a dysfunction is a reflection of a dysfunction: a definition that adds nothing to our knowledge.

Here Moncrieff follows Thomas Szasz in finding a lack of resemblance to physical disorder to be the primary problem with the concept of mental disorder (see Fulford et al. 2013).¹ In pursuing this, the critical psychiatrist not only fails to see the complexity of the concept of physical disorder, but also commits the same error as the biological psychiatrist. The latter implies that an ever longer awaited complete neurochemistry of mental health conditions would solve the conceptual problems. The former—the critical psychiatrist—implies the converse; that the absence of proof for the “existence of separate and distinct foundational processes,” as Moncrieff (2014, XX) puts it, proves that mental health conditions are not disorders. As we have argued elsewhere, identifying the biological basis for a set of behaviors or symptoms does not in itself pick out what is pathological or disordered: for example, a complete description of the neurochemical states governing sexuality would not permit the inference that homosexuality is a disorder, any more than discovery of the neural correlates of falling in love or criminality would make these mental illnesses (Bingham and Banner 2012). Neurobiological changes—their presence or their absence—tells us about conditions when we find them by other means, but it does not tell us what is or is not a disorder. The same arguments could be run for underlying psychological processes. Consequently, emphasis on scientific progress or failure to progress in understanding the neurobiological correlates of mental health conditions does little to advance the conceptual debates, a point that may help to explain the impasse in the ongoing exchange between...