Review by Slava Greenberg, University of Southern California, Email: slavagre@usc.edu
Keywords: identity; mental illness
The debate over the Diagnostic and Statistical Manual of Mental Disorders has been exhausted in psychiatry, medicine, medical humanities, and philosophy — as the scope of the 600-page-long volume indicates– yet the population most affected by the consequences of these debates are psychiatric institutions’ survivors, scholars and activists in the mad pride movement are excluded. Despite not explicitly or intentionally engaging with Disability Studies, Defining Mental Disorder is aware of disability culture and activism, and references it through antipsychiatry. The editors of the volume, by Luc Faucher and Denis Forest, introduce Jerome Wakefield’s “harmful dysfunction analysis” (HDA thereafter) of mental disorders through surveying his critics and set out to attract researchers and students in clinical psychiatry, social work, philosophy of mind, and philosophy of psychiatry. Despite the exclusion of Disability Studies scholars, we can still benefit from some of its perspectives on issues related to disability classification, dysfunction, and harm as they may offer some insights into the construction sanism.
In 1992 Jerome Wakefield, a scholar specializing in the conceptual foundations of clinical theory, published two papers; one is a general presentation on HDA contrasted with rival conceptions of mental disorders and the other –most relevant to this journal is a critique of the definition of mental disorders as “unexpected distress or disability” that is used in DSM-III-R published in 1987. The two, Faucher and Forest explain, offer two different implications, one is more philosophical and the other is more of a dialogue with medical research and its critique. HDA is suggested by Wakefield as a definition to mental disorder and the outcome of applying “conceptual analysis,” i.e. a tool to judge the merits of competing accounts of what mental disorder is. In these two articles, Wakefield contrasts concept and theory of disorder; the concept answers the question ‘What are mental disorders?’ and the theory suggests a general explanation to the question ‘Where do mental disorders come from?’ The distinction between these two had been recognized by Wakefield as being crucial to the DSM because HDA is composed of two claims; first is that disorders are dysfunctions of mental mechanisms with harmful consequences, i.e., socially constructed, and the second is that the dysfunction can be biologically or factually traced within an individual (Faucher and Forset 2021, i-xi).
The book’s significance for Disability Studies lies in the anti-medicalization and anti-pathologizing aspects of Wakefield’s theory and its critique. As the editors point out, Wakefield’s book titles announce his work problematizing psychiatry, e.g. The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (Horowitz and Wakefield 2007) or All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders (Horowitz and Wakefield 2012). The editors write that: “The rejection of psychiatry as a whole, as well as its overextension, can be understood as two consequences of the same set of difficulties that reinforce each other. According to Wakefield, both derive (at least partly) from a lack of proper understanding of what mental disorders are. In particular defining mental disorders exclusively through their unhappy consequences (they cause harm and often distress), or by the use of evaluative notions (something being ‘wrong’ with a given individual), has the undesirable consequences of blurring the distinction between genuine disorders and problems in living, unusual, or disapproved behaviors.” The main example is that of the drapetomania as a disorder that was meant to protect slave owners from slaves fleeing, serves Wakefield to show that the conceptual validity is a specifically philosophical task (Faucher and Forset 2021, xii). However, it in fact reinforces abolitionist perspectives of psychiatric hospitals.
The editors offer an extensive document and lively contemporary conversation between Wakefield’s approach to mental disorders and his critics in various fields. Several of the volume’s chapters and responses may be of particular interest to Disability Studies scholars, activists, and community members interested in debates over the definitions of disability and mental health. Chapter 1 “DSM in the Light HDA” (and conversely) by Steeves Demazeux argues that Wakefield’s HDA is in agreement with the spirit of modern psychiatry and the conception of mental disorders in DSM-III. Furthermore, Demazeux claims that Spitzer who led the conception of the DSM-III did not in fact give a prominent role to the criteria of dysfunction as suggested by Wakefield but rather focuses on the essential criteria of “distress and disability” are essential to the identification of mental disorders. The chapter contextualizes the emergence of HAD within the context of psychiatry during the 1980-1990 (Faucher and Forset, xviii). Chapter 7 “Doing without ‘Disorder’ in the Study of Psychology” by Harold Kincaid identifies three of Wakefield’s most prominent contributions: (1) maintaining a ‘healthy’ skepticism concerning psychiatric classification, (2) supplying reasons for the belief in a nonarbitrary distinction between disorders and nondisorders, and (3) assessing specific psychiatric categories (depression, phobias, etc.) to determine whether or not they capture (only) disordered conditions (rather than problems in living). Kincaid argues that Wakefield’s defense of antipsychiatrist claims of medicalization of normal life can be accomplished without a definition of what disorders are (Faucher and Forset, xx).
The final chapter –perhaps the most relevant to recent conversations in Disability Studies in light of Liat Ben Moshe’s timely and brilliant Decarcerating Disability: Deinstitutionalization and Prison Abolition (University of Minnesota Press 2020) – “On Harm” by Rachel Cooper expresses agreement with Wakefield on centering harm in discussion of mental disorder as well as a disagreement with his stance on harm as what is devaluated by a given society. Cooper asserts that “we should not think in terms of disorder when people are a cause of harm without being harmed themselves. Cooper stresses that in the context of the DSM-5, more than ever, the emphasis on harm is linked to a key concern of reflection on psychiatry: preventing the unwarranted medicalization of ordinary life” (Faucher and Forset, xxv). Cooper’s chapter raises the main missing question in the volume: who is harmed by these definitions and classifications?
I turn to Liat Ben Moshe’s Decarcerating Disability to address the disability studies lacuna in the Defining Mental Disorder volume. Ben Moshe explains that “analyzing incarceration and deincarceration without disability/madness lens casts away ways of understanding disability/madness as lived identity and a way to be in view of the world (i.e., an ontology and epistemology), as it intersects with race, gender, nationality, and other axes” (Ben Moshe 2020, 2). Similarly, discussing mental disorders without the members of the movement of people with psychiatric disabilities whether institutionalized or living in the community, particularly around issues of harm may not only further stigmatize the dangers of the community but may anchor the movement away from what Ben Moshe offers in deinstitutionalization through a complex critique of psychiatry.
Furthermore, read through Ben Moshe’s abolitionist perspective, the volume elaborates on rather than critiques models of classification, which in turn may feed into normalizing and rehabilitating medical narratives instead of unveiling them. The diagnostic tools like the DSM (and ICD) assessing mental disorders value independence and self-determination through which they are “constructed as skills or traits that can be mandated, regulated, and taught to those (backward, retarded, primitive, degenerate) who are assessed whether they ‘have it.’ The burden of proof is on the person who needs to be as normal or comparable as possible to their peers, but not on the peers or social system that creates segregation from those deemed as nondisabled” (Ben Moshe, 80). What is lacking in any debate about ableism and sanism is a crip/mad of color perspective as articulated by Ben Moshe, a perspective that exposes these values and the ways in which they are used to pathologize and incarcerate cognitively disabled people, women, indigenous people, black people, and their intersections (ibid), as well as trans and mad folks.
Works Cited
Ben Moshe, Liat. 2020. Decarcerating Disability: Deinstitutionalization and Prison Abolition. Minneapolis; London: University of Minnesota Press. https://doi.org/10.5749/j.ctv10vm2vw
Faucher, Luc, and Denis Forset. 2021. Defining Mental Disorder: Jerome Wakefield and His Critics. Cambridge, MA; London, England: The MIT Press. https://doi.org/10.7551/mitpress/9949.001.0001
This review was published as part of Disability Studies Quarterly, Spring/Summer 2022.
Beginning with Volume 36, Issue No. 4 (2016), Disability Studies Quarterly is published under a Creative Commons Attribution-NonCommercial-NoDerivatives license unless otherwise indicated.
Disability Studies Quarterly is published by The Ohio State University Libraries in partnership with the Society for Disability Studies.