Gary Chan, Professor of Law, Associate Dean (Faculty Matters & Research), Singapore Management University
The issue of mental illnesses and health has received increased media coverage lately. We sometimes hear and read about the mentally ill person being subject to medical care and treatment, detention in psychiatric institutions, or even ostracisation from the rest of society. What does it really mean to say someone is mentally ill or suffers from mental disorder?
In his seminal book, The Myth of Mental Illness (1974), Thomas Szasz had regarded mental disorder as a myth. Psychiatry to him was merely a study of personal conduct not illnesses. However, the existence of mental disorders or illnesses is not generally disputed now. But its precise definition remains elusive. The late psychoanalyst RD Laing saw mental illness as a reaction of a person to abnormal social pressures resulting in deviations of his or her conduct from social norms. An English judge had suggested that the term “mental illness” should be based on how the ordinary sensible person would understand it – a definitional approach which understandably allows judicial flexibility but is, at the same time, somewhat unsatisfactory.
Mental Disorder as a Hybrid Concept of Natural Dysfunction and Harm
I wish to examine one concept of mental disorder. According to Jerome Wakefield in the American Psychologist (1992), a mental disorder is a harmful mental dysfunction. A mental dysfunction refers to the failure of the mental mechanism to perform a natural function for which it was designed by natural evolution. Harm, on the other hand, are consequences that are deemed negative based on socio-cultural norms. So a person with mental disorder is one who suffers from a natural mental dysfunction which results in harmful effects.
According to him, mental disorder as ‘harmful dysfunction’ is therefore a hybrid between purely scientific accounts and purely normative accounts of mental disorder. The two accounts are useful for explaining the concept of mental disorder.
So a person with mental disorder is one who suffers from a natural mental dysfunction which results in harmful effects.
First, the scientific account. Mental processes are naturally selected and have natural functions. Wakefield explains that a function of an organ (such as the heart pumping blood) is distinct from its other effects (sounds produced in the chest). A function is defined as the purpose for which an organ or mechanism is designed in order to causally explain the existence, structure or activity of the organ or mechanism. Only effects that are non-accidental are important for understanding the natural function of the organ or mechanism. When the natural mechanism in question produces remarkable benefits and depends on “intricate and harmonious interactions”, we infer that the effects are non-accidental.
Second, the normative account. Harm refers to negative consequences which affect a person’s well-being. As a normative concept, harm is not concerned with explaining the cause of the mental condition. Wakefield gives clear examples distinguishing natural dysfunction from harm. Marital and occupational conflicts are socially harmful but not natural dysfunctions, however a breakdown or total loss of function would count as a dysfunction (such as a total hallucination where the perceptual apparatus of a person with respect to his environment breaks down).
Why should we subscribe to a “hybrid” concept? For one, a purely factual/scientific notion of mental disorder seems incomplete. Take the example of the scientific notion of biological disadvantage in terms of survival and reproduction. Biological disadvantage is essentially a relative concept that is dependent on statistical deviation. If a purely scientific account of disorder is applied, different rates of fertility between populations may lead to the conclusion that lower fertility is a disorder in one society but not the other. This is not desirable. Something appears to be missing here. The concept of biological disadvantage does not distinguish between disadvantages due to a dysfunction in natural mechanisms and those arising from the harmful environment.
Conversely, a natural dysfunction does not necessarily result in biological disadvantage. For instance, a natural dysfunction such as a condition that results in the slowing of the ageing process might well be advantageous to the individual. Though a natural dysfunction, it is not a disorder to begin with. This is where the separate concept of harm can play an important role in determining the scope of mental disorder.
In addition, the purely normative account of mental disorder may fall short. Such an account can be utilised as a form of social control. It can lead to social stigma associated with the purely normative concept of mental disorder. In the past, for example, there was the notions of “drapetomania” associated with slaves who fled from their masters, childhood masturbation disorders and the classification of homosexuality as mental disorders. These were “mental disorders” made up to explain social deviations, which in hindsight have been marginalised to the fringes of scientific literature. To pre-empt such stigma, mental disorders should be defined not only with reference to harms but also natural dysfunction based on fact and biology.
Wakefield writes about the divergence between ‘natural dysfunction’ and ‘harm’ by referring to male aggression and reproductive fitness. He first notes that “high levels of male aggression might have been useful under primitive conditions, but in present-day circumstances such aggressive responses might be harmful”. Second, he observes that “[s]mall decreases in reproductive fitness can be important over the evolutionary time scale”, but they are “not necessarily harmful in the practical sense relevant to disorder”. From the above, he suggests that the mental health theoretician is interested in the “function that people care and need within the current social environment” and not merely those based on evolution.
Thus, harm is based on the assessment of current social needs and circumstances unlike the concept of natural dysfunction which is based on a significantly longer time scale. As Wakefield states in a subsequent article, the inability to read due to a dysfunction of the corpus callosum (the part of the brain linking the left and right hemispheres) is a harm in modern-day literate societies but not in pre-literate societies. On the other hand, the linguistic mechanisms that supply the human capacity for communications are natural functions.
“Hybrid” concept of natural dysfunction & harm
Harm is based on the assessment of current social needs and circumstances unlike the concept of natural dysfunction which is based on a significantly longer time scale.
Natural Mental Dysfunction and Harm – Not So Distinct?
The above assumptions about the distinct requirements of mental disorder does not however tell the full story. Natural dys(function)s and harms are not as distinct as Wakefield made them out to be. For one, harm and dysfunction are, in substance, effects that occur in the environment. Harms are adverse effects that are socially assessed. Similarly, a natural function refers to effects which are non-accidental based on the benefits produced, and their intricate and harmonious interactions.
Further, the concept of natural dysfunction is undergirded by natural selection and evolutionary design. Mental mechanisms such as cognitive, affective, motivational and behavioural dispositions are part of the evolutionary processes. The concept of natural (dys)function can evolve and change over time. A mental mechanism does not have fixed or universal attributes but are adaptive in nature. In this regard, socio-cultural norms – which are important for determining harm – share similar adaptive features.
Bergner had argued that Wakefield’s concept of mental disorder raised an epistemological objection: that it is impossible to be certain about mental disorders since it is dependent on knowledge about internal mental mechanisms and their evolutionary history which are largely absent. Wakefield’s response was that indirect evidence would suffice if they gave rise to the inference that the mental mechanism in question has failed to perform a function based on natural design. This implies that precise knowledge about the mental mechanisms and their evolution would not be necessary for determining a natural dysfunction.
In his later work, Wakefield notes that due to local cultural reasons, the “symptomatic expression of a dysfunction, or the symptomatic indicators of dysfunction versus normality” may vary though “cultures, whatever their values, cannot construct disorders from whole cloth”. This is based on an application of DSM diagnostic criteria in the US and Taiwan. The differences observed there pertained to academic stress and the relative emphasis on individuality and family between US and Taiwan. The upshot seems to be that culture can affect the determination of the dysfunction requirement. Though Wakefield did not explicitly say so, from a conceptual perspective, the relevant cultural norms may be indirect evidence for inferring natural design from the “symptomatic indicators of dysfunction”.
Natural dys(function)s and harms are not as distinct as Wakefield made them out to be…Culture can affect the determination of the dysfunction requirement.
Consider the norms in a particular society X which expect their young adults to withstand stress at work with relatively greater stoicism than those from another society Y. For society X, there may be a high threshold of mental fortitude expected of a young working adult when faced with stress at work, which is not present in society Y. As a result, a weakened mental condition that results from work stress expected of a person of a certain level of mental fortitude may be regarded as dysfunctional (failure of the mental mechanism) in society X but not in society Y. The societal norms may constitute indirect evidence for assessing the symptoms in order to make the inference that the mental condition that arises in society X should be considered a mental dysfunction. If so, the determination of mental dysfunction is not totally separate and distinct from socio-cultural norms.
Finally, there are grey areas as to whether a mental condition falls under a natural dysfunction or social harm. For example, should we regard a deterioration of memory as a natural dysfunction or social harm or both? Not all of us have perfect memories, and the decline of memory is part of the natural ageing process. Given these background circumstances, at what point does a decline in memory become a natural dysfunction? In the case of Alzheimer’s disease which is associated with the accumulation of amyloids in the brain, this would clearly be a natural dysfunction. Barring a clear scientific and biological basis for a mental condition, whether the deterioration of memory per se constitutes mental disorder may depend on the extent to which the person’s capacity for retaining (and consequently using such) information has been seriously compromised or can be traced to a biological dysfunction of the brain.
The societal norms may constitute indirect evidence for assessing the symptoms in order to make the inference that the mental condition that arises in society X should be considered a mental dysfunction. If so, the determination of mental dysfunction is not totally separate and distinct from socio-cultural norms.
Alternatively, we can legitimately look at the deterioration of memory from the lens of the adverse effects on that person’s ability for social communication and interactions which constitutes social harm. Memories of past events and relevant facts constitute the building blocks for sharing one’s own experiences and beliefs with others and for navigating his physical and social environment. This is an important aspect of his personhood and identity. Given that man is a social animal, the natural design of mental mechanisms is arguably to facilitate and enhance social communication and interactions.
Wakefield’s distinction between harm and natural dysfunction is useful in clinical treatments and for alleviating social stigma associated with mental conditions that are designated as harmful by society though lacking in biological basis. The distinction is also important for comparison with the purely scientific and purely normative concepts of mental disorder.
That being said, the concept of social harm is not always separate from that of natural dysfunction. Natural selection and evolution impact affect the determination of a natural dysfunction. The ‘nature’ in ‘natural dysfunction’ is neither fixed nor universal. This allows for some interaction with socio-cultural norms. Hence, the determination of natural dysfunction is not based solely on the strict aetiology of mental mechanisms and their evolutionary history, but may be inferred from indirect evidence that a mental function has failed to perform as naturally designed. Finally, it is not always clear whether a case falls under natural dysfunction or social harm or both where the factors underlying the social norms and nature can sometimes be inextricably linked.
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About the author:
Gary Chan is a Professor of Law and Associate Dean (Faculty and Research), School of Law, Singapore Management University. His main research interests are Tort Law, the Singapore Legal System and Ethics. He has published numerous books, chapters and journal articles and participated in conferences in Singapore and abroad. He is the co-author of The Law of Torts in Singapore (Academy Publishing) and is also a member of the Editorial Board of Torts Law Journal. Gary Chan was appointed amicus curiae and appeared before the Singapore Court of Appeal.
He graduated with an LL.B (Second Class Upper Honours) from the National University of Singapore and obtained his LL.M (Merit) from the School of Oriental and African Studies, University of London. He also obtained a Bachelor of Arts in Philosophy (Second Class Upper Honours) from the University of London, Masters of Arts in Philosophy of Religion and Ethics (Merit) from the University of Birmingham as well as a Masters of Arts (Southeast Asian Studies) from the National University of Singapore. He is an Advocate and Solicitor of the Singapore Supreme Court and an Attorney & Counselor-at-law (New York).
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“What I did was find two people who are very close to me and mentioned how I am feeling to them,” says UK illustrator Sharmelan Murugiah. “It just opened me up a little in order to then seek more professional help and really look into myself and figure some shit out.”
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