Four Ways of Going Right
Anya Plutynski on how function and dysfunction co-exist in psychopathology
“Four Ways of Going “Right” – Functions in Mental Disorder” by Anya Plutynski in Philosophy, Psychiatry, & Psychology is one of those papers that I wish I had written because of how well it captures and elaborates on ideas that have been swirling in my own mind. Plutynski distinguishes four ways in which aspects of mental illness can be said to be functional, and argues that “functional talk in this context is neither inconsistent with viewing some disorders as dysfunctional in one of several senses, nor inappropriately adaptationist, provided we keep these senses of function distinct…” (The paper is open access for the next two weeks.)
Some pertinent excerpts:
“… a state of affairs can be “functional” in some respects, and “dysfunctional” in others. Taking both perspectives on the same state can yield fruitful insights into etiology and treatment, as has been argued in the context of somatic disease (Plutynski, 2018). Key to this possibility is first, that a candidate condition can be decomposed into discrete parts or processes, or habitual patterns of behavior and affective response. Second, functions are context dependent (e.g., a trait that might be “optimal” at one stage of development, or benefit the organism at one temporal scale, but yield dysfunction at another stage or scale). Thus, when clinicians and researchers refer to mental disorders or disease (or, more often, features or aspects thereof) as “functional” (in one or more of the several senses specified below), and “dysfunctional” in another, they are not necessarily making a claim that is inconsistent. A habituated behavior, affective response, or combination of both, might be functional in one environment, or at one stage of life, and less so (or not at all functional) in another.”
“There are (at least) three common senses in which mental disorders are typically described as “dysfunctional”: they may involve disruptions to selected mechanisms, they may involve failure of some part or process of a biological or psychological mechanism to play its causal role in the overall system of which it is a part, or they may involve disruptions to social roles. “Social-role functions” concern “whether a person is able to function well at school, at work, or in interpersonal relationships.””
Building on Matthewson and Griffiths’s (2017) “four ways of going wrong,” (another paper I love), Plutynski offers (at least) four ways in which “function” talk in psychiatry can be understood — four ways of “going right.”
“the condition (or aspects or features of a condition) a) served some function in the evolutionary past, and still performs that function (“mental disorder as adaptation”), b) served a function in the evolutionary past, but it no longer performs that function (“mismatch”), c) served some (either psychological or biological) function at some stage of life, but no longer currently (an “adaptive response gone awry”), or d) serves some psychological function currently, but in the long run is less than optimal in service of an individual’s overall goals (“suboptimal response”).”
“… referring to aspects or features of mental disorder (habits of belief, affective response, and behavior) as “functional” (in some sense), has been key to developing effective treatments for conditions like anxiety, depression, and trauma. For instance, a therapist will attend to a client’s patterns of psychological responses to specific events, interactions, or personal losses, in service of discerning what pattern of belief, emotion, and behavior has become typical or habituated for them. To be sure, there are different theories about what prompts such patterns, leading to different clinical recommendations, but key for our purposes is that patterns of social adjustment and emotional regulation are identified in light of their actual and potential “functional” roles in the psychology of the agent.”
“… the last two senses of function (“adaptive response gone awry” and “suboptimal adaptive response”) both play important roles in clinical practice. First, as we’ve seen, a central presupposition of many individual therapies is that behaviors, beliefs, or dispositions may have served some (psychological) function at some stage in life or may currently serve some function. Such a behavior, belief, or disposition may help one preserve consistency with an “internal” psychological state (a belief, value, or preference), but not in a way that helps one achieve long-term goals. Discovery of such patterns and replacement of them with more optimal patterns are considered key elements of many therapeutic interventions.
Second, such functional behavioral, belief, or dispositional states may be attributed not only to agents, but also whole family units, or social groups, and may serve the interests of the group, or be advantageous to one or several members, but harm others. Here, the group is treated as a functional unit. This view of the family as a “system,” where everyone plays a “functional role,” is sometimes described as a “systems” view of the family (Broderick, 1993; Kerr, 1981/2014), or what is sometimes called “family systems” theory. This approach takes the family as a functional unit, where group members take on various roles, which may either serve the collective advantage of all, or serve some, at a cost to others. These patterns of relationships are sometimes referred to as “dysfunctional,” but the individual roles of each member are taken to serve some “function,” in that they allow for the persistence and relative harmony of the group… These social roles are functional, in Cummins’s sense of part function, in that however disadvantageous the role is for any individual, their activity preserves the stability of the group.”
“Embracing a variety of potential functional roles of aspects or features of mental disorders is thus fruitful for both investigative and therapeutic contexts, whether in generating hypotheses, encouraging collaborative research, or attending to diverse kinds of evidence, which may well provide insight into therapeutic targets and methods that would otherwise be lost. My view thus challenges a reductive, monistic view of “function” and dysfunction in psychiatry. Monist presuppositions can limit scientists’ and clinicians’ hypotheses about what similarities matter, and how, which can in turn limit options for diagnosis, treatment, and explanation. The monistic “dysfunctionalist” paradigm can thus lead us to ignore the many complex causal factors in interaction that yield a disorder.”
I am in complete agreement with challenging reductive, monistic views of function and dysfunction. An implicitly monistic, dysfunctionalist attitude has dominated medical psychiatry for the last three decades, and is important to contest.
At the same time, we should also be wary of monistic functionalist paradigms; while such views are currently quite fringe, they are not absent, and they are popular in certain circles that are highly critical of psychiatry. It has been interesting for me to see how philosophical debates on function/dysfunction have been recruited in service of a Szaszian agenda, with arguments along the lines of, “Most conditions we currently call mental disorders are functional in some sense; therefore, psychiatry is wrong to classify them as disorders, since disorders require dysfunction; and therefore, medicine has no legitimate jurisdiction or authority over these conditions…” The term dysfunction itself has become anathema to some people — they think of it as an inherently stigmatizing term when applied to the mind, with no redeeming qualities. This may sound extreme, but if you spend enough time on the “anti-psychiatry” corners of Twitter, you will see how attractive such views are to some people (even to some philosophers, psychiatrists, and psychologists, who ought to know better).
When I teach psychiatry residents about the history of the classification of psychotic disorders, I point out how Bleuler – who coined the term schizophrenia – was of the view that delusions and hallucinations were functional responses recruited to help the individual navigate the world in the context of a more fundamental brain malfunction. As Anne Harrington described it in Mind Fixers, “There was no point, Bleuler said, in trying to find a biological cause for those symptoms, because they were not caused by brains gone wrong. They were instead caused by patients’ use of psychological mechanisms (especially the kinds identified by Freud) to defend themselves against a world that they experienced through brains that didn’t work right.”1 At the very origin of our modern concept of schizophrenia is this complex interplay between function and dysfunction! For contemporary versions of such ideas, consider the hypothesis that delusions are a “doxastic shear pin”, a mechanism that errs so as to prevent the destruction of the machine (brain) and permit continued function (in an attenuated capacity) (Fineberg & Corlett, 2016). “We argue that delusions form when the shear-pin breaks, permitting continued engagement with an overwhelming world, and ongoing function in the face of paralyzing difficulty.” Even delirium, Mark Oldham speculated in his Mixed Bag post for this newsletter, may serve a function similar to fever or pain. Yet neither delusions nor delirium represent states of health!
The idea that “functions” and “dysfunctions” are not necessarily mutually exclusive – that something can be functional in one sense and dysfunctional in another sense – is a powerful antidote to binary thinking. We should seek to recognize the complex interplay of function and dysfunction in psychiatry – as it exists in all medicine.
The idea that “functions” and “dysfunctions” are not necessarily mutually exclusive – that something can be functional in one sense and dysfunctional in another sense – is a powerful antidote to binary thinking. We should seek to recognize the complex interplay of function and dysfunction in psychiatry – as it exists in all medicine. What ails our bodies is neither wholly functional nor dysfunctional, and the same is true for what ails our minds. Psychiatrists and psychoanalysts, throughout the history of the discipline, have been comfortable talking about purpose and pathology in the same breath.
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Mind Fixers, pp 45-46