On December 1, Mad in America published an article titled When Homosexuality Came Out (of the DSM). The author is Vivek Datta, MD, MPH, a British physician who is currently a second year psychiatry resident at the University of Washington, Seattle. The article was also published the same day on Dr. Datta’s blog site, Medicine and Society.
The article focuses on the removal of homosexuality from the DSM, which occurred in 1973. Dr. Datta discusses this issue and various related themes, and he draws some conclusions that, in my opinion, are unwarranted and misleading.
Here are some quotes from Dr. Datta’s article, interspersed with my comments.
“Paradigmatic of the social nature of psychiatric diagnosis, the purging of homosexuality from the psychiatric nomenclature highlights the instability of the psychiatric sign: once signifying disease and perversion, homosexuality came to be recognized by the establishment as a normal variant of human sexuality.”
The purging of homosexuality from the DSM does indeed highlight the “instability” of psychiatric labels. Homosexuality was a “psychiatric illness” prior to 1973; after 1973 it was a variant of normal. Similarly, but in the opposite direction, childhood temper tantrums used to be a variant of normal, but, thanks to the promotional efforts of pharma-psychiatry, are now considered to constitute a psychiatric illness (disruptive mood dysregulation disorder).
But instability isn’t the only issue. The fact that these human activities can become illnesses or cease to be illnesses by the voting authority of the APA suggests, at least to me, that psychiatry’s so-called nosology is spurious. The instability of psychiatry’s “diagnoses,” which Dr. Datta mentions, is indeed a reflection of the social aspect of psychiatric labeling, but it is also, and much more fundamentally, a reflection of its spuriousness.
If people with real diseases, pneumonia or kidney failure, for instance, were to become dissatisfied with receiving these diagnoses, and were to stage protests, initiate lawsuits, etc., it wouldn’t materially alter their diagnosed status. They would still have pneumonia or kidney failure or whatever. The medical specialties involved can’t vote these illnesses out of existence any more than they can create new illnesses by fiat. Psychiatry is the only medical specialty that can do this. And it can do this because it has decreed, arbitrarily and without justification, that all significant problems of thinking, feeling, and/or behaving are psychiatric illnesses.
It is a pity, and also noteworthy, that Dr. Datta did not take the opportunity to point this out.
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“As discussed above, the removal of homosexuality from the DSM was the result of sociopolitical forces, and not a reflection of scientific advancement. Even within psychiatry, the mass proliferation of psychiatric diagnoses is viewed as something commercial. Up until the 1970s psychiatric diagnoses were not necessary to treat individuals with a wide range of problems, and psychiatrists had little competition from other mental health professionals. With the growth of clinical psychology and other mental health professions who could provide psychotherapy more cheaply, psychiatrists needed to maintain their moral authority over the mental life that had come under their purview. What psychiatrists, as physicians, could do that others could not was make diagnoses. Thus the medical profession created new diagnoses for the range of mental life that psychiatrists were already seeing in their offices; and these became the signifiers that these patients had a medical illness that required treatment. The growth of psychopharmacology allowed the boundaries for these new diagnoses to expand, creating new markets, not only for the pharmaceutical industry but also for the mental health field. There was no problem too small to warrant pharmaceutical relief.”
These are complex issues. Dr. Datta asserts that up until the 70’s, psychiatrists had little competition from other mental health professions, but as competition of this kind began to emerge, they needed to medicalize the human problems that they encountered in order to maintain their “moral authority” in these areas. I’m not sure that psychiatrists ever possessed moral authority in the usual sense of the term, but setting that aside, it should be emphasized that they didn’t need to spuriously medicalize these problems. Rather, they chose to do so. Faced with the prospect of losing turf and prestige, they fabricated an elaborate house of cards, foisted this hoax onto their clients and the general public, marginalized all opposition, and routinely suppressed evidence of the subsequent destructiveness and disempowerment. This is not, I suggest, how a profession with moral authority would respond to increased competition.
But there is a much more significant aspect to the competition issue that Dr. Datta completely ignores. And that is psychiatry’s competition with natural helpers. In earlier times, and certainly into the 50’s, 60’s, and 70’s, problems such as shyness, worry, temper tantrums, feelings of guilt, experiences of failure, painful memories, bouts of depression, etc., were routinely dealt with by the individuals themselves, with help from parents, siblings, extended families, friends, co-workers, clergy, barbers, etc… In effect, these natural helpers were psychiatry’s competition in the “treatment” of these problems that have, since about 1980, increasingly come to be seen as illnesses requiring professional psychiatric intervention. In order for psychiatry to expand, the role of these natural helpers had to shrink. And shrink it has under a barrage of psychiatric assurances that these problems are illnesses (“just like diabetes”), that they need professional treatment, and that amateurish interventions are likely to be counter-productive. Psychiatrists routinely, and disrespectfully, marginalized these natural helpers, and relegated them to the status of compliance monitors – encouraging the “patient” to take the “medications” to “treat” his “lifelong illness.” Psychiatry didn’t need to do this. Psychiatry chose to do this for reasons that had nothing to do with client welfare, and everything to do with psychiatric profit and hegemony.
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“But what of the social and political forces that facilitated the growth of mental illness? At the same time that homosexuality was losing its status as mental disorder, the US was in the midst of a deepening economic crisis. By 1980, the year of publication of DSM-III, a new republican government headed by Ronald Regan entered the White House. Rather than draw attention to the psychiatric casualties that would amass under neoliberal policies, it became convenient to locate mental illness within the self – in brain, cell, and molecule – rather than as a product of community, society, and state. It is for this reason that psychiatrist Joanna Moncrieff has suggested that a “marriage of convenience” exists between biopsychiatry and the politics of neoliberalism. A biological model that was gaining ascendance was fortified by the political expedience of supporting a paradigm of psychic discontent that obfuscated the wider social, economic and political forces at play. In the same way the removal of homosexuality from the DSM was not the result of scientific advancement but political will, the solidifying of disease status of minor psychiatric diagnoses and their biological basis are more the result of these same forces than scientific triumphalism.”
In discussing and analyzing human activity, it is certainly important to remain cognizant of the various cultural, economic, social, and political forces that have an impact on human decisions. But it is equally important to recognize that these forces are themselves created, shaped, and nurtured by the decisions of influential people. Certainly, the practice of spuriously pathologizing individuals serves to draw attention away from social, political, and economic issues. But by the same token, emphasizing the social, political, and economic issues serves to draw attention from the fact that psychiatry’s ardent and unchecked drive towards the medicalization of every conceivable human problem was primarily the result of decisions taken by psychiatry’s leadership with the wholehearted endorsement of the rank and file. Psychiatrists were, at all times, firmly in the driver’s seat in their profession’s descent into moral and intellectual bankruptcy. The medicalization travesty was not something that was perpetrated on psychiatry by outside forces. Rather, it was something that psychiatry, with eyes wide open, inflicted on its clients and on society generally.
And psychiatry’s motivation in this regard was greed, prestige, and the desire to retain hegemony in an area in which at the present time, they can claim no particular expertise or experience, i.e. the provision of real help to people who are troubled by problems of thinking, feeling, and/or behaving.
And incidentally, note the word “minor” in Dr. Datta’s last sentence, the presumed implication of which is that he is excluding “major” psychiatric diagnoses from his critique. In reality, there is no more evidence supporting the disease status of major psychiatric diagnoses than minor ones.
It is noteworthy that in his final paragraph, Dr. Datta mentions the British psychiatrist Joanna Moncrieff, and the impression given is that his and Dr. Moncrieff’s positions are broadly similar. And indeed there may be a good deal of overlap. But with regards to the ontological status of psychiatric “illness,” Dr. Moncrieff is unambiguous:
“Thus I refer sometimes to ‘mental illness’, although I do not consider that psychiatric conditions are usefully or validly regarded as illnesses.” (The Myth of the Chemical Cure, 2009, palgrave macmillan, p xi)
Dr. Datta, of course, is entitled to critique as much or as little of his profession as he chooses. But I think it’s important to clarify two important issues. Firstly, one of the effects of Dr. Datta’s critique is to relieve psychiatry of blame: in the framework sketched out by Dr. Datta, the present scandalous state of affairs is not the result of corruption, greed, and venality within the profession, but rather is the result of social, economic, and political “forces.” Secondly, although Dr. Datta’s critiques are in some respects far-reaching and insightful, he does appear to endorse the disease status of at least some psychiatric diagnoses.
The problem with this kind of partial critique of psychiatry by one of its own members is that it conveys the impression that compromise is possible – that psychiatry is taking our concerns on board and is agreeing with us. But this impression can be misleading.
The fact is that psychiatry’s primary premise: that all significant problems of thinking, feeling, and/or behaving are illnesses – is false. Apart from those psychiatric diagnoses that have been clearly established as “due to a general medical condition” or “due to the effects of a substance”, there is no substantive evidence to support the disease status of the wide-ranging DSM entities. As long as psychiatry clings to the obviously spurious notion that distress or impairment constitute illness, then there can be no valid compromise, even if individual psychiatrists express a willingness to cede the matter with regards to some conditions. The problem for psychiatrists, however, is that as soon as they acknowledge the truth, and abandon their basic falsehood, there is no longer any need or justification for medical involvement in these areas, and they will cease to exist as a profession.
What psychiatry has been doing for the past 50 or 60 years is obfuscating the issues in the hope that their nosological edifice will ultimately be rescued by neuroscience. They asserted the known-to-be-false chemical imbalance theory with vigor, and now as it crumbles under the criticism of anti-psychiatry, they are asserting – again without evidence – the neural circuitry anomalies theory.
Individual psychiatrists, of course, have to find their way through this intellectual and moral quagmire as best they can. Some, and perhaps most, just ignore the issues and go on pushing drugs as they have been trained to do. Others vehemently deny the arguments from this side of the issue. Others ostracize us as “deniers,” on a par with evolution-deniers and conspiracy theorists. Most of the leadership continue to use spin and PR in a futile attempt to offset valid and legitimate criticism.
In this context, Dr. Datta’s approach – which incidentally is similar to that adopted by Allen Frances, MD – is relatively rare: agree with the opposition on secondary issues, but hold fast on the core principles. It is analogous to jettisoning the cargo to save the ship. With psychiatry, however, it is the ship itself that is flawed.
Psychiatry is not something basically sound that needs some minor corrections or repackaging. Psychiatry is something fundamentally flawed and rotten. The notion that all significant problems of thinking, feeling, and/or behaving are by their very nature illnesses is the fallacy from which all psychiatry’s destructiveness flows. And no amount of repackaging can correct that fallacy. And by the same token, no significant progress can be made in this area until that fallacy is finally and totally discarded.