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Symposium III: Conceptions of Disorder

The Concept of Disorder Revisited: Robustly value-laden despite change

Rachel Cooper (Lancaster)

Abstract

Our concept of disorder is changing. This causes problems for projects of descriptive conceptual analysis. Conceptual change means that a criterion that was necessary for a condition to be a disorder at one time may cease to be necessary a relatively short time later.  Nevertheless, some conceptually-based claims will be fairly robust. In particular, the claim that no adequate account of disorder can appeal only to biological facts can be maintained for the foreseeable future. This is because our current concept of disorder continues to be laden with ethical and political values in multiple different ways.

Biography

Rachel Cooper is Professor of History and Philosophy of Science at Lancaster University. Her research mainly concerns issues in the philosophy of medicine, especially psychiatry. Her publications include  Diagnosing the Diagnostic and Statistical Manual of Mental Disorders (Karnac, 2014), Psychiatry and the Philosophy of Science (2007, Routledge), and Classifying Madness (Springer, 2005).

Doctors without ‘Disorders’

Lisa Bortolotti (Birmingham)

Abstract

On one influential view, the problems that should attract medical attention involve a disorder, because the goals of medical practice are to prevent and treat disorders. Based on this view, if there are no mental disorders then the status of psychiatry as a medical field is challenged. In this paper I observe that it is often difficult to establish whether the problems that attract medical attention are caused by a disorder and argue that none of the notions of disorder proposed so far offers a successful demarcation criterion between medical and non-medical problems. As an illustration, I consider why delusions are considered pathological and whether they attract medical attention in virtue of being pathological, where ‘pathological’ stands for ‘being caused by a disorder’. Although there are several promising answers to what makes delusions pathological, available accounts of the pathological nature of delusions fail to distinguish delusions from other irrational beliefs that are not typically thought of as pathological; and cannot explain why delusions typically attract medical attention whereas other irrational beliefs do not.

Biography

Lisa Bortolotti is Professor of Philosophy at the University of Birmingham. Her research interests are in the philosophy of psychology and psychiatry with a focus on belief, rationality, and mental health. For five years (2014-2019), she led an ERC-funded project on the potential benefits of irrational beliefs, called PERFECT. She is the author of Delusions and Other Irrational Beliefs (OUP, 2009), Irrationality (Polity, 2014), and The Epistemic Innocence of Irrational Beliefs (OUP, 2020).

The supplementary volume for the conference will be available from 3-13 July.

Comments

  • Elliot Porter

    10th July 2020 at 7:25 pm

    Hi both. These were very interesting talks. Thanks.

    Both of you at some point mentioned the Wakefield style harmful-disfunction view of disorder, the strengths of which are that it invites us to be very careful with the term ‘harm’. (A congenitally deaf child is arguably not harmed by not hearing when born to deaf parents, whereas they might be harmed if they were made to be hearing, as it could divorce them from their parents experience and culture).

    Part of the worry, if I understand, is identifying the function that ‘dysfunction’ varies from, ie, distinguishing variation from function. I wonder if you have thoughts about something like Bolton’s view? As I recall it, he takes the target of psychiatry to be whatever problem the patient comes to the clinic asking for help with. So we don’t need an order, or disorder, all we need is evidence that ‘this’ kind of complaint can be resolved with ‘that’ kind of tool, and the psychiatrist’s toolkit including ‘that’ tool. (Been a while since I read his book so I hope this is a fair summary).

    Does this cede away too much, or do you think this is a viable way of understanding the object of psychiatry?

    1. Rachel Cooper

      10th July 2020 at 9:20 pm

      Thanks for the question Elliot. I like Derek Bolton’s work very much, and I think he’s right in saying that the issue of whether or not a client has a mental disorder very rarely arises in mental health practice. For an individual mental health practitioner it may be fine to take it that the would-be patient has a problem, and to help if they think they can.

      BUT, I think what Bolton misses is how much pre-filtering goes on before a potential patient ever goes to see a mental health professional. A potential patient only gets to a mental health professional if they and/or other lay people suspect that they have a mental disorder. As such, for the most part any potentially tough questions as to whether the person’s problem is possibly a disorder, or maybe better thought of as something else – a moral weakness, or a social/ educational problem, or a normal variation, or what have you will be resolved before they go and see a psychiatrist. For example, suppose my kid has problems in school, I will only start to wonder if they have a learning disability and maybe take them to see a doctor after I have worked through other possibilities. So I will likely ask their teachers is their work seems within the normal range (i.e. rule-out the possibility that their inability to write is typical for little kids), and then maybe try bribing or punishing the kid (to rule out the possibility that they’re just not trying), and maybe try a different tutor (to rule out the possibility that they’re being poorly taught), before I ever take them to a therapist. Lay people typically try to rule out non-disorder possibilities before going to a professional, and because lay people have a reasonable idea what sort of condition might count as a disorder this means that most of the potential clients a mental health professional sees will plausibly have a disorder. Note that this is likely especially so in eg the UK NHS – where it’s often very hard to get to see a mental health professional.

      I think there are contexts in which the question of whether a condition is a disorder matters. Although an individual mental health professional may well get by okay if they adopt a policy of treating anyone who comes to see them who has a problem they think they can help with, there are important contexts in which such an approach will not do. Our current concept of disorder plays a role in decisions about fairness and justice, and for such questions it will often not be enough to know that someone has a problem and that medical techniques might help. Consider the following case: many students wish they could concentrate better and there are drugs that improve concentration – but we often want to distinguish between those who have ADHD (a disorder) and those who just have normal problems in concentrating. The distinction plays a role in decisions about fairness – students with ADHD can take drugs to improve concentration in exams, students without ADHD aren’t supposed to; the NHS will pay for the medication of those with ADHD and not to help those who’d just like to concentrate better etc.

      1. Elliot Porter

        11th July 2020 at 2:21 pm

        Hi Rachel,

        Thanks for your response.
        I think part of my reticence is that i’m not sure disorder is fit to play the role it gets assigned in a lot of our thinking about justice/fairness. (I haven’t written that chapter of my phd yet, but i’ll get to it eventually). I think we can explain our reasons for permitting use of Ritalin etc in exams, on the NHS’s dime, for people with ADHD and not for others without deploying a concept of disorder.

        The concentration difficulties that ADHD cause tend to put one at a disadvantage vs others in one’s society. Difficulties concentrating can hurt your exam grades, make it hard to meet deadlines at work… ie, give you a lower class degree and get you passed over for promotion, compared to people without those difficulties. The justice concern here seems to be relational to me. We have this drug that will protect you from being de-elevated in relation to your fellow citizens, and for basically republican reasons, we should make it freely available to you, and let you use it in the settings where your most at risk of your ADHD creating relations of disadvantage.

        The reason we don’t let people without ADHD use such drugs in exams is that it just creates an arms race. The purpose of the drug in this context is to level the playing field, not earth up the playing field at the same slope. The reason we don’t readily give out such drugs to people who just want to concentrate better is that these drugs have side effects and our knowledge of how drug use effects the brain in the long term is pretty thin, and the NHS has only so much money to spend and meeting the preferences of would-be-novelists like me lose out in triage against people who have justice-based demands on the health service.

        Without a concept of disorder at play, we still get to say that we should let people with ADHD use these drugs, including in exam settings, and others should not be allowed to. But what we also get to say is that in a society where
        a) relations of equality are so robust that differences in ability to concentrate wouldn’t disadvantage people meaningfully, and
        b) we know that the available drugs have no harmful side effects, and
        c) there is no scarcity of the drugs (so triage isn’t a worry)…
        … then it seems fine for people who just want to concentrate better to take drugs that help them finish their novel.

        I think we can still get the justice results we want from a theory that just looks at variations as ‘helpful’ or not, or ‘satisfying preferences’ or not. (I did have some thoughts on the first argument you made, but i forgot what they were so they can’t have been that important).

        1. Elliot

          11th July 2020 at 3:04 pm

          Edit: having read your response to Lubomira’s question i think i had misunderstood part of your project. My thought about the filtering role was definitely mistaken so i’ve some pacing around to do on that.

        2. Rachel Cooper

          11th July 2020 at 4:34 pm

          Thanks. I think you’re right that some other society (maybe ours in the future) might solve justice/ fairness type issues without using a concept of disorder. But, this being granted, the way we manage many such issues in our society at the moment is via distinguishing between disorders and other conditions.

          I think one difference between Lisa’s paper and mine is that her perspective is much more revisionist. Lisa’s making claims about the concepts we should use (or not use, when it comes to ‘disorder’). I’m making claims about how our current concept of disorder works.

          There are a number of reasons I’m cautious about engaging in revisionist projects regarding ‘disorder’. First the roles played by our current concept are complex, and the consequences of being considered disordered (or not) are massively context-dependent. I think this means it’s hard to predict what sorts of revisions would end up being most useful. Second, I think that actually bringing about conceptual change is really hard – especially when it comes to everyday and much-used concepts, like disorder, as opposed to more technical concepts. In this area I don’t think that any philosophical proposal to revise our current concept stands much chance of success. So, I see my project as being one of description and critique, rather than revision.

    2. Lisa Bortolotti

      10th July 2020 at 10:11 pm

      Dear Elliot, yours is an excellent question. I am sympathetic to pragmatic approaches to what determines the scope of medical practice.
      Suppose my child has problems in school (Rachel’s example). Are those problems medical problems, that is, problems that can be alleviated or even solved by means of a medical intervention? It may be that my child has undiagnosed dyslexia which causes some delays or that they can’t read fluently due to blurred vision. It is also possible that my child is just overwhelmed because we recently moved house and they haven’t got used to their new school yet. So they lack concentration and motivation. Different factors may contribute to explaining the problems. A good idea of the primary cause of the problems can help decide how best to intervene, or whether it is appropriate to intervene at all, so it is worth investigating what causes the problems. But what I want to avoid is the idea that, if the cause of my child’s problem is primarily social or psychological, then my child’s problem stops being a medical problem and appropriate interventions are ruled out unless a disorder or a malfunctioning is identified. If there is an intervention that can support my child in navigating their school environment, then that intervention should be made available to my child. The presence of a disorder or a malfunction should not make a difference.

  • Lubomira Radoilska

    11th July 2020 at 9:44 am

    Hi, Lisa, Rachel! Thanks for your papers! I also have a question for both of you: Would it be helpful, on your respective accounts, to think of ‘disorder’ as an essentially contested concept with a range of viable, partly overlapping, partly competing conceptions? Could this way of conceiving ‘disorder’ allow us to maintain a healthy interest in its conceptual analysis without at the same time committing to a narrow or value-neutral interpretation of the role of medicine in general and psychiatry in particular?

    1. Lisa Bortolotti

      11th July 2020 at 10:52 am

      Hello Lubomira!

      I am not saying that the notion of disorder is useless in all domains—it is possible that it has some currency in medical research, for instance.

      But in the context of medical practice my impression is that it does not add anything and it potentially makes some things worse—for instance generating the sort of filtering that Rachel was describing in her answer to Elliot. By “it does not add anything” I mean that it does not help demarcate medical from non-medical problems.

      Would you agree?

      1. Lubomira Radoilska

        11th July 2020 at 4:03 pm

        Thanks, Lisa!
        I was wondering if we no longer use ‘disorder’ as at least a contributive factor (rather than a decisive one) for figuring out what conditions to treat medically, would that still allow us to distinguish between treatment and enhancement or is that distinction another example of why on your view ‘disorder’ is not fit for purpose?

        1. Lisa Bortolotti

          12th July 2020 at 7:44 am

          Dear Lubomira, I can see why the notion of disorder is used to attempt a distinction between therapy and enhancement. I don’t have a fully worked out position on this but it seems to me that, if we were to accept that disorders are not central in the project of demarcating medical practice, we would probably lose interest in the distinction between therapy and enhancement.

          We would still want to have ways to prioritise some medical interventions, of course, but it is not clear that the distinction between therapy and enhancement is the best way to do so. The interests of individuals and communities and the social context would play an important role in determining which problems deserve our limited resources.

          1. Lubomira Radoilska

            12th July 2020 at 11:33 am

            Thanks, Lisa! This is very helpful.

    2. Rachel Cooper

      11th July 2020 at 12:03 pm

      Thanks for the question. Your question and also Lisa’s paper are helpfully pushing me to try and get a bit clearer what the project of getting an account of disorder might be about.

      I think the project I’m engaged in is initially one of descriptive conceptual analysis. I’m interested in figuring out how our current concept of disorder works, and how it is that we currently determine whether particular conditions are disorders or not. I think that our current concept of disorder presently plays a number of roles for us – eg in fixing who will get treatment (at least when it comes to funded treatment), who will be eligible for sickness benefits, who will be eligible for essay extensions etc etc.

      But although I think our current concept of disorder presently plays a number of roles, I don’t take myself to be committed to the claim that our current practices are justified and should necessarily continue as they are. At this point my project is basically descriptive, I want to understand our current ways of thinking.

      I think my descriptive project has reached a point where I have reached some conclusions – namely I think that our current concept of disorder is such that what conditions count as a disorder depends on various political and ethical judgments and not only on biological facts. In answer to your question Lubomira, I therefore think that our current concept of disorder is essentially contested in the sense that there will be cases where whether we count a condition a disorder depends on value-judgments about matters such as the proper role of the state, and how much we are willing to pay for treatments. These sorts of questions will be contested. I think this is what’s currently going on in debates over the social model of disability. Advocates of the social model will claim that in the case where a wheelchair user has no legs, the disability is caused by the lack of ramps in the world rather than by their physical difference. On my account, their claim is grounded in their belief that it would be better to change the world to include more ramps than to change the person’s body. Others might contest this claim.

      Although, as I’ve said, my project is at this point descriptive, I also accept that description isn’t the end-aim of philosophy and there are important questions to be asked about whether our current practices are justified and how we might proceed in the future. I take it, Lubomira, that your thought is that maybe it would be good to let different groups use ‘disorder’ in slightly different ways – that different concepts of disorder might work well in different contexts. Although this sort of approach may work well for many scientific concepts, eg lots of people argue for something like this re ‘species’, I have some doubts whether this will work for ‘disorder’. Typically, I think different groups can be permitted to use different concepts in different contexts when those groups are relatively isolated from each other – they can then talk within their group as they find most useful. But ‘disorder’ often plays a role in decisions that involve cross-cutting different contexts – if my employer asks for a doctor’s note when I go off sick they don’t want to know whether I have a disorder as ‘disorder’ is used by psychiatrists (but maybe not by employment lawyers, or even by cancer-specialists), rather such practices only work on the assumption that everyone uses ‘disorder’ in the same sort of way.

      1. Lubomira Radoilska

        11th July 2020 at 4:07 pm

        Thanks, Rachel!
        The thought I had about different conceptions of the same essentially contested concept is as follows: rather than agree to disagree (e.g., Group X will use among themselves the concept in an X-sort of way, and Group Y, in a Y-sort of way, while both Groups are aware of the alternative use without sharing in it), most concept-users operate with different conceptions without necessarily realising that the guiding criteria of what they would consider, for instance, ‘disorder’ in some set of cases are different from the criteria they would apply in another set of cases. There will be some overlaps but also cases that are contested as they would satisfy the guiding criteria for one conception but not another. Importantly, these conceptions are irreducible (it would be a mistake to resolve the matter by ‘giving up’ one of the conceptions).

        1. Rachel Cooper

          11th July 2020 at 4:46 pm

          Thanks, that would be an interesting possibility to explore. I guess the way to investigate such a possibility would be to examine how people respond to potential problem cases within a particular contextual frame, eg it might be possible to prime for a physiological-type approach by getting people to think about possible changes that might be detected in a lab, as opposed to being primed to think about whether someone is able to work or not. And, I imagine it might be that within such different contexts people would judge problem cases differently. Do you have any other examples in mind where something like this happens?

          1. Lubomira Radoilska

            12th July 2020 at 11:46 am

            Thanks, Rachel! The example I had in mind had to do with our practices of being and holding responsible, on a pluralist understanding of responsibility, such as the three-fold account offered by D Shoemaker in Responsibility from the Margins (OUP, 2015): responsibility as (1) answerability, (2) accountability and (3) attributability. In many cases, we don’t need to differentiate between these due to overlap in criteria. As a result, we might think that a unified responsibility framework is the way to go. If so, however, cases of, say, full accountability without attributability become hard or contested as the conditions for the former are fulfilled but those for the latter are not.

  • Gilly Singh

    11th July 2020 at 11:52 am

    Hi Lisa and Rachel,

    I found both of your talks very interesting and I do have at least one question (potentially more).

    Do you think that focusing on a purely medicalised account of mental disorder/disability could be the root cause of misunderstandings about what me mean by the concept of disorder in general and the concept of mental or psychological disability in particular?

    I am reminded of Elizabeth Barnes’ “mere-difference” view of physical disability and how she argues in favour of the concept that to have a physical disability is simply to have a minority body. This means that it is possible, and even likely, that aspects of a physical disability can cause harm or be considered disordered without saying that the physical disability itself is a harm. It also shifts the focus of how to overcome barriers caused by ohysical disability on to society and how it relates to those with minority bodies.

    Do you think Barnes’ work in widening the scope of how we understand physical disability could be applied to the field of mental or psychological disability/disorder?

    (I knew it would turn into more than one question.)

    Thank you both for your talks and the work you have done.

    1. Rachel Cooper

      11th July 2020 at 12:16 pm

      Thanks for the question. I think a ‘minority mind’ view is a reasonable way to think about some cases that have traditionally been considered mental disorders. There are some people diagnosed as having ‘mental disorders’ who, maybe with some changes to our society, can find their difference to be largely unproblematic and in some ways beneficial. Examples might be some people with autism, people who hear benign voices. But there are also many cases of mental disorder where I think the mere difference view is less plausible. I find it hard to see how conditions that produce depression, anxiety, and panic could be rendered okay by social changes.

    2. Lisa Bortolotti

      11th July 2020 at 12:35 pm

      Hello and thank you for your question. What you raise is something I have been thinking about recently although I haven’t reached any general conclusion. In the paper I make a point about delusions that I think is relevant: people with delusions often experience harm.

      In some cases, e.g. where the delusion has a very upsetting content, it is clear that having the delusion is harmful. In other cases, there is harm, but it is not clear whether the harm comes from the delusion itself or comes from some other phenomenon that (a) causes the harm and the delusion, or that (b) is an effect of having the delusion. Take (a): maybe it is the unusual experience that the delusion aims to make sense of that is harmful. Take (b): maybe it is the societal response to reporting delusional beliefs that is harmful.

      I tend to agree with Rachel that in some cases changing the social world would not eradicate the harm associated with having delusions, but I do acknowledge that in most cases the harm experienced by people with delusions is a combination of the adverse effects of having the belief and the adverse effects of living in a society that ostracises and stigmatises certain forms of difference.

  • Rachel Cooper

    12th July 2020 at 12:28 pm

    Hi Lisa

    I think one point on which we may disagree is that you think we currently do and should think medical treatment justified in a whole range of cases where we don’t think someone has a disorder.

    I think our current practice is such that the class of conditions for which we think medical treatment justifiable is pretty much co-extensive with the class of conditions we consider disorders. It’s true that doctors also engage in preventative medicine – but this is to avoid future disorders. And pregnancy and child birth – but these are high risk activities and we might think of the medical attention here as being to make sure disorders don’t occur (like having medical staff on hand at a rugby match).

    There are also some cases where medical treatment is permitted even though we don’t think there’s a disorder. Eg plastic surgery – but here there seems to me a difference in that this is generally considered enhancement – it’s something people can pay for if they like, but not something we tend to think people have any kind of right to.

    In the paper you say that medical attention is appropriate when people can’t sleep whether or not the insomnia is a disorder. And in the comments here on children with problems learning you make a similar point.

    I guess I think that in the insomnia and child cases we think medical treatment is appropriate only in those cases where it seems likely that the person has a disorder. If you can’t sleep but it’s because of your noisy neighbours, I don’t think we would consider medical intervention appropriate. Similarly with the kid, I think we’d only think it right that they receive medical treatment in cases where we think they likely have a disorder. If they’re not learning because they’re not interested, or because the teacher is boring I don’t think we would use medical treatment.

    I’m not suggesting that definite evidence of something ‘being wrong’ within the patient is required. I don’t think we hold that medical intervention is only justified if an analogue of something missing on a brain scan is found. But still in those cases where we think medical intervention justified we think that it’s likely that the cause of the problem lies within the patient.

    1. Lisa Bortolotti

      12th July 2020 at 6:37 pm

      Thank you for this Rachel. I noticed we disagree about whether medical intervention can be justified in cases where a disorder is not present.

      I think that, in order to be plausible, the view that only problems that involve disorders can be addressed by medical intervention needs to rely either on an extremely broad notion of disorder or on an extremely narrow notion of medical intervention. Why shouldn’t I be offered sleeping pills or advice on how to sleep better if I have problems at work which negatively affect my sleep? Surely, I should also address those problems in non-medical ways, but isn’t it my problem deserving of medical attention and medical care when it compromises my health and wellbeing?

      Something similar can be said for the case of the child whose reading is delayed. If they have blurred vision, they can get prescription glasses and if they have dyslexia they can get support from learning difficulties experts. But suppose they are overwhelmed and stressed due to recent changes in their lives, such as a sudden move or a new sibling. Why shouldn’t they benefit from the advice of a specialist teacher or an educational psychologist who can help them catch up with their classmates? Why shouldn’t their parents be helped identify ways to support their child at this difficult time? I find the view of medical professionals as pill dispensers too narrow. And I don’t believe in any sharp dichotomy between mental and somatic health. We are people (not brains plus bodies) and should receive care as people.

      In real life things are complicated and I suspect that most problems affecting people’s health and wellbeing are caused by a multiplicity of heterogeneous factors. Even when the cause of the problem seems to be “internal”, it is very challenging to identify what processes (if any) are dysfunctional and what is the source of the harm or suffering the person experiences. This applies to schizophrenia or depression but also to debilitating physical conditions with uncertain causes such as chronic back pain. So, making care hostage to the identification of disorders is impractical and would dramatically reduce the scope of medicine.

      I do see the weakness in my current position, that there is no neat demarcation between medical and non-medical problems. That can be impractical too. It is just a sort of impracticability that I am more comfortable with.