What is Normal & Who's to Say? Psychiatrists Decide...
American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM)
The psychiatric labels assigned by medical doctors and psychiatrists are based upon shoddy science. The list of "mental health disorders" is constantly expanding. Why? Because labels figure prominently in deciding whose psychotherapy will be paid by insurance companies, who will be hospitalized against their will, who may be declared by a court of law to be incompetent or too disturbed to have custody of their children, who will be allowed to grant or withhold permission to perform surgery on their bodies, and on and on.
How are decisions made about who is normal? Paula Caplan, psychologist, as a former consultant to those who construct the "bible of the mental-health professions," the DSM, offers an insider's look at the process by which decisions about abnormality are made. To a large extent scientific methods and evidence are disregarded as the handbook develops. Below is an excerpt from a book by Paula Caplan on this subject.
They Say Youre Crazy
by Paula J. Caplan, Ph.D.
I have written this book with a very limited purpose in mind: to help people see how decisions are made about who is normal. I believe that knowing how such decisions are made can help a person overcome the damage that is done to so many who are called - or who consider themselves - abnormal. As a clinical and research psychologist who for some years worked as a psychotherapist, I have seen a great many people who have suffered such harm. As a former consultant to those who construct the worlds most influential manual of alleged mental illness, the American Psychiatric Associations (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), I have had an insiders look at the process by which decisions about abnormality are made. As a longtime specialist in teaching and writing about research methods, I have been able to assess and monitor the truly astonishing extent to which scientific methods and evidence are disregarded as the handbook is being developed and revised.
I have made no attempt to document the long, horrific history of mistreatments and misdiagnoses by mental health professionals of all kinds, since others have done so in remarkable books. Mistreatment is an almost inevitable result of diagnosis that is not done with a sense of responsibility and humanity. My primary focus in this book, though, is on the here and now and on how the most powerful mental health enterprise in the world - the American Psychiatric Association - is defining abnormality, mental illness, or mental disorder, rather than on the definitions consequences. The point is not that decisions about who is normal are riddled with personal biases and political considerations but rather that, by dint of a handful of influential professionals efforts, those subjective determinants of diagnoses masquerade as solid science and truth.
I would ask readers to do me the favor of remembering, as you read my book, that this is neither an anti-psychiatry nor a "Lets-trash-all-therapists" book. Its main focus is quite specifically on the disingenuous and dishonest process of constructing the worlds most influential handbook of "mental disorders."
This book is also not much about whether most of what is called mental illness has a biological basis or about the "medicalization" of what Thomas Szasz refers to as peoples "problems in living," although I do refer to this issue several times. I do believe that there may be some biological or physiological basis for some of the things that are currently called psychiatric disorders. However, so much of the research on these possible causes is so deeply flawed that it seems dangerous to draw very definite conclusions about them. R. Walter Heinrichs, for instance, recently wrote a thoughtful review of seventy years of research on what "schizophrenia" might be, how variously "it" has been defined, what might cause "it," and what "treatments" might be helpful for "it." His conclusion was that very little is known or understood and that the label still suffers from what he calls "a heterogeneity problem," a polite way of saying it is so variously applied that it is losing much of its meaning. This is particularly worrying both because research in this area has such a long history and because it has generally been assumed that whatever "schizophrenia" is, it is known to be genetically based. Now, it appears, what seemed certain is not.
When responsible reviews of research about diagnosis and treatment of mental disorders are carefully conducted, uncertainty is often the result. Much of what is labeled "mental illness" would more appropriately be called problems in living, and some has been shown to result from such problems as dietary deficiencies or from food or environmental allergies. What is important for this book is that, although some DSM diagnoses supposedly have some physical origin (hormonal, genetic, brain-based, etc.) and others supposedly result from peoples experiences in their families or their allegedly "sick" kinds of motives and feelings, all of that labeling is based on the DSM folks choices about whom to declare abnormal. As psychologist Carol Tavris has observed, "the DSM is not called the Diagnostic and Statistical Manual of Mental Disorders and a Whole Bunch of Everyday Problems in Living." It is marketed simply as a manual of mental disorders.
I do not claim that everyday problems are the only reasons that people might display what are classified as the symptoms of mental illness, and I do not claim to understand all of the possible sources of such troubles. However, I do believe that some of the masses of money, time, and energy spent in developing, revising, and marketing the DSM might be more productively used in exploring other possible causes of peoples troubles. Furthermore, much of the time and energy that professionals who use the DSM invest in learning about and trying to apply its contents could be more usefully invested in such endeavors as paying careful, caring attention to what ones patients say and working, free from dogma, to understand what helps them. (In the DSM, the authors do not even address the question of what treatments might help with which kinds of problems.) But today, in most settings where new generations of psychiatrists and other physicians, social workers, psychologists, and psychiatric nurses are trained, the DSM is the key volume about mental illness that all trainees must learn from cover to cover. It is also used as the key volume for a great deal of the research on mental health and mental illnesses funded by government agencies and private foundations. For years, I had - somewhat tongue-in-cheek - described the DSM as the "bible of mental health professionals." Then I saw an advertisement in which a book about the DSM was promoted with this quotation from Donald Godwin, chairman and professor in the Department of Psychiatry at the University of Kansas: "Like all semireligious works, DSM-III needs an exegesis."
When mental health authorities are asked questions on television and radio phone-in shows, they often refer to the DSM as though it were scientifically proven gospel, as though saying, "It is here in the DSM" makes it true. The DSM is a weighty volume in both its sheer physical size (nearly three pounds) and the aura of scientific precision that emanates from it: Each diagnostic category has a multidigit number attached to it, a list of criteria, and a "cutoff point" indicating that in order to warrant this particular label, a person must meet, for instance, six of the nine criteria listed. In any debate in Western culture, it usually strengthens ones position to claim that one is scientific, rational, and objective, while the other side is "politically motivated," irrational, and subjective. Although increasing numbers of people recognize that complete objectivity is impossible and that even seemingly rational claims that scientists make about their research are often both politically and emotionally motivated, the tendency to accept high-status medical scientists and practitioners words as truth is still widespread. Nearly always, those who have the most power - such as the APA - are those who claim to be objective and have the easiest time persuading people to accept that claim.
The DSM is also big business for its publisher, the APA: A recent revision yielded more than a million dollars in revenue, since each time a new edition appears, libraries and many practicing therapists - both psychiatrists and others - and mental health researchers have to buy the updated version. The 1987 edition was translated into Chinese, Danish, Dutch, Finnish, French, German, Greek, Hungarian, Italian, Japanese, Norwegian, Portuguese, Russian, Spanish, Swedish, Turkish, and Ukrainian. Related products are also marketed, including "various casebooks, tape cassettes, minimanuals, workshops, interview protocols, and computer programs." Products marketed for the previous edition and the current one include casebooks, interview guides, a study guide, a sourcebook, an audiotape, a videotape, a training guide, and several computer software packages.
Insurance companies, general practitioners, and lawyers make frequent use of the manual, insurance companies to decide which patients to reimburse for their inpatient or outpatient treatments. In fact, it has been described as "a surprising runaway best-seller, primarily because of sales to non-psychiatrists," whose numbers are legion. Kirk and Kutchins report that between 1975 and 1990,
In all, the DSM-III-R is reported to have sold about 1.1 million copies in less than six years.
Although my focus is on the DSM, I could not attempt in a single book to address the vast array of its biases, examples of sloppiness and illogical thinking, and just plain silliness. I do hope that readers who wish to learn about more than I have covered here will have a look at some of the excellent books and papers on this subject listed in the bibliography.
As I have written elsewhere, I believe that far too many people who are badly treated because of their race, sex, age, class, sexual orientation, mental or physical condition, physical appearance, and so on end up seeking psychotherapy because they mistakenly believe that their unhappiness stems from something within themselves. Too much contemporary treatment by mental health professionals, including treatment influenced by the DSM, maintains this almost exclusive focus on individuals psyches, as if the major sources of their troubles came from within them.
I do not intend for this book to destroy anyone or any institution. Rather, I long for it to help reveal the truth and encourage the openness and honesty of the individuals and institutions that represent themselves to the public as members of the helping professions who will assist them with their troubles. Without complete honesty and openness and without high moral and scientific standards and an overriding emphasis on understanding how we affect the people we purport to help, we cannot truly help, and they ought not to trust us when we say that we shall. As Jerome Frank has written, "The unattainability of the ideal is no excuse for shirking the effort to obtain the best available."
Certainly, some people hurt themselves or hurt or frighten others. Some people suffer intense emotional pain, some are outcasts, some are out of touch with what most people would consider reality. All of this is terribly sad and worrying, and as a society, we must find ways to alleviate these problems. I do not claim to know how best to do so. I honestly dont know, when I see someone screaming that thousands of bugs are crawling over him or that she is getting special messages from St. Jude, why that is happening. I certainly dont claim to know how to take away the anguish and confusion of everyone who feels them, and this book is not about that. But it does relate to all of these people, kinds of problems, and feelings, and how they are dealt with. And I do know that DSM-type enterprises have not been much help in alleviating human suffering. As a specialist in research methods, I want people to know how sparse are the research and even the logical thinking on which this diagnostic manual is based. I also want it known that researchers have found very few answers to these questions through using labels of mental illness.
I do intend this to be an anti-elitism book, since I want us all to be able to make an informed assessment of the people we allow to decide whether or not you and I and our loved ones are normal. Rarely are mental health professionals questioned about how they decide which people and what behavior are normal, and too rarely do the professionals themselves think critically about what they do. Laypeople generally hesitate to question those who seem to be experts in a mystifying or highly technical field; to do such questioning can feel like asking the clergy if there really is a God. It can also feel presumptuous: "Who am I to question someone who went to school for so many years and learned about all of this stuff? My questions will probably be stupid. And what if my questioning just makes the person angry?" Reluctance to question authorities tends to intensify when, as with mental health professionals, we see them in a time of desperate need. As I have written elsewhere, there is a whole panoply of reasons that the therapists and researchers themselves so often fail to think critically and questioningly about what they do. Questions that are rarely asked come to seem unworthy of being asked, unjustified, or unwarranted, and so the question of who is normal and who can legitimately answer that question is seldom raised. I hope that this book will encourage readers to overcome this kind of reluctance to question. We need not hesitate to think critically about what therapists and therapy researchers say and do, because, as Carol Mithers has noted, "Although the discipline presents itself as a science, its entire history is one of a series of new techniques and schools of thought." Therapy has been defined as an "unidentified technique applied to unspecified problems with unpredictable outcomes," and longtime psychotherapy researcher Hans Strupp has written: "Psychotherapy has become a billion-dollar industry . . . lacking clear boundaries, with hazy quality control and relatively vague ethical standards."
Identifying herself as a former mental patient, Judi Chamberlin has written: "Leaving the determination of whether mental illness exists strictly to the psychiatrists is like leaving the determination of the validity of astrology in the hands of professional astrologers. While occasional psychiatrists (or astrologers) may question the very basis of the discipline they practice, such behavior is understandably rare, since people are unlikely to question the underlying premises of their occupations, in which they often have a large financial and emotional stake."
Before we look at what the DSM group did, I think I ought to describe my attitude toward authorities and experts. Through almost all of the years of my formal education, from nursery school until partway through graduate school, I assumed that authorities knew best and held dearly the interests of those over whom they had power. I believed this so fervently (and sometimes obnoxiously, I suspect) that I was the kind of child who thought students who threw spitballs when the teacher briefly left the classroom were lacking in moral fiber. Rare experiences in high school, occasional ones in college, and most of my graduate school experiences revealed to me that authorities motives are not always altruistic and their procedures not always fair or logical. By now, more than two decades after finishing graduate school, my work increasingly involves questioning authorities and experts, but I find that I nevertheless tend, like most people, to start by assuming that those who have power are right - and that they do the right thing. I realize that this may sound strange, coming from someone who has been called antiauthoritarian and radically feminist, but each time I find that an authority has behaved irresponsibly or has lied or has been cruel, I feel a renewed sense of disappointment. I wish the world were a safer place than it is. It gave me no pleasure, then, to watch the unfolding of the disturbing story of how the DSM authors decide who is normal, but I tell it here because I do believe that the truth helps make us free.
Say NO To Psychiatry!
DSM-IV published by the American Psychiatric Association
They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal by Paula J. Caplan, Ph.D.
Making Us Crazy: DSM: The Psychiatric Bible and the Creation of Mental Disorders by Herb Kutchins, Stuart A. Kirk
The Myth of Mental Illness: Foundations of a Theory of Personal Conduct by Thomas S. Szasz, M.D., Professor
Law, Liberty, and Psychiatry : An Inquiry into the Social Uses of Mental Health Practices by Thomas S. Szasz, M.D., Professor
DSM-IV Casebook: A Learning Companion to the Diagnostic and Statistical Manual of Mental Disorders by Robert L. Spitzer, Miriam Gibbon, Andrew E. Skodol, Michael B. First
DSM-IV Made Easy: The Clinician's Guide to Diagnosis by James Morrison
Diagnostic Criteria from DSM-IV (4th Ed) by John S. McIntyre
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