Wakefield’s Harmful Dysfunction Theory of Mental Disorder

This is now my fourth post in a series on health and disease. I spent the last two posts discussing Boorse’s naturalism, which attempts a purely value-free definition of health and disease. In this post, I will discuss Jerome Wakefield’s “harmful dysfunction” theory of mental disorder, which is sometimes considered a “hybrid” of naturalism and normativism.

My focus here will be on a single article, “The concept of mental disorder. On the boundary between biological facts and social values” (1992), although Wakefield follows this up with several later elaborations. Wakefield has doctoral degrees in social work and philosophy and has extensive clinical experience, in addition to holding a professorship in the NYU school of social work . Aside from his classic articles about mental disorder, he is also known for a book co-authored with Allan Horwitz, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007). Wakefield has a public reach unusual for philosophy of psychiatry—to my recollection, he is regularly cited by DSM chairs, and a quick Google search finds him quoted on NPR and in Vice, the New York Times, and others news outlets. From high altitude, Wakefield’s goal seems to be to defend the concept of mental disorder against the sort of anti-psychiatry Szaszian critique to which Boorse was responding, but also to restrict the concept in order to prevent the medicalization of ordinary human experiences, such as grief. Incidentally, I think this battle on two fronts is quite consistent with the ethos of the social work profession, whose members both treat people with mental illness and address non-psychiatric problems in living related to social injustice or complications in person–environment interactions (see “Concept of Mental Disorder,” pp. 373-74).

Wakefield’s position is often called a hybrid view because it contains two components, a naturalistic account of the failure of internal biological functions and a normativistic account of harm as viewed from social values. I should stress too that he limits his account to the concept of mental disorder and does not, like Boorse, give a more sweeping account of health and disease in physical medicine. He states his thesis thus: “I argue that disorder lies on the boundary between the given natural world and the constructed social world; a disorder exists when the failure of a person's internal mechanisms to perform their functions as designed by nature impinges harmfully on the person's well-being as defined by social values and meanings” (p. 374).

Like Boorse, Wakefield thinks that a naturalistic account of diseases or disorders (he treats “disorder” as the more encompassing term) must turn on account of problems with biological functions. Boorse, it should be recalled, thinks that a value-free account of biological dysfunction (and ipso facto mental dysfunction) can be given insofar as a given functional system in the human body or mind fails to do what it was “designed” to do, where “design” is understood in terms of natural selection, that is, in terms of contribution to survival and reproductive fitness. It is at this point that Wakefield parts ways with Boorse. Wakefield sees three problems here (actually, this is my simplification and consolidation of his objections):

1. First, the focus on contribution to survival and reproductive fitness leaves out conditions that cause pain and suffering but do not adversely affect long-term survival or reproduction, such as (possibly) chronic pain or psoriasis. Likewise, some conditions may very slightly reduce fertility but at a level that is negligible from the standpoint of the individual—and both possibilities apply to mental disorders too (p. 378). 

2. Second, Wakefield argues, as a kind of reductio ad absurdam, that the reduced reproduction and survival account does not have a principled way out of viewing being subjected to racism or poverty as pathological:

“differential fertility rates may exist between populations defined by racial, ethnic, economic, sex, personality, and many other variables. Are all these variables to be considered candidates for pathology? For example, is it a disorder to be a young Black urban male in 1990s America because that ‘set of characteristics’ corresponds to increased mortality? The problem is that the definition does not distinguish between disadvantage due to dysfunction of internal mechanisms and disadvantage due to harmful environments.” (p. 379)

Now, it might be retorted that the final sentence here gives the solution to the problem: disorders are dysfunctions resulting from internal mechanisms that typically reduce survival and reproductive fitness. The problem is that this line between internal mechanisms and social environment is none too clear when we remember that human beings are social creatures:

“But because humans are social animals, it is impossible to separate the functioning of the organism from all consideration of how others respond…. Even in the case of schizophrenia, which Kendell [another figure in the naturalist camp] argued is a pathology in part on the grounds that schizophrenic individuals have reduced fertility, it seems likely that the lower fertility is at least in part due to the reactions of potential partners to the schizophrenic person's mental condition, thus putting in question whether schizophrenia is indeed a disorder according to Kendell's account. (Similar questions can be raised about the source of schizophrenic individuals' higher mortality.)” (p. 379)

This line of objection corresponds to a certain kind of disability-justice-type objection to Boorse, namely, that he reifies the effects of a discriminatory social environment. This is similar to the now-classic distinction in the disability rights movement between impairment and disability. In a future article, I hope to discuss an important paper by Ron Amundson on this point, “Against Normal Function.” 

3. The naturalists commit the “sociobiological fallacy,” which consists of “misinterpreting evolution as conferring on the organism a general tendency to maximize fitness,” rather than a set of mechanisms that maximize fitness under the determinate environments in which the organism’s traits were naturally selected for (p. 379). Put differently, that a particular organism has reduced longevity or fertility in today’s world does not necessarily mean that an internal failure to perform the functions for which the organism was “designed” has occurred; it may only mean that the environment in which we live now matches up poorly with the features we evolved to have under different environmental conditions (p. 379). For Wakefield, “It is the failure of specific mechanisms to perform their assigned tasks, rather than lowered fitness in itself, that shows that something has gone wrong with the organism” (p. 379).

In short, Wakefield treats dysfunction as a necessary but not sufficient condition of disorder. Having criticized the shortcomings of the naturalistic position on disorder, he now offers his own hybrid theory, which contains both a normative or value-based component and a naturalistic dysfunction component:

“A condition is a disorder if and only if (a) the condition causes some harm or deprivation of benefit to the person as judged by the standards of the person's culture (the value criterion), and (b) the condition results from the inability of some internal mechanism to perform its natural function, wherein a natural function is an effect that is part of the evolutionary explanation of the existence and structure of the mechanism (the explanatory criterion).” (384)

Dysfunction, then, is not enough; the dysfunction must also cause harm to the individual in whom it occurs.

Unfortunately, Wakefield offers little elaboration on the harm condition. Do all harms as judged by cultural standards count, or only some? And what if the individual’s values are out of line with the culture—or what if it is not clear what the cultural values are, perhaps because there is debate or conflict internal to the culture?

Perhaps one way to get more purchase on the value component is to look at how it may help make sense of controversies in psychopathology. In the conclusion of the article, Wakefield applies the harmful dysfunction analysis of disorder to historical debates around female orgasm. He contrasts the Victorian physician William Acton’s view that, for women, orgasm during sex is a form of excessive excitation and is thus pathological with the mid-century sexologists Masters and Johnson’s view that for women not achieving orgasm during sex is a form of pathology. (Wakefield is a bit unclear here, but I think he is talking about the debate about vaginal orgasm v. clitoral orgasm.) This is an interesting example because it looks like a case in which there is a polar disagreement about what is naturally functional or dysfunctional—and yet the whole debate is rather obviously underwritten by deep-seated norms governing how we regard women’s sexuality.

I find Wakefield’s analysis rather lacking, however. He writes: “Only further facts about the nature of the mechanisms involved in female sexual response, and the evolution of those mechanisms, can resolve such debates.” Now, “only” is a strong thing to say here. Indeed, the whole point of the preceding pages was, I had thought, to say that all those further facts could do is yield a necessary condition for disorder, but not a sufficient condition. Indeed, Wakefield immediately continues:

“In principle, Acton and Masters and Johnson might have been able to reach agreement on what constitutes female orgasmic dysfunction if they had full knowledge of the evolutionary history of female sexual capacities. However, according to the view presented here, it is possible that agreement on the facts about function and dysfunction might not lead to agreement about which conditions are disorders because of differences in values (e.g., is orgasm in intercourse a desirable goal?).” (p. 386)

I think there are three issues here. The first is that, regardless of what the facts may yield, the example really does seem to turn on broader normative (and not just factual) questions about the proper telos of sex, about how sex ought to go, and these, in turn, are inseparable from gender norms, as well as more encompassing conceptions of the good life for human beings and the place of orgasm therein.

Building off of this first point, one could also argue here that the example is a case in which the value component and the factual component of the theory come apart. Which is it? I find myself wanting to ask Wakefield. Is “full knowledge of evolutionary history” here in principle dispositive of the disorder question, or is the value question dispositive, or are we supposed to weigh them somehow? At very least, in this example, we no longer seem to be dealing with the simplicity of necessary and sufficient conditions for disorder. Instead of, “X is a disorder if and only if it meets these two conditions,” we now have something more like: “Consider these two frameworks and apply them with differing weights on a case-by-case basis.”

The third problem is maybe the most fundamental. There is a longstanding and well-defended position in the philosophy of science that says something basically like this: Scientific inquiry is not nor should it be entirely value free. Values actually play an integral role in the conduct of scientific inquiry. And so it is a misunderstanding to separate “knowledge of evolutionary history” from exploration of, say, how gender norms have shaped and ought to shape inquiry into female orgasm. This is all too complicated to get into here, but I may return to it in the future.

To conclude, I think Wakefield unearths some important problems in Boorse’s naturalism, especially for the analysis of mental disorders. His harmful dysfunction account is an intriguing attempt to straddle the fact/value distinction, but it is ultimately slim on the value side; and in practice the harmful dysfunction theory ends up being less clear, less necessary-and-sufficient, than Wakefield may want it to be. Finally, Wakefield begins to develop a different kind of criticism of Boorsian-style naturalism, namely that it misunderstands evolution. I wish he had elaborated on this point more.