This review of Creating Mental Illness, by Allan Horwitz, appeared in American Journal of Bioethics 4.2 (2004):70-72
Allan V. Horwitz. Creating Mental Illness. Chicago and London. University of Chicago Press, 2002
In Creating Mental Illness, medical sociologist Allan Horwitz proposes a definition of mental illness, which he argues is close to the official definition used by the American Psychiatric Association in recent editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The definition of mental illness that Horwitz defends depends essentially on the concept of a harmful internal dysfunction, which he explicitly takes from Jerome Wakefield’s well-known approach; (see for example, Wakefield 1992). Horwitz argues the adequacy of such a disputed definition has to be judged by its usefulness, and a central task of this concept is to distinguish between mental disorders and normal reactions to social stressors. However, he claims that modern psychiatry has lost sight of this distinction, and has come to include many normal reactions to difficult circumstances among the conditions it classifies and treats as mental disorders. He lays the blame for this trend at the feet of psychoanalysis and symptom-based approaches to classification of mental disorders, which both tend to blur the distinction between internal dysfunction and normal reaction. Horwitz argues that while psychiatry has moved towards an explicitly neurophysiological understanding of mental illness, it has retained the overly-broad definition of mental disorder. He suggests that this serves the interests both of the profession and the interests of the powerful pharmaceutical industry. His conclusion is that psychiatry should narrow its classification of mental disorders to those conditions that are clearly harmful internal dysfunctions and as a society we should pay more attention to the social conditions that cause people distress.
Horwitz provides a wealth of detail to make his case. He surveys the history of psychiatry in the twentieth century, paying particular attention to the influences leading to the publication of DSM-III in 1980. His account tends towards the skeptical, prioritizing sociological and economic explanation over the logic of scientific discovery, and is heavily influenced by Kirk and Kutchins (1992). He documents many cases of surveys that report a large proportion of the population has mental disorders, and traces these apparent discoveries to overly-inclusive criteria that depend solely on lists of symptoms. He argues that surveys that fail to ascertain whether the symptoms indicate disorders. For example, he suggests that wrestlers who choose to lose weight quickly to qualify for particular weight classes, and who then eat large amounts of food afterwards would satisfy criteria for bulimia nervosa, when in fact they do not have a mental illness. Horwitz argues that surveys claiming, for instance, that 23 million people suffer from generalized anxiety disorder or that 14 percent of Americans have an alcohol disorder, tend to massively overestimate the numbers of people with mental illness. He insists that for a condition to count as a valid mental illness, it should arise “in the absence of any cause that would expectably give rise to them, be of severity and/or duration disproportionate to their precipitating cause, or persist after the causes that gave rise to them disappeared” (98). He argues at length that most of the conditions currently classified as mental disorders do not meet these any of these criteria. On his view, the clearest examples of valid mental disorders are schizophrenia and manic depression, and he is suspicious of the many other conditions that are often classified as mental illness.
To consolidate his argument, Horwitz addresses the purported biological understanding of mental illness, and points out methodological problems in many studies that apparently prove the genetic basis of many mental disorders. He claims that the rates of most mental disorders apart from schizophrenia vary widely across different cultures, and uses this to underline his skepticism about the validity of the classification of these less serious conditions as mental illness. Turning to talk therapy and medication, he presses the point that therapeutic effectiveness is no proof that the original distress was really a medical condition rather than a symptom of social problem.
Many of Horwitz’s criticism of psychiatry are thoughtful, well argued, and reasonable. He poses many important and pressing questions. However, his starting definition of mental disorder is highly problematic, and this flaw undermines the central argument of the book. He shows little awareness of the vigorous debate over the definition of mental illness and in particular over the adequacy of Wakefield’s approach (see Perring, 2002 for a survey of the literature). Even without entering into the literature on the topic, the problems for Horwitz’s definition are easily seen by considering how it would apply to other medical conditions. For example, a knife wound needs to be treated by a doctor, yet it need not involve any failure of the internal functions of the body. Indeed, the normal functioning of the body is what leads to the healing of the wound. Similarly, a person with a common cold is fighting off a virus in a normal way, but is not suffering from an internal dysfunction. Applying Horwitz’s approach to such cases would have the unacceptable implication that they are not medical conditions. What is more, while it may be possible to know with some confidence when an unusual physical condition counts as an internal dysfunction, our intuitions are far less clear when it comes to mental conditions. Wakefield has appealed to evolutionary psychology to provide an account of normal function, and has received much criticism for doing so. Horwitz does not make such a move, but provides no alternative account, and he provides no justification for his conception of dysfunction. If a person going through a stressful divorce becomes depressed, for example, he assumes that this is a normal reaction. However, others will argue that the stress of the divorce has caused an internal dysfunction. One needs an independent and compelling account of normal emotional function to settle such a disagreement about when a person has an internal dysfunction, but Horwitz provides no such account.
While Horwitz seems to regard it as a conceptual truth that mental disorders should not include normal reactions to social conditions, he also indicates at various points that the validity of a definition should also be assessed in terms of its social consequences. Yet he does not make clear what he takes to be the detrimental consequences are of medicalizing everyday unhappiness and how people's personal psychological troubles could be better through a more social approach. One can agree with Horwitz that we would do well to look at social causes and cures for the widespread incidence of personal distress and psychopathology without accepting his narrow approach to the definition of mental disorder. It is a legitimate concern that taking an increasingly psychiatric approach to people's unhappiness could lead us to overlook social solutions, but we need some evidence that this is indeed a significant trend in contemporary society. Horwitz does not provide any such evidence, and one may wonder what evidence there is. It could be plausibly argued that despite the language of neuroscience spreading to our ordinary self-descriptions and advertisements for antidepressants, both the general public and the mental health profession remain very much aware of the causal relation between social trends and mental disorders. One might speculate that the reason we often use the tools of psychiatry to treat social problems is not that we have overlooked the social causes, but rather that we have not found available social interventions that are as effective. While Horwitz's proposal to restrict the domain of psychiatry to the most serious mental illnesses is intriguing, the danger is that it would simply result in fewer people with emotional or behavioral problems receiving help of any kind.
In summary, Creating Mental Illness is a noteworthy contribution to the literature evaluating psychiatric nosology. It embraces a medical model of major mental illness such as schizophrenia and manic depression, yet takes a skeptical and antipsychiatric attitude towards other conditions currently classified as mental disorders. This duality is premised on a distinction between emotional and behavioral conditions caused by internal (mental) dysfunctions and those which are a normal response to difficult circumstances. Horowitz's argument suffers from the weakness that he does not provide a clear and plausible account of how to draw this distinction and he does not address the considerable body of philosophical literature that has already demonstrated the difficulty in providing this distinction with a value-neutral foundation.
Kirk, S.A., and H. Kutchins. 1992. The Selling of DSM: The Rhetoric of Science in Psychiatry. New York: Aldine de Gruter.
Perring, C. D. 2002. Mental Illness. The Stanford Encyclopedia of Philosophy (Spring 2002 Edition), Edward N. Zalta (ed.), URL = http://plato.stanford.edu/archives/spr2002/entries/mental-illness/
Wakefield, J. C. 1992. The concept of mental disorder: On the boundary between biological and social values. American Psychologist. 47:373-88.