Head Games

What are the rules for defining mental illness?

Jacob Sullum from the January 2003 issue

(Page 3 of 3)

Here is where Horwitz runs into trouble. As persuasive as he is in debunking psychiatry's pseudomedical pretensions, his own approach relies far too much on murky, tendentious definitions that cannot be applied objectively. "Psychological dysfunctions exist when some internal system of cognition, memory, linguistic ability, motivation, aggression, or perception is unable to perform properly," he explains. "A mental disorder indicates that something is wrong with the capacity of an internal mechanism to perform as it is designed to perform, not that an individual has made poor choices in how to behave. This incapacity renders a person unable to conform to social rules and so their impairment is involuntary....The distinction between mental disorders and deviant behavior is the distinction between people who can't conform and those who won't conform."

Horwitz concedes that telling the difference may be tricky. "The boundaries between 'appropriate' and 'inappropriate' functioning will often be very fuzzy," he says. "The value component of the appropriateness criterion in definitions of mental disorders insures that all disorders will have blurry rather than distinct boundaries." He cites pedophilia as an example. "Adults who sexually molest young children...are generally treated as having criminal responsibility for their behaviors because of the extreme social abhorrence of child molestation," he says. "The distinction between people who can't function appropriately and those who won't function appropriately is far more a moral value judgment than a judgment based on psychiatric knowledge."

It's hard to see how the odiousness of a crime can indicate that it was not the product of an "internal dysfunction." Indeed, people often make the opposite argument: that a crime was so heinous no sane person could have committed it. Horwitz appears to be dodging the implications of his claim that "internal dysfunctions" can make people do bad things. (As Szasz is fond of noting, Congress did something similar when it arbitrarily excluded pyromania and kleptomania from the conditions covered by the Americans with Disabilities Act.) It seems preferable simply to discard the concept of uncontrollable impulses, especially since Horwitz does not explain what causes them (saying only that "social as well as biological or psychological factors might be responsible") or how to distinguish them from ordinary urges.

Although Horwitz rejects the biomedical view of (most) mental disorders, he clings to its most troubling tenet: that people with mental disorders are not responsible for their actions. Whether mental illness is attributed to a hypothetical brain disease or to an "internal dysfunction" of indeterminate origin, the moral implications are the same. Which is why the world needs more skeptics like Szasz, who try to set limits when doctors charge past their proper domain.