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