Defending Social Objectivity for "Mental Disorder"

First, I want to thank PPP for the privilege of having my work read and commented on by esteemed colleagues. In this response, I briefly review some of the key issues that they have raised. These issues include 1) the usefulness of a definition of mental disorder for North American psychiatry, 2) the absence of a concrete criterion to address the demarcation problem, 3) the place and role of values in such a demarcation, and 4) the worries of over-inclusiveness, problematic values and imposition of values.

The Usefulness of a Definition of Mental Disorder for North American Psychiatry

The first question that needs to be clarified is raised by Waterman's commentary (2021): Is it really necessary to define mental disorder and mental health? Here I feel I should clarify a background assumption of my account, and more generally of what I see as legitimate motivations for the quest of defining mental disorder. I agree that defining concepts should be done according to the function(s) of these concepts in particular contexts (see Gagné-Julien, forthcoming). In the context of psychiatry, Waterman cites Varga's impetus for a definition of mental disorder: 1) to match medicine conception of disorder 2) to reduce stigmatization. I tend to depart from Varga's impetus. Rather, I think that in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (rather than in general), a definition of mental disorder should play at least two roles: To explain and justify why a condition is conceived as a mental disorder and why it has been included as such in the DSM. If no definition of mental disorder is available, then no explanation or justification is available to ground the decision to conceptualize a particular condition (e.g., major depressive disorder) as a disorder. I think this is problematic for an influencing tool like the DSM not to offer any "satisfying" definition of mental disorder in this sense.

I agree with Waterman that the core activities of psychiatry are patients care and research. But I also believe that what conditions are perceived to be mental disorders influence these core activities. For instance, if major depressive disorder is seen as a mental disorder, then resources for care will be developed and research will be pursued to understand better the condition and to develop possible treatments. I also agree with Waterman that in its actual state, the DSM definition of mental disorder is of little use in explaining and justifying the inclusion of particular conditions in the manuals with regards to the goals of care and research. So far, these reasons are implicit and potentially problematic. But because the DSM (and the inclusion of particular conditions as mental disorders) influences for which conditions psychiatry will develop caring resources and research projects, I believe a satisfying definition of "mental disorder" is still needed in the DSM.

The Place and Role of Values in the Definition of Mental Disorder

In his commentary, Tsou (2021) asks why we should locate values at the level of dysfunction rather than at the level of harm. I think it's important to emphasize that my argument for the adoption of an amended version of the causal role theory of function (CR) is based on the rejection of the value-freedom thesis usually associated with the notion of dysfunction. That is, I give credence to arguments that have shown that functional attributions are value-laden, or for Wakefield's evolutionary theory of function, that this is not an appropriate theory of function to define mental disorder (e.g., see Bingham & Banner [2014], Doust, Jean Walker, & Rogers [2017], and Binney [2018a, 2018b]). Therefore, I am not arguing that we should locate values at the level of dysfunction. Rather, I take for granted that most functional attributions in medicine and psychiatry are valueladen, and I propose a framework to manage this value-ladenness as objectively as possible (since avoiding this value-ladenness is hardly feasible). Because functions are value-laden, I do not see the interest of maintaining...