"Beyond biological and social normativity: varieties of norm deviation and the justification for intervention" - Andrew Evans (University of Notre Dame),

Synthese, 2025

By Andrew Evans

What does it take for a condition of the mind to count as a “mental disorder”? This question has dominated the field of philosophy of mental health for decades. The answer has both practical and theoretical significance, impacting clinical practice, research priorities, and the way people who struggle with psychological distress conceive of themselves (Tekin, 2011). There are three common approaches to answering the question. The first, naturalism, conceives of mental disorders as scientifically discoverable, objective matters of fact (Boorse, 1976, 1977; Kendell, 1975). An opposing perspective, normativism, says that that mental disorders are value-laden and primarily socially constructed (Bolton, 2008; Cooper, 2002; Sedgwick, 1973). And a third option, hybridism, combines these two approaches: mental disorders are partially objective and partially socially constructed (Biturajac & Jurjako, 2022; Murphy, 2006; Wakefield, 1992).

In my recent paper—which appears in the Synthese topical collection “The normativity of mental health conditions”—I challenge the dominant framework for defining “mental disorder.” While the differences between naturalism, normativism, and hybridism have been widely discussed and debated, I contend that there is an often overlooked similarity between them: each approach conceives of mental disorder as norm deviation. For naturalism, mental disorder is a deviation from biological norms (characterized by evolutionary fitness or design). Alternatively, normativism conceives of mental disorders as deviations from social norms. Hybridism, then, emphasizes the importance of both biological and social normativity. Conceiving of the “mental disorder” debate this way shifts the focus away from a fact/value dispute, recasting it as a disagreement over the relevance of different types of norms. Further, mental health treatment is reconceived as an attempt to correct norm deviations.

This shift in perspective raises two important questions: (a) Are biological and social norms the only sorts of norms relevant to mental disorder? (b) Should addressing norm deviations continue to be a major focus of mental healthcare?

Beginning with (a), I introduce three new concepts: individual normativity, well-being normativity, and regulatory normativity. A condition deviates from individual norms when it is a marked change from the subject’s baseline, a condition deviates from well-being norms when it makes the person worse off, and a condition deviates from regulatory norms when it inhibits one’s ability to skillfully regulate one’s cognitions and emotions (Leder & Zawidzki, 2023).

To see how these types of normativity relate to mental disorder, consider the following example from my paper:

Val is a middle-aged woman who had a fairly average childhood and early adulthood, which were generally free of worries. However, for the last few months, she has been plagued with uncontrollable anxious ruminations. For hours each day, Val can’t help but think that she is worthless and that other people see her as incompetent. This leads her to avoid other people, and so she tends to feel lonely and isolated.

It could be that there is a biological dysfunction underlying Val’s condition, or perhaps the condition contradictions the conventions of Val’s society. However, these are not the only normative considerations present in this case. Val’s condition is atypical for her, makes her life worse, and involves cognitive dysregulation, therefore deviating from individual, well-being, and regulatory norms. These other normative considerations are missed if we conceptualize Val’s condition only through the standard framework. Cases like this demonstrate that the field of philosophy of mental health should move beyond its narrow focus on biological and social normativity.

Next, I turn to question (b): Should addressing norm deviations continue to be a major focus of mental healthcare? Approaches such as the neurodiversity paradigm, social model of disability, and Mad discourse have put pressure on the assumed connection between norm deviation and psychiatric intervention (Beresford & Russo, 2016; Chapman, 2019; Just Fancied a Rant Clare, 2011; Kinn 2016; Rashed, 2018; Sen, 2011; Walker, 2013). Drawing on these critical approaches, I argue that whether treatment is justified depends, in part, on the type of norm deviation being intervened upon.

Biological and social norm deviations do not, in themselves, justify a treatment response. Imagine someone who has occasional, pleasant hallucinations. This condition might involve an underlying biological dysfunction, and it also may go against cultural norms. However, if the hallucinations do not bother the person and do not impact their ability to meet their life goals, I argue that this situation does not call for mental health intervention. We can contrast this case with that of Val. We don’t know if Val’s condition deviates from biological or social norms. But we do know that it is out of the ordinary for her, it negatively impacts her well-being, and it causes trouble with self-regulation. Given these other normative considerations, a treatment response makes more sense for Val. Using these examples, I show that the standard focus on biological and social normativity is limited, and that other types of norm deviation are more likely to indicate a need for intervention.

With the concept of “mental disorder” so muddled, one might wonder where the field should go from here. One option—which I briefly consider in the conclusion of the paper—is to discard the term altogether. Lisa Bortolotti (2020) has recently pursued a similar line of thinking:

“[The] notion of disorder is not central to the project of establishing the status of psychiatry. There is no available notion of disorder which make sense of the scope of medical practice, mainly because medical attention and medical care are appropriate responses to a variety of problem people experience, independently of whether we identify such problems as pathological.” (p. 163)

This option, which we might call “mental disorder eliminativism,” would radically alter our current way of thinking about psychological distress. Cooper (2020) cautions that the “mental disorder” concept can be useful for determining when certain behavior should be excused from blame and also for establishing proper medical authority. Further, in the United States and elsewhere, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is profoundly entangled with how people receive care and how that care is paid for by insurance companies and government programs. Given these risks, one may hesitate to drop the concept “mental disorder” altogether.

An alternative would be to embrace pluralism. Here, we would still use term “mental disorder,” but it would be in full recognition that its meaning changes depending on the context. Sometimes “mental disorder” would refer to biological dysfunction, other times it would mean a condition that is socially unacceptable, and still other times the term would refer to a condition that detracts from well-being, impacts one’s ability to self-regulate, or is personally atypical.

But pluralism also comes with costs. If “mental disorder” means different things in different contexts, there would be negative impacts on clinical communication, translational research, and patient self-understanding.

Given these drawbacks, eliminativism is the better option. Already, many clinicians resist pathologizing psychological distress and often see the DSM merely as a bureaucratic obstacle to providing necessary care (Whooley, 2010). And after decades of debate, there is still no widely agreed upon definition of “mental disorder.” While it is true that eliminativism would disrupt the status quo, movements like Critical Psychiatry, Disability Studies, and Mad Pride have demonstrated that the current mental healthcare system is in need of significant reform. Pluralism causes confusion without any call for change. Given these considerations, I think it would be best to explore alternative ways of understanding psychological distress which do not involve the “mental disorder” concept.

References

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Biturajac, M. & Jurjako, M. (2022). Reconsidering Harm in Psychiatric Manuals Within an Explicationist Framework. Medicine, Health Care and Philosophy, 25, 239-249.

Bolton, D. (2008). What is mental disorder? An essay in philosophy, science, and values. International perspectives in philosophy and psychiatry. Oxford University Press.

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Bortolotti, L. (2020). Doctors without “Disorders.” Aristotelian Society Supplementary Volume 94(1), 163-184.

Chapman, R. (2019). Neurodiversity Theory and Its Discontents: Autism, Schizophrenia, and the Social Model of Disability. In Ş. Tekin and R. Bluhm (Eds.), The Bloomsbury Companion to Philosophy of Psychiatry. London, New York, Oxford, New Delhi, Sydney: Bloomsbury Academic. 371-389.

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Walker, N. (2013). Throw Away the Master’s Tools: Liberating Ourselves from the Pathology Paradigm. Neuroqueer: The Writings of Dr. Nick Walker. https://neuroqueer.com/throw-away-the-masters-tools/

Whooley, Owen. 2010. “Diagnostic ambivalence: Psychiatric Workarounds and the Diagnostic and Statistical Manual of Mental Disorders.” Sociology of Health & Illness 32, no. 3: 452-469.