Mental Disorders: A Scepticism of Gentle Variety

"The place the essay has ended up can be described as sceptical – a scepticism of the gentle variety. Having considered the ways in which mental disorder is understood in psychiatric practice, the explicit definitions in the diagnostic manuals, and bearing in mind the clinical problems that they characterise, and having examined the more elaborate, rigorous definitions in the surrounding literature, the most influential of which is due to Jerry Wakefield, and the sociological approaches, and the paradigms and general findings of the current science – there ends up being, so far as I can see, no stable reality or concept of mental disorder; it breaks up into many, quite different kinds, some reminiscent of an old idea of madness or mental illness, others nothing like this at all. This instability and fragmentation corresponds to diversity in the phenomena, in current clinical services, and in current terminology. I would have settled for one clear proposal as to what mental disorder really is, but couldn’t find one. 

That said, the scepticism is just about whether there is something stable, fixed and distinctive here, for which ‘mental disorder’ is a suitable name. It does not include doubts about the reality of the phenomena: the distress and disabilities that people bring to the clinic, and the need for psychiatric, or more generally mental health professional care. The domain of healthcare as a response to personal distress and disability seems to me permanent, only mistakenly seen as something to be deconstructed away. There may be no clear basis for distinguishing between mental health problems and social problems, or between mental health problems and ‘normal – more or less normal – problems of living’, but what distinguishes healthcare is the response to the person involved. The response is care for the individual, based on professional training, science and expertise, distinct from social or political action, or religious judgement, or demands for self-reliance. By all means there is then a debate to be had as to the pros and cons of one kind of response as opposed to another, a debate involving many stakeholders, with some clear cases, and many controversial boundary issues, but healthcare has a permanent seat in the debating chamber."

From the Oxford series 'International Perspectives in Philosophy and Psychiatry'