Luc Faucher - Defining Mental Disorder: Jerome Wakefield and His Critics

Denis Forest and Luc Faucher

Jerome Wakefields work is at the center of the contemporary debate as to the nature of mental illness (and the related question of psychiatrys scope and limits), a decades-old debate in both scientific and philosophical literature. His key proposal, the harmful dysfunction analysis of mental disorders (HDA thereafter), has been discussed at great length by scientists and philosophers alike. In psychology, discussions of Wakefields proposal abound in special issues of journals (see, e.g., Journal of Abnormal Psychology [1999] and World Psychiatry [2007]), but although philosophers have commented on and criticized Wakefields position on many occasions (see, e.g., Nordenfelt 2003; Bolton 2008; Gold and Kirmayer 2007; Murphy and Woolfolk 2000; Murphy 2006), no book or special issue of a major philosophy journal has been dedicated to the task of offering a survey of these critiques.

With this volume, we propose to remedy that situation, and for the occasion, we have gathered together some of todays most eminent and up-and-coming philosophers of psychiatry to discuss Wakefields position as well as its theoretical implications and empirical consequences. We hope that the resulting collection of chapterswith extensive replies from Wakefield himselfmay be of interest to researchers and students in several related fields ranging from clinical psychiatry to social work, as well as philosophy of mind and philosophy of psychiatry.

HDA is the claim that a disorder is a harmful failure of some internal mechanism(s) to perform a naturally selected (designed) function (Wakefield 2000, 253). This notion was originally presented by Wakefield in two papers published during the same year (Wakefield 1992a, 1992b). At first sight, each of these papers is quite different: one is a general presentation of HDA, contrasting it with rival conceptions of mental disorders. The other is a critique of the definition of mental disorders as unexpectable distress or disability that is used in the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) (published in 1987). In fact, these two articles offer two different perspectives on the implications of HDA: one is more philosophically oriented and deals with foundational issues; the other is more of a dialogue with medical research and practice and deals with the empirical consequences of theoretical choices, a type of research that the majority of Wakefields subsequent publications can be grouped into (e.g., the two books coauthored with Allan H. Horwitz; Horwitz and Wakefield 2007, 2012). Since 1992, Wakefield has vindicated his thesis on many occasions, without revising it significantly. Critiques of HDA have tended to focus keenly on the terms dysfunction and harmful, but analysis is no less important to understand the nature of his project. HDA is offered as a definition of what a mental disorder is, but it is also the outcome of the application of a method, the method of conceptual analysis, and it would be an error to separate the two.

Wakefield characterizes conceptual analysis in the following manner: In a conceptual analysis, proposed accounts of a concept are tested against relatively uncontroversial and widely shared judgments about what does and does not fall under the concept. To the degree that the analysis explains these uncontroversial judgments, it is considered confirmed, and a sufficiently confirmed analysis may then be used as a guide in thinking about more controversial cases (Wakefield 1992b, 233). Conceptual analysis is a tool that allows one to judge the merits of competing accounts of what a mental disorder is, HDA being one of the latter. These merits can be evaluated using two criteria. One is that a proper analysis of the concept allows us to correctly specify its extension. The characteristic tone of many of Wakefields publications derives from the critical use of this method: (1) if analysis A of the concept of mental disorder (C) were sound, then condition X would not be a disorder and condition Y would, (2) but it is uncontroversial that X is recognized as a disorder and that Y is not; (3) accordingly, A is not an adequate analysis of C. For instance, if post-traumatic stress disorder (PTSD) is commonly recognized as a disorder and is quite expected in the context of trauma, then the previously mentioned