The Contrast Class for Madness and Mental Disorder

A fundamental issue in philosophy of psychiatry is the demarcation problem regarding what distinguishes genuine mental disorders from non-disorders. Since the 1960s, naturalist, normative, and hybrid accounts have been defended. Naturalists argue that mental disorders are defined by impediments to normal biological functioning (Boorse, 1976). By contrast, normativists argue that mental disorders are classes of abnormal behavior that society judges to be undesirable and harmful (Cooper, 2005; Sedgwick, 1973; Szasz, 1961). Hybrid theorists argue that genuine mental disorders must satisfy both naturalistic and normative criteria (Tsou, 2021b; Wakefield, 1992). A common assumption in some of these accounts is that the proper contrast class for mental disorder is normal human psychology and behavior. Although few have articulated what “normal psychology” entails (cf. Boorse, 1976), this contrast class implies that individuals who are free of mental disorder possess some minimal (“normal”) capacity for human reasoning or rationality.

In a provocative article, Justin Garson (2023) critically examines the role of reason and rationality in current philosophical theories of mental disorder. He challenges the contemporary orthodoxy that psychological normality (“sanity”) is the proper contrast class for mental disorder, and he rejects the related assumption that mental disorders are paradigmatically marked by the absence of reason. Garson motivates this argument through a historical examination of late modern theorists of madness (viz., Wigan, Heinroth, and Kant), who aimed primarily to distinguish madness from conditions involving detriments to psychological function (‘idiocy’), rather than conditions marked by psychological normality (‘sanity’). For Garson’s late modern theorists, “madness, in its very essence, involves not the absence of reason, but its presence—but in a perverse or unexpected form.” This historical perspective, Garson contends, forces us to reassess the contemporary assumption that psychological normality (‘sanity’) is the proper contrast class for ‘madness’ or ‘mental disorder.’

Garson’s analysis aims to reorient the debate about defining mental disorder by challenging the framework that mental disorder (or madness) should be defined negatively as the absence of reason. Specifically, Garson rejects two entrenched assumptions in the contemporary debate on defining mental disorder:

1. 1. The proper contrast class for mental disorder is psychological normality (‘sanity’).

2. 2. Mental disorder involves detriments to inferential reasoning (‘reason’).

Garson rejects (1) and (2) based on the late modern insight that madness is not marked by the absence of reason, but the presence of a perverse form of reasoning. If there is an “inherent rationality” to madness, then madness cannot be distinguished by the presence or absence of reason. Accordingly, Garson argues that: “We must relearn what it is to define madness positively, in terms of a positive trait or essence or capacity . . . and specifically in terms of an unconventional or surprising [‘perverse’] implementation of reason.” In Garson’s ideal, philosophers of psychiatry should aim to articulate varieties or subclasses of ‘perverse reasoning’ (e.g., psychosis, mania), which are marked by “some additional psychological power.”

Garson’s argument that mental disorders do not necessarily involve detriments to rationality is unobjectionable; however, his argument for shifting the contrast class of mental disorder is unconvincing. Although the signs of some mental disorders (e.g., schizophrenia, bipolar disorder) appear to involve detriments to rationality, there is no general agreement that all mental disorders necessarily involve such detriments (Bortolotti, 2013). For example, depression is a consensus mental disorder that does not necessarily involve detriments to rationality (cf. Tsou, 2013). This stance on whether mental disorders necessarily involve failures of rationality, however, does not imply anything about what the proper contrast class for madness or mental disorder is.

Garson’s argument for shifting the contrast class of madness and mental disorder away from ‘psychological normality’ (‘sanity’) to ‘detriments in reason’ (‘idiocy’) is uncompelling. For Garson, the lesson of late modern theorists is that madness should be defined in positive terms (i.e., perversions of reasoning) or as a positive trait, essence, or capacity, rather than negative terms (i.e., failures of reason). Is the difference between ‘perversions of reasoning’ and ‘failures of reasoning’ as stark as Garson presents? What difference does it make if we conceptualize psychosis or mania as perversions of reason, rather than failures of...