Fanatical about "harmful dysfunction"

Wakefield is fanatical about "harmful dysfunction". We should be thankful for that. For his robust rhetoric has spectacularly succeeded, where decades of rigorous argument have spectacularly failed, in getting values on the agenda of psychiatric classification.

Yes, values. As a good rhetoretician, Wakefield focuses his audience's attention where their interests lie, on the empirical elements in the meaning of "disorder": this is why so much of his extensive output is concerned with defending a definition of "dysfunction" derived from evolutionary biology. "Evolution" and "biology" both have a reassuringly empirical ring. And so far as the DSM at least is concerned, this is precisely where the interests of Wakefield's audience lie: DSM-IV is explicitly evidence-based (1); and the American Psychiatric Association's agenda for DSM-V is predominantly an empirical research agenda (2). But even as Wakefield offers his audience what they want, an empirical definition of dysfunction, he is getting them to accept what they might otherwise resist, that "disorder", the concept with which DSM is concerned, has also a non-empirical, and specifically an evaluative, element in its meaning as well.

There is a kind of conceptual conjuring trick at work here. Wakefield presents "harmful dysfunction" fact-side up, but it is the value-side that the trick is all about. The trick is well turned, rhetorically speaking. Superficially, the trick is about "dysfunction" (fact-side) and harm (value-side). Thus far Wakefield's audience may feel reassured that even if disorder is, as Wakefield calls it, a hybrid (fact + value) concept, it is the (supposedly value-free) concept of dysfunction that psychiatric classification is (really) all about. But the trick runs deeper than this. For by liberally employing terms like "failure", Wakefield shows that his definition of dysfunction also has an underlying value side as well as the fact side he presents us with (3). As with "disorder" then, so with "dysfunction", Wakefield is able to present his definition of "dysfunction" fact-side up, while all the time it is the hidden valueside that is doing the (logical) work.

Like all conjuring tricks, once it is recognized for what it is, it is easy enough to see how it is done. Wakefield's citations alone illustrate what have been called the "3Rs" of rhetoric, Repetition, Repetition, Repetition - nearly half of Wakefield's citations are self-citations. His citations also show a good deal of the fourth 'R', rhetorical revisionism.

In a less rhetorical piece, the British psychiatrist and epidemiologist, the late Robert Kendell, instead of being assigned the relatively trivial role of pointing out the importance of resolving the value status of psychiatric diagnostic concepts, might have been credited as the first, over twenty years before Wakefield, to apply evolutionary biology to the problems of psychiatric classification (4). In a less rhetorical piece, similarly, the American philosopher, Christopher Boorse, instead of being accused of failing "to address (the) value component", might have been credited as the first, over twenty years before Wakefield, to propose a hybrid, fact + value, analysis of the medical concepts, and in two of the very articles cited by Wakefield (5,6). In a less rhetorical piece, finally, the block of no less that 16 citations described by Wakefield as being about "natural functions", i.e., about functions defined value-free, might more accurately have been described as contributions to a still unresolved debate about whether or not functions, let alone dysfunctions, can be naturalized at all, and let alone in the way proposed by Wakefield (7).

It might be thought that the presence of these rhetorical devices in Wakefield's work undermines his position. But that would be to stand outside the paradigm. As rhetorical devices, they are appropriate, well deployed, and effective.

Problems internal to the paradigm, on the other hand, do become apparent when, in the last part of his paper, Wakefield seeks to apply his analysis to some of the problems of the DSM. Thus, the rhetorical need for a single oft-repeated message leaves Wakefield at risk of appearing insensitive to the limitations of his own approach. The examples he gives are real enough: there really are these problems with the DSM; and they really are in part due to the difficulties of defining disorder. But beyond an earlier promissory note on a future neuroscience, Wakefield fails to show what, if any, specific contribution his "harmful dysfunction" definition of disorder makes to resolving the problems in question. Wakefield's examples are thus exemplary in form but have no exemplary content.

A second and more serious problem internal to the paradigm arises from Wakefield's rhetorical need to focus his audience's attention on the empirical element in the meaning of "disorder". For this leaves him at risk of appearing to neglect the resources of the many nonempirical disciplines available for tackling (alongside and in partnership with empirical disciplines) the problems of psychiatric classification. Such resources include, for example, work in the philosophy of physics on the local nature of scientific validity (8); work in the philosophy of mind on the irreducible role of individual judgement (as in "clinical judgement") (9); and, specifically on values, work in such areas as linguistic analysis (10), phenomenology (11) and analytic philosophy (12), relevant to improving the processes of psychiatric diagnostic classification, i.e., to improving how our classifications are first developed and then actually used in dayto- day practice.

Still, these resources will be of little effect unless values and other non-empirical elements in the meaning of disorder are at least on the agenda of psychiatric classification. That is why, if getting them on the agenda has taken a conceptual conjuring trick, we should be thankful that Wakefield is fanatical about "harmful dysfunction".