One of the sets of terms that gets thrown around a lot in therapy and psychology circles is high functioning vs. low functioning. I’ve seen it most often when referring to people with autism, but it gets used in many contexts. High functioning individuals with mental illness are usually considered those who can hold down relationships, a job, look presentable, and live independently. Low functioning individuals are defined as those who need help with basic tasks.
There are a lot of problems with this terminology, many of which Leah Harris identifies at Mad in America. It tends to divide people into absolute groups rather than recognizing that people have strengths and weaknesses, it doesn’t allow for change, it can easily set apart high functioning (and not worthy of treatment) from low functioning (and not competent to advocate for themselves or have voices that we hear). More often than not the definition of functioning is related to capitalism: can you work and contribute to a capitalistic society?
“Functioning” terminology does a lot of disservices to people with mental illnesses and leaves a lot of people who have mental illnesses stuck on the outside of conversations about treatment and policy. But it has a pretty strong pull for a lot of people. It makes an intuitive kind of sense. Some people seem to be getting through life better than other people in terms of their relationships, their distress, their overall levels of happiness. Shouldn’t we be able to talk about that? Shouldn’t we be able to talk about the fact that some people need more support than other people?
Yes and no. Functioning can mean a lot of things depending upon what it is the aim is. If the aim is functioning within typical societal structures and capitalistic expectations, then the functioning model is deeply unhelpful. But what might be helpful is understanding that mental illness can deeply impact an individual’s ability to function as they would like. It can keep them from reaching their own goals, or pull them into behaviors that violate their values. One of the framings that DBT provides is the idea of effectiveness: will your action be effective at helping you reach your goals and bringing your life more in line with what you imagine you’d like it to be?
Functioning can run parallel to that in many ways. And this points to a larger problem with how our society conceives of the purpose of people. Society tends to see people as cogs in the larger machine rather than individuals who have different goals and wants. There is no singular good life, which means that there is no single way to function correctly. Even more than that, people are considered to be functional or non functional rather than societies. Individuals are not the only ones who can and should make adjustments to reach a better level of functioning.
Neurodiversity has been positioned as an alternative to the model of functioning by some people, but I don’t think that the two have to be diametrically opposed if we reframe what it is that an individual is functional at. Neurodiversity allows for a variety of paths and goals, and measuring functionality within that framework allows us to talk about how much support an individual might need or how far along a road to recovery they might be without silencing anyone.
I’d like for us to reconsider our aims when it comes to treatment of mental illness. Is it to create people who can fit into the society that we already have without rocking the boat, or is it to help individuals be satisfied with their lives and live in ways that are fulfilling to them? I vote for the latter.