Skepticism about mental disorder

One of the most conceptually puzzling things about the phenomenon of mental disorder is that there are intelligent people who deny that it exists. Nothing is a mental disorder or illness, so they say. This may be a difficult claim to fathom, given everything said about mental disorder so far in the book and in the culture at large. But puzzles are puzzles and should not be neglected. Unscrambling this particular puzzle contains lessons for a theory of mental disorder. Theorists who deny the existence of mental disorder are sometimes called “anti-realists” – in

opposition to so-called “realists”, who affirm the existence of mental disorder. Isn’t it wholly absurd to deny the existence of mental disorders? After all, we have diagnostic

manuals to identify them, don’t we? Psychiatrists seek to treat them. Doctors are not trying to trick people into believing in mental disorders. The anti-realist agrees, of course, that there are thick manuals as well as caring and well-intended psychiatrists. Anti-realists don’t reject the existence of people who talk as if mental disorders are real or of books that purport to identify disorders. No, they reject the existence of mental disorder itself. Is anti-realism warranted? What considerations may lead a person to be an anti-realist?

Some intelligent people find various arguments compelling for an anti-realist position. In this chapter I plan to look at two varieties of anti-realist argument – two forms of radical skepticism about mental disorder. One I call metaphysical anti-realism, and the other moral anti-realism. First, just below I offer a very brief sketch of each form. Metaphysical anti-realism/skepticism: Very briefly, and leaving out details, some medical

scientists and others believe, on broadly empirical and philosophical or metaphysical grounds, that reference to the mind or mentality of a ‘mental’ disorder can and should be eliminated or superseded and displaced by a brain-centered or physicalistic/materialistic and non-mentalistic understanding of a mental disorder. Given such displacement or replacement, no condition

deserves or should deserve, they believe, to be classified as a mental disorder. The number of mental disorders, just like the number of unicorns and goblins, is zero. Moral anti-realism/skepticism: Very briefly, and leaving out details, some critics of the very

existence of a mental disorder charge that the attribution or ascription of mental disorders to people is a morally unacceptable or ethically misbegotten practice. It is morally unacceptable or ethically misbegotten because it is a human dignity violating or respect for persons undermining process. If we truly, it is said, wish to help people who suffer from mental disturbance or distress, we must jettison the concept of a mental disorder or illness and re-describe the condition. We must replace the concept with morally alternative concepts or ways of thinking. These alternative ways should help us to understand and treat people who are mentally disturbed or troubled as compromised, although still fully responsible and not-ill agents. No condition should, they think, be labeled as a mental disorder. Re-describe it as an unwelcome condition, often requiring outside help perhaps, but not as a disorder or illness. Though not enamored of either form of skepticism or anti-realism about mental disorder, I am

convinced that each harbors important and useful lessons for a theory of mental disorder. The main lesson of metaphysical skepticism is that the category of mental disorder has important implications for our understanding of the causal-explanatory power of mind and mentality in the physical world. These implications must be properly understood and addressed, if a concept of mental disorder soundly and sensibly is to apply to persons. The main lesson of moral skepticism is that a diagnosis of mental disorder is morally contestable territory. Recognizing that the attribution of mental disorder is morally contestable territory is not the same thing as maintaining that the medical or psychiatric norms or standards for mental disorder cannot be objective or warranted or that the assessment of a mental disorder necessarily produces wholly intractable moral quandaries. But it does mean that protection or preservation of a person’s dignity and self-respect must be a moral constraint on diagnosis and treatment. Ethically demanding standards for diagnostic labeling and care should be observed. If or when the social power of psychiatric diagnosis is overlooked, “we risk overlooking the moral impact diagnosis has on people’s lives” (Sadler 2004b: 175). In this chapter the lessons of each form of anti-realism develop over the course of examining

each type of skeptical argument. In the first section of this chapter I plan to examine metaphysical anti-realism about mental disorder.