Sunday, July 14, 2013

But This Diagnosis Is Just Right!

I've begun reading Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life (Morrow, 2013), by Allen Frances.  Frances, now retired from his profession, was chairman of the American Psychiatric Association task force that produced the fourth edition of the Diagnostic and Statistical Manual, or DSM-IV, so his "revolt" is noteworthy.  Saving Normal appeared on the library shelf at almost the same time as Mad Science, so I picked it up even though I didn't know at the time who Frances was.

Frances confirms some key claims of Mad Science, for example that
Billions of research dollars have failed to produce convincing evidence that any mental disorder is a discrete disease entity with a unitary cause.  Dozens of different candidate genes have been "found," but in follow-up studies each turned out to be fool's gold.  Mental disorders are too heterogeneous in presentation and in causality to be considered single diseases; instead each of our currently defined diseases will eventually turn out to be many different diseases [19].
But this admission occurs in the context of a bad argument:
Some radical critics of psychiatry have seized on its definitional ambiguities to argue that the profession should not exist at all.  They take the difficulty in finding a clear definition of mental disorder as evidence that the concept has no useful meaning -- if mental disorders are not anatomically defined medical diseases, they must be "myths," and there is no real need to bother diagnosing them ... "Saving normal" is taken by them to its logical extreme -- the extremely illogical position that everyone is normal.
Frances equivocates here, between "mental illness" and "mental disorder," though it may be that the vagueness of the term "mental disorder" is part of its usefulness.  That might not be a problem if psychiatrists hadn't long claimed, and continue to claim, that mental disorders are anatomically defined medical diseases, despite the absence of evidence for that claim.  Notice that in the first passage I quoted, Frances claims that "each of our currently defined disorders will eventually turn out to be many different diseases"; there's no evidence for that one either.

(Incidentally, Frances doesn't seem to consider the useful distinction between "normal" and "normative" in his discussion.  What is "normative" -- accepted by a society as the proper way to behave -- is not necessarily "normal" in the sense of widespread or prevalent.  Confusion between those senses of the word "norm" often leads to problems in disagreements about society and its values.)

Now, as I wrote yesterday, it doesn't follow that because "mental disorders" are not (as far as we know) anatomically defined medical diseases, that people don't suffer from them, or that they shouldn't be helped to feel better.  Frances doesn't cite or any quote specific offenders who declare that there is no real need to bother diagnosing them.  The logical question would be more along the lines of: if these problems are not diseases, is "diagnosis" the right word for trying to make sense of them, even to classify them?  The very word "diagnose" begs the question by implying that we are dealing with diseases, that a medical metaphor is a good way to make sense of them.  The authors of Mad Science wrote, for example:
A fidgety boy or an adult who thinks the devil is out to kill him does not need to be labeled as suffering from a brain disease called Hyperactivity Disorder or Delusional Disorder. They are more usefully and honestly called … a fidgety boy and a person with incredible, scary beliefs. People who are distressed or misbehaving can be helped without inferring some, as yet undiscovered, neurological defects [321-322].
To say that mental illness is a "myth" doesn't mean that people aren't suffering: it means that the word "mental illness" imposes a conception of what is wrong with such people that attempts to make sense of it, without regard to whether it's accurate.  (Analogously, Robert Wilken's The Myth of Christian Beginnings didn't deny that Christianity began at some point in time: it discussed a myth about those beginnings.)  As Thomas Szasz (presumably one of the "radicals" Frances is attacking), wrote in 1960:
While I have argued that mental illnesses do not exist, I obviously did not imply that the social and psychological occurrences to which this label is currently being attached also do not exist.  Like the personal and social troubles which people had in the Middle Ages, they are real enough.  It is the labels we give them that concerns us and, having labelled them, what we do about them.
"Mental illness" is an analogy whose structure posits that minds can be ill just as bodies can be ill.  Maybe psychiatrists would have a stronger case if they stopped claiming that mental illnesses have a physical basis, and take advantage of the fact that the mind is inaccessible to direct measurement and diagnosis.  But to do so would undermine their efforts to establish psychiatry as a science.  "Disorder" is not much better, because it's used in medicine to refer to physical ailments and is probably borrowed by analogy for mental ones: again, it assumes what needs to be proved.

Frances goes on to declare:
This shibboleth can be believed only by armchair theorists with no real life experience in having, living with, or treating mental illness.  However difficult to define, psychiatric disorder is an all-too-painful reality for those who suffer from it and for those who care about them [18].
As already noted, those "radical critics" don't deny that people diagnosed with "mental illness" really are suffering, so that part is a straw man.  Thomas Szasz, probably the most prominent of the radical critics, was not an "armchair theorist with no real life experience": he was a psychiatrist by training, with years of clinical experience.  R. D. Laing, another radical theorist unnamed by Frances, also was a psychiatrist with clinical experience in dealing with "mentally distressed people."   Some laypeople probably misunderstood these men's theories, but the same can be said of laypeople who garble mainstream psychiatric theory and practice.  Frances's dismissal of them as "armchair theorists" is profoundly and disturbingly dishonest.

Frances goes on to offer an analogy between psychiatric diagnosis and umpiring in baseball.  He imagines three thought-umpires with "competing opinions on how well we can ever apprehend reality":
Umpire One: "There are balls and there are strikes and I call them as they are."

Umpire Two: "There are balls and there are strikes and I call them as I see them."

Umpire Three: "There are no balls and there are no strikes until I call them."

Umpire One believes that mental disorders are real "diseases"; Umpire Three that they are fanciful "myths"; Umpire Two that they are something in between -- useful constructs that provide no more (but no less) than a best current guess on how to sort psychiatric distress [19].
This, of course, is the ever-popular The-Truth-Lies-Somewhere-In-Between move, and as usual, the middle of the road just happens to be where Allen Frances is standing.  As I've already argued, Umpire Three is a straw man.  Umpire One is the mainstream of contemporary psychiatry.  But the position of Umpire Two, as Frances explicates it, doesn't help his argument; I'd say that it actually undermines it.

Balls and strikes are constructs, as he says: they can be defined by objective, clearly defined criteria (which is more than can be said for Frances's "mental disorders").  They did not exist, however, until human beings created and defined them.  Those definitions can and do change, not to achieve a better approximation of reality, but "in an attempt to control the balance of power between pitchers and hitters."  In principle, they could be completely abolished and replaced with a different classification for pitches that batters don't intercept.  This is not the lesson Frances wants us to take away from his analogy.

Now consider a couple of cases.  Stuart, Gomory and Cohen pointed out in Mad Science that "many women were identified and sorted into an early category of 'witches,' but that sorting did nothing to establish the validity of the idea of witches" (174).  Indeed, credentialed professionals wrote diagnostic manuals to enable reliable diagnoses of witches.  Later radical critics -- mostly,  no doubt, armchair theorists with no real life experience in having, living with, or dealing with witches -- denied that there was any such thing as witchcraft, and therefore no real witches.  Some revisionists argued that there were real witches, but they were good people, unjustly vilified and persecuted by the patriarchal church.  Others, moderates like Umpire Two, argued that there were witches, but they had been misdiagnosed: they were really mentally ill, not worshipers of Satan.  It was less often argued that their accusers were delusional, but given the quality of the evidence available, armchair diagnosis at a remove of centuries ought to be attempted with more humility and caution than most of its practitioners have displayed.

Next, consider the case of homosexuality.  Kirk, Gomory and Cohen argue in Mad Science that the removal of homosexuality from DSM in 1973 constituted part of the crisis of legitimacy in psychiatry that led to the 1980 DSM-III.  How could homosexuality go from disease to health virtually overnight?  In fact, it didn't quite happen that way.  First, the status of homosexuality had been disputed in the mental health professions for many years, as exemplified by Sigmund Freud's statement that "it cannot be classified as an illness" in a 1936 letter to an American mother.  Second, though homosexuality itself was depathologized, the APA continued to classify distress over being gay as an illness eligible for treatment, and didn't condemn change therapy for another thirty years.  Third, the opponents of the change were correct that it was largely motivated by "politics"; but the original classification had been no less political, based on social prejudice rather than scientific evidence.  The trouble was that this was true for most psychiatric diagnoses, which is why Robert Spitzer set out to revise the DSM to provide a scientific patina of reliability for diagnosis in the future.

So: there were those who saw homosexuality as an obvious dread disorder; there were those, no doubt armchair theorists with no real life experience in having, living with, or dealing with homosexuality, who denied that there was any such thing as a homosexual; then there are those in the middle, who only wanted to help those poor souls struggling with same-sex desires.  Many gay people do feel distress about being gay, and it can be argued that this is due to social pressure from an antigay environment.  But how does a clinician decide?  How do those tasked with defining diagnoses of "mental disorders" tell?

Ironically, the current trend, championed by psychologists and the main stream of the American gay movement, is to insist that homosexuality is a biologically based condition; it may even be physically inscribed in the brain.  If Simon LeVay's research had been available to the APA in 1973, maybe homosexuality could have remained in the DSM -- though that was the opposite of LeVay's intention  in doing his work.  Despite this, I haven't heard of any attempts in the APA to reinstate homosexuality as a diagnosis, no doubt for political reasons.  The status of homosexuality (which isn't listed in Frances's index; I don't know if he'll discuss this ancient history in the pages to come) is a stumbling block for the whole question of psychiatric diagnosis.

I'm going to continue reading Saving Normal, to see what else I can learn from Frances's perspective, but I'll be reading critically, with appropriate skepticism.  He may be engaged in a revolt against some practices of his profession, but he's still a very protective insider.