Mental Disorder and the Boundaries of Illness

Can we draw a boundary that places some of our moods, experiences, beliefs, and behaviours within the remit of mental disorder and so within the province of psychiatric care? Can we assert that this person’s sadness is no longer continuous with everyday sadness and has crossed over into a clinically significant condition such as Depressive Disorder? Clinicians are able to offer positive answers to these questions: with the aid of diagnostic criteria for disorders of the mind, and with their expertise with similar cases over many years, they proceed to determine whether the person’s condition is of a nature and degree that warrants a psychiatric diagnosis.

But when we ask whether we can make these distinctions what we are questioning is the justification for our judgements as clinicians. Could it be that sadness is too hastily diagnosed as Depressive Disorder? Could it be that the threshold for acceptable grief is being drawn too tight? Could it be that we, as a society, no longer see value in sadness as such and so endeavour to eliminate it? Could it be that normality is being ‘medicalised’?

These concerns suggest that the judgements that we make – and which appear to be objective – harbour certain values: sadness holds us back, teaches us nothing, and needs to be treated; ‘voices’ are merely ‘hallucinations’ that have no interpretive relevance – there is nothing to learn from them; modes of attention that privilege mind-wandering (e.g. ADHD) are detrimental to learning and need to be controlled.  

As a way of pushing against this claim, and as a way of protecting a region of illness and incapacity from the excesses of over-interpretation, there have been many attempts in philosophy to clarify the boundaries of mental disorder. The reasoning was this: if we are able to define mental disorder without appeal to values, if we are able, that is, to define a scientific, objective concept of disorder, then we could respond to the accusation that psychiatry trespasses into areas of life that have nothing to do with medicine. The argument would be that the boundaries of mental disorder are not determined by our values but by our nature (hence the approach came to be known as naturalism). However, support for this view has not been forthcoming. Despite decades of sophisticated philosophical work, it has not been possible to define mental disorder in a way that excludes values.

Now, the fact that naturalism has not been able to resolve our disagreements concerning what is mental disorder does not make these disagreements disappear; they shift elsewhere, and if we go along with where they have moved to, we might be able to acquire some clarity in understanding their nature. The particular disagreements that I address in An Approach to the Boundary Problem (Rashed 2021) arise from the challenge of mental health activism to social and psychiatric notions of mental illness. I am referring here to particular approaches within Mad Pride activism, where activists resist the medicalisation of madness by rejecting the language of 'mental illness' and 'mental disorder' and presenting madness as grounds for identity.

There are many approaches in mental health activism; there are those, for example, that focus on improving services and reforming psychiatry within a broadly medical model. But Mad activism goes beyond this and formulates the problem as one to do with respect and recognition. What is at stake is the way in which people's identities are publicly represented and valued, with the dominant view of madness as a disorder of the mind being seen as an affront to identity. In this respect, the aims of Mad activism overlap with those of other social movements that not only oppose discrimination but seek cultural change in the wider society. Mad activism is trying to emulate the success of these movements by broadening the cultural repertoire as it pertains to madness beyond medical and psychological models of illness.

The central claim of Mad activism is that madness can be grounds for identity, and the central demand is for society to recognise the validity and value of Mad identity. From this claim and demand we can see that Mad activism transforms the debate surrounding the boundaries of illness. It shifts the debate from a concern with naturalism and the definition of disorder, to a concern with individual and social identity, and with social recognition. Possible disagreements are therefore no longer about the limits and meaning of mental disorder but about the limits and meaning of identity and the scope of recognition. In other words, we encounter other boundary problems.

This should be evident once we examine the central claim of Mad activism, which is that 'madness can be grounds for identity'. The problem here is that phenomena such as unusual beliefs (delusions), passivity experiences (e.g. thought insertion), voices (hallucinations), and extremes of mood undermine identity formation in various ways. Is it possible to reconcile this with a political demand that presupposes certain capacities for identity formation? In An Approach to the Boundary Problem (Rashed 2021) I examine these concerns and develop a set of concepts and judgements that can inform a new way of thinking about the boundary problem.

Mohammed Abouelleil Rashed is a researcher and lecturer in philosophy of psychiatry and a practicing community psychiatrist. He is the author of Madness and the Demand for Recognition: A Philosophical Inquiry into Identity and Mental Health Activism (Oxford University Press, 2019).