I wrote the Book of Woe really fast, at least for me. I signed the contract in May 2011. It always takes me a few months to get my head out of my ass after I sign a contract, so I started around Labor Day. I had my first draft finished in September 2012, edits done by xmas, with a publication date of May 2013. By way of contrast, I signed my Manufacturing Depression contract in June 2007. Before I could even put my head up my ass, I had to finish The Noble Lie, which I did in August. Around November, my wife said to me, “When are you going to start that book?”
“Book?” I said, although she may not have heard me, given the location of my mouth. A few days later, my editor called and asked the same question. So I started around Thanksgiving 2007. I finished in April 2009, with edits and so on through the summer and a publication date of Feb 2010. I never felt hurried.
I not only had less time with BOW, and an impending deadline that was real–the May 2013 release date for DSM-5–but I was writing about events that were happening as I wrote, and people who were not shy about contacting me with the latest developments, whereas with MD I was mostly writing about historical events and people who were dead. Dead people can’t sue, nor can they call you up and fight with you about their quotes. And then there were the google alerts–three or four a day on the DSM-5 account, thousands of links to click (or not to click and then to feel guilty for ignoring them.) I would be a terrible newspaper reporter.
All of which is to say that because I wrote the thing in a hurry, I left out some stuff. Actually, I didn’t leave it out. I just didn’t think of it. The story hadn’t percolated sufficiently. And some of what I didn’t see, I just can’t believe I didn’t see.
I wrote about one of the important points that I missed in a blog on newyorker.com. It’s about the way that the DSM-5 may not affect the overall prevalence of mental disorders, but rather simply reallocate the existing market to different products listed in the catalog. That’s part of an overall point that I do think I made, but not as clearly as I could have: that concerns over the DSM-5 are to some extent misplaced. The problem is not this particular revision, but the idea behind the book, which is that mental suffering can be understood and treated like infectious disease. That idea is wrong at so many levels that I don’t know where to begin. You’ll just have to read my book. But one thing is for sure: the American Psychiatric Association LOVES that idea, and has flogged it for all it’s worth. Which is, to judge from DSM-IV sales, hundreds of millions of dollars.
But something else I didn’t write enough about is perhaps more consequential. And that is the mystery of Allen Frances. It is hard to believe this, since he probably appears on about, I’m guessing, one-third of the pages in my book, and is surely what Larry Wright calls the “donkey” of my story, the character who carries the narrative. And what a narrative it is, or at least seems to be. Top psychiatrist comes out swinging against his own, and by his own analysis damages his profession by revealing what has always been implicit: that psychiatric diagnosis is closer to fiction than fact, and that the result has been rampant overdiagnosis and overtreatment.
It looks at first like a case of Ike Farewell Disorder, named (by me) for President Eisenhower’s famous farewell address, in which he warned the country of the necessity to “guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.” What a strange way to exit public life–with a warning that the tit you’ve been sucking all your life, and that over the last eight years you have been largely responsible for swelling beyond recognition with the juice of your Cold War, is too big, and maybe filled with poison. Of course, Eisenhower counseled moderation–a strong security state that doesn’t overstep–and would have been the first to cry foul if your average peacenik had suggested he’d crossed over to their side, but there was one question he just couldn’t answer: why should we leave the military-industrial complex in the hands of the military and industrialists? Or to put it another way, wasn’t his whole point that the government, the economy, and increasingly the society had been taken over, such that there really wasn’t anyone left to keep it the MIC in its place? Maybe Eisenhower didn’t grasp it, or maybe he didn’t want to, but the MIC was the natural offspring of capital and empire. Not even a bastard child, but the progeny that is inevitable when you put those two together.
It’s impossible to know what prompted Ike to renounce the MIC, even in the limited way he would cop to. And it is also impossible to know why Frances did it. But there is a difference–and not only that Eisenhower is dead and Frances very much alive. It’s also that I got to talk endlessly with Frances, and not a bit with Eisenhower. And I could not get anywhere with him on the subject. To hear him tell it, it was not any kind of about-face for him to go on a jihad against the DSM-5. Like Ike, he just wanted to give his successors the benefit of his experience and warn them against the excesses that needed to be checked. He was just being reasonable. He had kept silent in the face of other psychiatric overstepping, so in this sense he was atoning. But as for the way that psychiatrists had seized sovereignty over out inner lives–about this he remained sanguine. No conversion, no atonement, no penance, no second thoughts.
Like Ike, Frances wasn’t criticizing the institutions that gave rise to the pathology. He was criticizing the pathology itself. But, unlike Ike, Frances felt compelled to address that institution at its heart: the DSM’s overall reliance on expert consensus rather than scientific fact. The reason the DSM-5 was so dangerous, he argued, was that it overlooked just how fragile a system the DSM is, how prone to pointless argument, to public embarrassment, and ultimately to diagnostic epidemics and other psychiatric excess. The APA was abusing its power, apparently out of ignorance of how difficult it is to steward the DSM, how easily it can be exploited, especially by drug companies, and how crucial it is to protect its flaws from public scrutiny.
But for Frances, power does not necessarily corrupt. He believes that it is, in the right hands, something that can be used for good. He took umbrage anytime I, or anyone else, suggested that the problem with DSM-5 was only the latest instance of the problem of DSM. He accused me of indulging in conspiracy theories when I argued that there were deep historical forces at work here. His was a one bad apple theory, the bad apples being the current regime at the APA and their patrons in the drug industry. And here is where I think I might have let him off the hook too easily.
Why do people haul out the one bad apple theory? Why did the US Government fall all over itself to blame Abu Ghraib on a girl who liked to take pictures and a man who got a kick out of humiliating prisoners? Why do politicians argue enthusiastically for gun control via plucking out those w ho shouldn’t have weapons rather than via controlling guns? There are surely lots of reasons, but at least one has to be damage control. The Pentagon wants to keep the spotlight off the volunteer army, off the admixture of sex and violence it uses to motivate soldiers (see or read Jarhead if you don’t believe me), off the utter vileness of the Iraq war, off the themes of domination and rape that have characterized empire since, well, since empires began. The politicians…oh, don’t get me started. You know why they want to divert attention from the longstanding historical tensions about the 2nd Amendment. Talking like that gets you in trouble with the not-so-well-regulated militia called the NRA.
So what was it for Frances? What was he protecting? He’ll tell you it was the patients, the people who, upon hearing that psychiatrists really don’t know what mental illness is, let alone which ones exist, will go off their meds and push people in front of subway trains or shoot up schools. And while there must be people who will do that, I’m not sure we have any evidence that mayhem committed by the mentally ill spikes whenever someone publicly questions psychiatry’s authority over them. I mean, Robert Whitaker wrote a pretty well researched book about the way that mental illness was caused by psychiatric drugs, but I don’t recall hearing about an epidemic of noncompliance among mental patients. I wrote a pretty convincing (if I do say so myself) takedown of the depression industry, and Jerry Wakefield and Allen Horwitz, not to mention Irv Kirsch, have weighed in on the drug side of that “epidemic,” but that hasn’t stopped 11 percent of American adults from sticking with their antidepressants. So this just can’t be the whole reason.
So I doubt that this is the only reason, and if it is, then Frances’s mission is pretty misbegotten. It’s also unnecessary. Regimes at the APA come and go,. If the organization continues in its current direction, bleeding money and members, it will eventually go the way of the Soviet Union (which, by the way, we mostly spent into the ground) and we won’t have it to kick around anymore. If not, then a more enlightened leadership will solve the DSM problem soon enough. And the drug industry–well, they’ve figured out that between the bad press and the bad clinical results (not to mention the complexity of the brain), they’re getting out of the psychiatric drug industry. There is not one major new psychiatric drug in the pipeline. The great thing about capitalism: once in awhile it kills something that ought to be dead.
No, I think the problem is more parochial even than that. I think Frances wants to protect his profession because it is his profession. He believes in it, and he is deeply offended by what he sees as its running off the rails. In this he’s no different from any of us. When our government or our sports team or our children do something we don’t approve of, it is really hard not to take that personally, as some kind of reflection of our own worth. And we will do what we have to to shatter that mirror without changing ourselves.
My favorite example of this is what happens every time a hunter kills a person, usually a fellow hunter, by mistake. Other hunters will quickly say, “Well, he wasn’t a real hunter. Real hunters don’t (fill in the blank with whatever mistake the hunter made). But of course he is a real hunter. He was in the woods with a gun, stalking animals, and nailed a person instead. What the hunters don’t want to say is that dead people are an occasional, but inevitable, result of having a bunch of armed people stumbling around the woods in close proximity to each other. And psychiatric overstepping is the inevitable result of having a bunch of experts armed with the power society invests in doctors stumbling around in the fields of the human mind, with no reliable safety on their rifles. Someone is going to get hurt, no matter who is in charge.
Of course, Frances knows this. There’s plenty of evidence that lots of people have been hurt since 1994, when his DSM came out. But strangely, it’s not possible to correlate the increase in diagnosis and treatment with the advent of the DSM-IV. That may be because we just don’t know how to measure something so protean as the effect of a diagnostic manual on the mental health of a society. But it may also be because the problem isn’t even in the DSM, let alone the DSM-5. It’s in the license psychiatry has been granted to medicalize our suffering, of which the DSM, any DSM, is only a symptom.
Allen Frances, as honest and forthright as he is, cannot possibly cop to this, because he holds that license and believes he deserves it. I wish I had taken him on more directly about this in my book.
It seems we have a major case of cognitive dissonance here, Gary. When I read your post I was bothered first by the dismissive references to Ike. It does not advance the dialogue to say that Ike was sucking the MIC tit all his life. His farewell speech in 1961 contained an enduring insight: that national security is paradoxically threatened by an unchecked military-industrial complex because both partners commit to flawed paradigms out of misguided self-interest and perverse incentives. This insight finds other applications today, such as in the academic-industrial-government complex. Ike’s warning went to other stakeholders besides the military and the executive branch of government.
Next I was bothered by the attitude that calls psychiatric diagnosis “closer to fiction than to fact.” Here cognitive dissonance enters again. We should recall that patients afflicted by serious disorders existed before the healing professions arose. The history of the healing professions is in large part a history of trying to make sense of those disorders – efforts at nosology, that is. Nosology is a prelude to differential treatments. But I think you invert the issue by the way you frame it. We are not bent on seizing sovereignty over the inner lives of patients, as you put it. The patients have always been there, afflicted by psychosis, mania, melancholia, crippling anxiety, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. The members of the healing professions did not manufacture these disorders – rather, people suffering from them came to us for help.
When you say Allen Frances believes that power in the right hands does not necessarily corrupt but can be used for good, I would disagree. Enter cognitive dissonance again. It is not a matter of power but of duty and obligation, essential features of a disinterested profession. I would make the same argument in the case of Ike: he was less interested in power for its own sake than in discharging what he saw as his duty over a lifetime in the military.
I have made my share of criticisms of DSM-5 but I take second place to nobody in affirming the reality of major psychiatric diagnoses. I caution against your inclination to over-generalize about the weaknesses of psychiatric diagnoses. Yes, there have been serious missteps – pediatric bipolar disorder and the elimination of the bereavement exclusion for major depression, for instance. Yes, some of the players seem driven by therapeutic zeal rather than by good clinical science. Yes, the black and white perspective turns to gray as we move further from ‘show stopper’ disorders to the extremes of normal variation. But I take exception when you say psychiatry has been granted a license to medicalize our suffering. The suffering was already there, as were the calls for help. Allen Frances does not hold such a license… he is discharging a duty.
I wish you well with your new book, which I am currently reading with pleasure and profit. You have much that is wise to say, as in your previous post on melancholia. Barney Carroll.
Agree with Dr. Carroll’s response. Criticizing the APA for the existence of the DSM misses the point – mental illness exists whether or not psychiatrists devise some way of describing it and categorizing it.
I perceive that Bernard Carroll misses Gary Greenberg’s drift, and inadvertently confirms Greenberg’s reasoning, when he writes as follows, above:
“The patients have always been there, afflicted by psychosis, mania, melancholia, crippling anxiety, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. The members of the healing professions did not manufacture these disorders – rather, people suffering from them came to us for help.”
There is surely no question that people have been suffering in brain and mind, over time. The Diagnostic Statistical Manuals have been attempts to describe and specify those sufferings. It does not follow from this that the descriptions now deemed authoritative are fully competent to an adequate understanding of brain and mind issues. It would be helpful if the Powers That Be might find a modicum of humility in applying constructs (as, “psychosis, mania, melancholia, crippling anxiety, dementia, autism, obsessive-compulsive disorder, delirium, catatonia”) that are — constructs.
Nicely said, Mary. I have no idea why this is so hard to put across to people like Barney, who has a quite capacious intellect. There is a difference between saying that the naming of a disorder carries with it all sorts of political and philosophical problems and saying that the naming of a disorder creates the suffering. Doctors don’t create illness. They create our means of understanding it. They do this better in some cases than in others.