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Mental Disorders
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by Allan V. Horwitz
University of Chicago Press, 2002
Review by George Graham, Ph.D. on Apr 8th 2002

Creating Mental Illness

Imagine that, for whatever reasons and by whatever means, you could keep your mind/body alive long enough to experience life in, say, the twenty-third century.  How many sorts of classified types of mental illnesses and disorders would you find there?  The nearly four hundred of DSM-IV?  Only a few dozen?  Or perhaps several thousand?

If Horwitz has his way, only a few dozen, and perhaps even less.

According to Horwitz far too many “mental illnesses” exist.  All sorts of human distresses and disturbances are classified in DSM and comparable taxonomies as mental illnesses and disorders.  However, says Horwitz, the label “mental illness” is misapplied to most of them.  Some “disorders” are normal and appropriate reactions to stress.  People react distressfully or unhappily to social or individual circumstances.  Sill others are forms of social deviance that reflect the reinforcement practices of sub-cultures, the impulses of improperly socialized individuals, or the metabolisms of poverty and unemployment.  We need less “mental illness”.  Much less.  A few dozen perhaps.  Forces both medical and economic have created false truckloads of them.

The metaphysics of psychological distress or disturbance in the Horwitz-orientated style envisages two nonoverlapping domains of distress that are unequal in metaphysical standing and should be treated unequally or differently in medical practice and public policy.  Distresses that are genuine illnesses share a certain essential property that is unshared by conditions that are distressful or disturbing, in some sense, but which are not illnesses.

The essential property of mental distresses or disturbances that are illnesses is that they consist in something being wrong with -- dysfunctional about -- the mind/brain and such that, as a result, the behavior displayed is socially deviant or inappropriate.  Many conditions regarded by DSM as disorders fail to possess this stringent essential property. Schizophrenia does; panic attacks do not.  Bipolar depression does; heavy alcohol consumption does not.

Horwitz enters the strenuous debate over how to interpret the nature of mental illness.  However unlike many other parties to the debate he does not take himself to be defending realism (mental illnesses are real) against anti-realism (mental illnesses are not genuine illnesses) or anti-realism against realism.  He occupies a niche in the Sober Middle.  Some “illnesses” are real; some (many) are not.  This middle, this equator is dense with conceptual foliage and tough to pass through.  The best way in which to say something that others will read is to say something visibly clean and simple: to be a non-sober realist or anti-realist, with as few details, distinctions, case studies, nuances or qualifications as possible.  The Sober Middle, by comparison, can seem thick and laborious.

This book may seem dense and laborious.  The print is small.  The type is pale.  The chapter titles, with the likes of ‘The extension of mental illnesses into the community’ and ‘Diagnostic psychiatry and therapy’, appear like headings in a doctoral dissertation.  And although the book’s title is enticing, this book is not about creating mental illness as such, but about overextending the label “mental illness”.  However if you dismiss this book because of such surface qualities you will be making a big mistake.  For many readers of this review service this is a Must Read book.

The writing may not be media-attention getting, but the content is superb.  It is filled with insights into the social, historical, and economic forces responsible for the overmedicalization of human unhappiness and distress.  It offers careful analyses of the research methods and results of several different theoretical frameworks for understanding and treating mental disorder.  It both compassionately appreciates and prudently deprecates the use of pharmaceuticals in the treatment of mental illness.  It explores the pretensions of claims for the genetic determination of mental illness.  It admonishes recognizing how the vicissitudes of human social life quite often appropriately produce much depression, grief, and anxiety.  It urges temperance and restraint on the part of mental health professionals who otherwise too eagerly see gains both financial and social to be made by treating conditions that are not illnesses as illness.

All sorts of topics that have received much discussion of late in the literature on mental illness find mention and use here.

·                    Rise and fall of Freudianism.

·                    Dramatic onset of diagnostic psychiatry.

·                    Illness as disease.

·                    Deinstitutionalization of the mentally ill.

·                    Competing forces of research and clinical practice on the evolution of schemes of psychiatric classification.

·                    Overemphasis on reliability in the justification of mental illness categories.

·                    Proper roles of symptoms, context, and etiology in diagnosis.

·                    Social construction of multiple personality disorder.

·                    Status of schizophrenia.

·                    Stress and vulnerability.

The list goes on.

In recommending this book so strongly I am not endorsing each of Horwitz’s attitudes or judgments, of course.  The philosopher, and one of his intellectual confidants, Jerome Wakefield has contributed, Horwitz reports, to his reliance on the notion of internal dysfunction (something wrong with the mind/brain) to help to distinguish genuine from non-genuine mental illnesses.  Wakefield’s efforts at defining “mental illness” are among the best in the literature, but I remain skeptical about the notion of an internal dysfunction to which they appeal.  Horowitz, too, has sympathy for the reality of schizophrenia as a discrete disease or illness that I am not sure I share.

However being of Sober Disposition myself, and not prone to idealize my likes to the point of flawlessness, the flaws in this book – its ‘Wakefieldism’, its under-appreciation of the motley character of schizophrenia – help to make it a book to take to the cottage this summer.  Mild disappointment is part of the interest of a book so otherwise illuminating and penetrating.

 

© 2002 George Graham

 

George Graham is a professor of philosophy and of psychology at the University of Alabama at Birmingham.  He is the co-author of When Self-Consciousness Breaks.  His ‘Recent work in philosophical psychopathology’ appears in the April 2002 issue of the American Philosophical Quarterly.