University Professor Jerome Wakefield Interviewed In Le Cercle Psy
An interview with Univeristy Professor Jerome Wakefield will appear in the February/March 2012 issue of the French psychology magazine Le Cercle Psy. Below are excerpts from the article by Sarah Chiche, which is posted online. The full article can be found here.
How would you characterize the idea of "harmful dysfunction," and why do you still think, after all the critiques you faced, that this is the only solid criterion to define a real disease?
The harmful dysfunction analysis is an attempt to answer a question that has perplexed social theoreticians and has been the subject of a lengthy and often acrimonious debate across half a dozen disciplines: What do we mean when we label someone as mentally disordered? That is: When someone is acting in a socially deviant or eccentric or irritating manner, when are they simply engaging in normal although perhaps problematic variations of human behavior versus when do they have a psychiatric disorder in which something has gone wrong with their functioning? This distinction has been of growing importance in a variety of medical, legal, and social contexts. The harmful dysfunction analysis has been very controversial because it is posed as a middle-ground in a traditional debate between two opposed answers to the question, "What is a mental (psychiatric) disorder?"
Note that the harmful dysfunction analysis is in fact intended to apply to medical disorder in general, both mental and physical. This is because one of the central questions I am trying to address, left over from the anti-psychiatry era, is: How is it that psychiatry is a genuine medical discipline like other medical specialties, treating conditions that are disorders in the same literal sense of ''disorder'' as is used in the rest of medicine? Psychiatry does many different things; for example, it helps people cope with the normal stresses of life, it tries to enhance performance, and it treats normal variations that are not in tune with our social values and demands (such a fear of public speaking, or difficulty sleeping during the day when one has shift work). But the heart of psychiatry is the treatment of mental disorder, and to understand psychiatry one must understand this core function.
Prior to about a century ago, psychiatric medicine was primarily concerned with conditions that were clearly mental disorders in the medical sense, where something had obviously gone wrong with a person's psychological functioning. These conditions typically incapacitated the individual and generally led to the person being placed in a mental asylum or hospital. Classic studies of mental disorder were focused on such populations. Nobody needed an analysis of the concept of mental disorder to see that these people were disordered in the medical sense, even though the problem was in their psychological functioning, not their physiological functioning (though of course the two were often linked).
However, as psychiatry moved into the community, the fact that psychiatric disorders are continuous with normal misery and normal eccentricity became a problem. In the community, how does one distinguish the mental disorders from all the other negative conditions, which might be quite similar on the surface, as in normal grief versus pathological depression? This issue has become of practical as well as theoretical importance in a variety of legal, research, and medical contexts.
One answer is the "values" approach, which holds that a disorder is simply a socially undesirable or harmful mental condition, perhaps one that is treated by physicians. A great variety of positions agree on this point -- including anti-psychiatric and constructivist "social control" views of psychiatry but also many others. The values view is appealingly simple and very attractive as a tool of social criticism -- if a condition is labelled a disorder just to express society's disapproval, that is easy to attack. But such views offer no constructive way to improve diagnosis, and most importantly do not express how we actually think about disorder; they are inconsistent with our shared intuitions about what is and is not a disorder.
This is because most negative conditions are just part of normal human variation -- they may be unfortunate or disapproved, but they are within normal range. For example, neither illiteracy nor an immigrant's inability to speak the local language are considered mental disorders, yet they are terribly impairing, and undesirable conditions -- whereas dyslexia and aphasia, where inability to read or to speak and anchored in brain dysfunctions, are disorders. Being a "night person" rather than a "morning person" in a 9-to-5-structured work culture is potentially disadvantageous, but considered a normal variation -- as is lack of talent and lack of skill, though all these conditions confer disadvantages. Fertility when pregnancy is unwanted, pregnancy when children are unwanted, and pain during childbirth are all undesirable conditions commonly treated by physicians, yet not considered disorders. Neither debilitating fatigue after exertion nor sleep -- probably the single most massively impairing human condition of all, rendering virtually everyone semi-paralyzed and periodically hallucinating for one-third of their lifespans -- are seen as disorders. Nor is delinquent behavior by rambunctious teenagers or horrifically painful grief after a loved one's death considered disorders ....
Now, the DSM's definition of disorder says that a disorder is a mental condition that is caused by a dysfunction in the individual -- social disapproval is not enough. However, there is no explanation of the notion of a "dysfunction." I proposed some time ago that the factual or scientific component in "disorder" requires that the condition must involve a failure of some mental mechanism to perform one of its natural, biological designed functions. This is highly inferential and speculative and fuzzy at this stage of knowledge of mental processes, but it is the conceptual target at which we aim nonetheless. Indeed, although both the notions of dysfunction and harm are fuzzy concepts, as long as they determine a range of clear cases on either side of the disorder/non-disorder boundary, they can provide a cogent and useful conceptual structure. Other useful categorical distinctions -- such as between night and day, or child and adult -- also have fuzzy boundaries, and pragmatic considerations determine specifically where the dividing line is drawn, yet they are important and useful concepts because of the range of clear cases they classify.
Today, we understand that "human nature" -- specifically, species-typical biological design -- is due to evolution through natural selection. So, dysfunction in the sense relevant to judgments of medical disorder consists of failure of internal mechanisms to perform biologically evolved functions. Just as one's heart is malfunctioning when it cannot pump blood as it was biologically designed to do, so features of the mind are malfunctioning when they cannot perform the functions for which they were naturally selected -- whether it is that anxiety appears out of the blue when there is no danger, as in panic attacks or generalized anxiety disorder, or forms of sadness occur without any relationship to external loss, as in major depressive disorder, or thinking or sleep or sexual arousal no longer work as biologically designed. The "dysfunction" component of the analysis means that, as far as the legitimate application of the concept of disorder goes, disorder cannot be manufactured from personal or social values and used as a cover for "treatment" in service of social control. The "dysfunction" requirement places a limit on what can be legitimately said to be a disorder, and explains why many negative conditions are not disorders -- because most negative conditions are not failures of internal mechanisms to be capable of their biologically designed functions.
In the book you co-authored with Allen Horvitz, The Loss of Sadness, you describe why the DSM went off track on the issue of depression. How did all this happen?
Traditionally, understanding the context of the patient's life has been critical to discriminating depressive disorder from normal sadness. Ever since the ancient Greek physicians and through to the early twentieth century, physicians and psychiatrists agreed that depressive disorder has many of the same features as normal grief or sadness after a major loss, so it was the context of the symptoms (i.e., were the symptoms a proportionate response to real losses such as death of a loved one, financial reversals, marital dissolution, or medical problems?) was a critical part of diagnosis of depression used to distinguish normal intense sadness reactions from genuine depressive disorders where something has gone wrong with mental functioning. The use of context has been lost in contemporary DSM psychiatric diagnosis due to a revolution in the way diagnoses are done. During the 1960s and 1979s, several factors converged to lead to a crisis in American psychiatry. There was the growing anti-psychiatry movement, which argued that psychiatry was not really medical at all but just a form of social control, and thus challenged psychiatry to defend its coherence. Psychiatric diagnosis was shown in studies to be remarkably unreliable, with different psychiatrists offering radically different diagnoses based on the same interview, and rates of diagnosis of even such basic categories as schizophrenia and manic-depressive disorder were found to differ greatly between the U.S. and Britain. Many new approaches to the causation of mental disorder had recently emerged to create a theoretically fragmented field -- ranging from newly successful biological ideas and behaviorist and cognitive approaches to family therapy and newer psychodynamic approaches diverging from classical theory. Each of these approaches used its own definitions, so research could not be compared and was not cumulative. Yet the definitions of disorders in earlier manuals had built-in classic psychoanalytic assumptions regarding conflict and anxiety being at the root of many disorders, but these assumptions had not been proved and were rejected by many of the newer views, so there was widespread discontent with the biases in the traditional definitions. At the same time, psychiatry was turning from its traditional focus on serious disorder in the asylum to the disorders in the community with all the complexities of distinguishing disorder from normal intense negative emotion. Finally, the move to take homosexuality out of the diagnostic manual led to a perceived need to justify with precision what was and was not considered a mental disorder.
Psychiatric diagnosis responded to these challenges and was transformed in 1980 with the publication of the third edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) under the leadership of Robert Spitzer. The World Health Organization's International Classification of Diseases (ICD), used widely in Europe along with the DSM, now follows much the same approach. The basic idea is to define each mental disorder using symptoms to present necessary and sufficient diagnostic criteria, free of any assumptions about what caused the condition and thus "theory neutral." Such definitions are more reliable in that diagnosticians can agree more readily on which symptoms are present than they can on what theory explains the symptoms. Rival theorists can agree that someone with certain symptoms is likely disordered and thus agree on these definitions, and then they can do research on the same kinds of conditions and compete to explain these disorders.
The problem that arose with depression is that the symptom definition was subject to large numbers of "false positives," that is, it encompassed many conditions that are not disorders but simply intense normal responses to loss. When epidemiologic studies are done of depressive disorder in the community, the rates of depression are highly inflated, suggesting that the vast majority of the population supposedly experiences a depressive disorder at some point in life. Policy analysts react by sounding the alarm that there is an epidemic of untreated depressive disorder, and enlist general physicians to treat this mammoth problem. Well-intentioned public service announcements or, in the U.S., direct-to-consumer medical advertising, educate people to watch carefully for the symptoms of depression and to be suspicious that they or their loved ones might have a serious mental disorder and a physician should be consulted if these symptoms occur. Physicians are taught to recognize and treat depression aggressively, primarily with medication. Moreover, we live in a high-pressure society oriented towards efficiency where there is decreasing tolerance of human frailty and (according to many young people) there is pressure if one feels "down" to go and get something for it from the doctor. All of this together leads to the routinization of medication for sad feelings under the label of depressive disorder. It narrows the scope of acceptable human emotion. There is nothing wrong in principle with using medication to lessen emotional suffering. However, one should take the risks of side effects with full awareness of whether one's condition is likely normal sadness or disorder -- one should not be misled by spurious diagnoses. Nor is medication proven to be more effective than several forms of psychotherapy. In any event, we have negative emotions for a reason, and intense sadness is often alerting us that things that matter deeply to us have gone wrong and that basic issues need in how one's life is going must be attended to.
You are about to publish a two-volume critical assessment of the "Little Hans" case, in which you dispute the validity and the truthfulness of a number of Freudian hypotheses. What is your view of psychoanalysis today? How does it relate to your reading of Foucault?
Obviously there are many newer approaches within psychoanalysis, but I believe there is still room for understanding where Freud went right and where he went wrong. I fund the recent "Freud wars" unsatisfying; neither the doctrinaire anti-Freudians nor the pro-Freudian camps seem to have fully satisfying arguments ....
I carefully examine Freud's case history of "Little Hans," a 5-year-old boy who had a horse phobia, and who was analysed by his father -- Max Graf, a Viennese musicologist and music critic who was a follower of Freud's and was guided by Freud in his analysis of Hans. (Hans was in fact Herbert Graf, who later became stage director of the New York Metropolitan opera, among other distinguished positions.) Freud had been accused, with ample justification, of forcing his patients into admitting to remembering the childhood sexual scenes he claimed supported his theories. The Hans case was his attempt to prove that what the childhood scenes he interpreted to his adult patients really do exist and can be more directly established in a child, without the layers of history and interpretation that leave so much room for suggestion in an adult. The Hans case is the most authoritative argument Freud ever presented -- and he continued to cite it as such throughout his life -- for the Oedipal theory.
In the first volume, I excavate Freud's thinking in a fresh way that reveals why his arguments are surprisingly brilliant in structure but nonetheless fail utterly when tested against the data of the case. I argue that, rather than supporting the Oedipal theory, the case was in effect a crucial experiment that disconfirm1ed it. If Freud had faced the facts, his Oedipal theory would have been abandoned in 1909, and psychoanalysis would have gone on to quickly become a more idiographic study of the individual's meaning system without preset doctrines about causes all neuroses. So, the conclusion of the first volume's evidential philosophy-of-science analysis is that the Oedipus complex is without evidential warrant in Freud's work, and that psychoanalysis took a "wrong turn" in 1909 from which it has taken a century to recover.
But why, then, has the Oedipus complex exerted such a hold on our imaginations for over a century? That is, given that there was so little support for the Oedipal theory in Freud's cardinal presentation, what explains the success of this theory within the social milieu into which it was introduced, and what has this theory done to us in terms of rearranging family power relationships? The question of why the Oedipus complex (and Freudian claims generally) has had such an outsized influence relative to the evidence has puzzled many observers .... My own thesis in this book is that the primary effect of the Oedipal theory -- and indeed its social function, that is, the reason it was so appealing and was accepted despite its weak evidential base -- is that for the first time it made physical affection between mother and son suspicious and even dangerous. And this in turn allowed fathers to retain some of their power as patriarchy in the family waned-- or in the most basic terms, it kept children out of the marital bed so that fathers could pursue the new goal of marriage that emerged at the end of the 19th century, sexual and emotional intimacy.
If the evidence was not there, then how does one explain the influence of the Oedipal theory? This question goes hand in hand with the question of what impact the Oedipal theory has had on all of us, on our culture -- what has it done to us? I believe that the acceptance and impact of Freud's Oedipal theory must be understood in terms of Foucault's construct of "power/knowledge," in terms of how the theory restructures power relations and supports evolving social values. Read with an eye to certain anomalies in the record, the case can be seen as a record of a struggle between a husband and wife over whether the child will have access to the marital bed over which the husband wants control. The dangerousness and pathogenic potential of physical affection between mother and son is in fact the way the Oedipus complex becomes primarily interpreted in the case record. The case occurred at a time when marriage was being redefined as essentially emotional and sexual in nature, and the child's presence in the marital bed became an issue. The Oedipal theory restructured family power in favour of the exclusion of children from the marital bed and more generally towards greater parental intimacy and away from parent-child intimacy.
My conclusion is that, although Freud in some respects was a revolutionary who contributed to the sexual revolution, he was also the theoretician most responsible for preserving Victorian ideas about the special dangerousness of sexuality and its central role in psychopathology. He "sexualized" the essentially non-sexual affection between parent and child, thus creating a sense of danger and self-consciousness in parent-child intimacy that resonates to this day in the way we feel about our children and in the arrangements we make for sleeping separately from them.