(This is the second of two essays about the New York Times' Sunday Dialogue called "Defining Mental Illness.)
The New York Times asked psychiatrist Ronald Pies to write a statement about psychiatric diagnosis for its March 24, 2013, Sunday Dialogue, and his statement was sent out ahead of time with invitations for others to respond. Some responses would be published right below Pies' piece, and Pies' answer to those responses would wind up the section.
Pies was an interesting choice. His Sunday Dialogue statement was a written as though psychiatric diagnosis were as scientifically grounded as clearly medical problems such as migraines — he says that psychiatric diagnoses are made like diagnoses of migraines, in that they are based on patients' history, symptoms, and observations — and that, if done carefully, assigning such diagnoses can even be humanizing, because patients are relieved to have their suffering given these labels. (For instance, he writes that it is important to tell one diagnosis from another but neglects to mention that the scientific research has shown conclusively that psychiatric diagnostic categories overlap hugely with each other as well as with clearly nonpathological behavior and feelings.) It is reprehensible that he failed to disclose the now well-established facts that psychiatric diagnosis is unscientific, does not reduce human suffering, and causes many kinds of serious harm. What is downright weird is that just over a year ago, he published a strong critique of psychiatric diagnosis (http://psychcentral.com/blog/archives/2012/01/07/why-psychiatry-needs-to...) called "Why Psychiatry Needs to Scrap the DSM System: An Immodest Proposal," in which he advocated doing away with that system in favor of carefully listening to the patient and trying to understand them rather than label them.
After his Times piece appeared, I wrote to draw the attention of the newspaper staff to his striking and total inconsistency, andI asked if they publish letters to the editor about Sunday Dialogue so that this could be made known. The response was that they do not publish letters about that column but that in any case they would not do so "mainly to attack the credibility of the writer; we prefer that the focus stay on the issue." How strange to cast my query as attacking the credibility of the writer rather than to make the point that readers have a right to know when someone given the prominent position of authorship of the lead piece in their special feature totally contradicts himself, because that surely sheds light on the way the issue is addressed.
The first "reader's" reaction printed was by Allen Frances, hardly an average reader, given that he headed the group that wrote the current and previous editions of the diagnostic manual. Frances, whose manuals are responsible for millions more people being pathologized than at any time in history, actually complained in the Times that "the realm of normal is shrinking." Less than anyone on earth should he be surprised. When at his invitation I served on two of his committees and repeatedly sent evidence of the abysmal quality of the "science" he was using to create and justify diagnoses and the devastation caused to people, he not only ignored but actually publicly denied that that was true. (That was why I resigned from his committees, feeling it was unethical and unprofessional to participate in that enterprise.) Even today, he professes to have had no way to predict how many more people would be diagnosed, despite his having added 77 categories to the 297 in the edition published just seven years before. (see Paula J. Caplan. 1995. They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal.)
In the Times piece, Frances called diagnosis "the essential prelude to effective treatment," though he more than anyone has seen ample evidence that this is untrue. In fact, the chances even that two therapists simultaneously meeting with the same person will assign that person the same label are poor, which of course means that diagnosis is not helpful in choosing treatment or improving outcome. (see Caplan, 1995, as listed above)
And Frances is a Johnny-come-very-lately when in the Times he presents as his own, new idea the proposal for Congressional action that I had initiated in 2002 with the two Congressional briefings I organized while he would continue until recently to defend uncritically his diagnostic empire. He seems to love my ideas, though, because also very recently, without attributing this one to me either, he suddenly proposed that the DSM carry a blackbox warning, one of the nine demands in "The Need and the 9 Demands" documented that I had written and that Jenny McClendon, Leah Harris, Debra Turkat and I had attempted to deliver last November 13 to APA headquarters (http://www.madinamerica.com/2012/11/the-apa-refuses-to-listen-to-voices-...). One can only hope that soon he will act on the pleas issued to him more than a quarter of a century ago, that he act to prevent future harm and redress harm that his editions have already caused. Instead, his emphasis is on trashing the next edition of the manual, which will indeed be terrible, in large part (though not entirely) because it is likely to include so much of the content of Frances' editions.
The next response in the Times feature came from Sera Davidow, who wrote as one who was diagnosed but who now directs "a recovery community for others who have been so labeled." She decimated Pies' absurd attempt to draw an analogy between psychiatric categories and migraines by saying that no one "attempted to hospitalize or medicate me against my will for [migraines]," and she describes how a person's psychiatric label often becomes their sole and demoralizing identity.
After Davidow's response came one from Patrick Singy, a historian and philosopher of science, who emphasized the need "to reflect on the much larger ethical, legal and social consequences of creating (or deleting) diagnoses."
Psychiatrist and psychoanalyst Leon Hoffman urged that each person be approached not for purposes of choosing a diagnosis but "as a unique individual" who, with the therapist, will decide on the best treatment.
The New York Times includes in its print edition only some of the responses they post online. My own did not appear in the print edition but followed Hoffman's online. Because some people have asked me about this, I can tell you that I have no idea how they choose which ones will appear in print, but it troubles me that only one response in the print version was from a woman. This is the version, slightly shortened from what I submitted, that appeared online:
"Surprising though it may seem, psychiatric diagnosis is not scientifically grounded, does not reduce human suffering, and carries risks of a wide array of serious kinds of harm. Even more disturbingly, it is totally unregulated, making it even less regulated than the financial institutions in this country.
I served for two years on two committees that wrote the current DSM but had to resign on ethical and professional grounds when I saw the way they ignored or distorted what high-quality research showed but presented junk science as though it were good when it suited their purposes.
The potential damage caused by a diagnosis is virtually limitless, including loss of custody of a child, loss of employment, skyrocketing insurance premiums, and loss of the right to make decisions about one's medical and legal affairs."
Omitted from my list of kinds of harm was the ultimate one: The physical death that too often results from various consequences of psychiatric diagnosis, sometimes caused by the unwanted effects of psychiatric drugs (and their interactions with each other) and sometimes from other causes, with the diagnosis always as the first cause.
Also appearing online but not in print was Laura Delano's description of how her initial relief at being diagnosed as mentally ill soon gave way to her feeling "stripped...of an authentic sense of self and of a connection to those around me, because my 'condition' made me different. Only in leaving behind that psychiatric diagnosis and the treatment it required did I find a path through my emotional struggles to the other side, where I could accept myself as I was, and be fully human again."
Two more responses appeared only online. Psychiatrist Michael F. Grunebaum was an argument that psychiatric diagnosis is a work in progress "with the shortcomings of any human endeavor in which scientific knowledge is incomplete." He apparently is entirely unaware that the DSM is not based on solid scientific knowledge, in contrast to being simply incomplete, and that difference matters enormously. Just ask the people whose lives have been ruined because of the mistaken belief that the labels they were given were scientifically supported and would lead to better things. The other response was from psychiatrist Victor A. Altshul, who pointed out how his profession has horribly stigmatized -- through diagnosis -- large groups of people. And he eloquently echoed the point that people are not their diagnoses: "It's all very well for a patient to know what he [sic] 'has.' But what he [sic] really needs is to know who he [sic] is. When that happens, the 'diagnosis' tends to disappear. It's just too little an idea to account for human complexity."
Finally, there came Pies' response to a few of the comments. Unsurprisingly, he selectively agreed that diagnosis leads to effective treatment, despite the absence of data supporting that claim. He took offense at Ms. Davidow's comments, claiming that it is "unfair" to blame psychiatric labels for the abridgement of civil liberties and excesses of the drug companies and that instead one must blame Pharma. It is nothing less than unconscionable for him or Frances or anyone else to try to steer the blame away from diagnosis, because psychiatric diagnosis is the first cause of virtually everything bad that happens in the mental health system. Few, if any, people have been deemed psychiatrically normal but then had terrible things done to them in the name of treatment or protection of themselves or others.
©Copyright 2013 by Paula J. Caplan All rights reserved