May 09, 2013
(+++) AXES TO GRIND
The Book of Woe: The DSM and the Unmaking of Psychiatry. By Gary Greenberg, Ph.D. Blue Rider Press. $28.95.
The troubles a book can cause! No, not this book, but the book about which this book is written: the Diagnostic and Statistical Manual of Mental Disorders, or DSM for short – the primary encyclopedic explanatory tool codifying mental illnesses. Periodically revised to incorporate new clinical research and understanding of mental illness, DSM was “DSM-I” at its first incarnation in 1952 and “DSM-IV” as of 1994 (with some textual updating in 2000). But a funny thing happened in the process of turning it into DSM-5, now identified with an Arabic rather than Roman numeral – or a very unfunny thing. The manual became a lightning rod for criticism by an increasing number of mental-health practitioners, some genuinely concerned and some rabble-rousing. One of the major critics is Gary Greenberg, a therapist in New London, Connecticut. The Book of Woe is Greenberg’s often-shrill 400-page attack on the DSM, the American Psychiatric Association (APA) and, foundationally, the whole notion of “official” diagnosis (and therefore treatment) of mental disorders.
A book like this would be a limited-interest academic or professional exercise if the underlying subject matter did not have such wide implications. Modern therapists sometimes forget that Sigmund Freud, a physician, saw psychoanalysis as a branch of medicine and tried throughout his long career to place it on the same plane as the study of physical illness – without success. Indeed, it was not uncommon for many decades during and after Freud’s life to have physicians who treated the body look down upon those treating the mind as witch doctors of a sort, as if illnesses not susceptible of direct laboratory measurement must be less “real” than those with readily confirmable diagnoses. In fact, critics of the DSM have long called the manual’s validity into question by saying that it does not draw on any agreed-upon scientific model of mental disorder and that it is unreliable because so many different diagnoses share overlapping criteria – making the assignment of a specific diagnosis to a particular patient a matter of the therapist’s personal preference or bias.
That is a reasonable concern. And critics have also pointed to changes in the DSM associated with differing societal attitudes as undermining its validity. Everyone would agree that cancer is a disease (a set of diseases, actually), but the DSM designated homosexuality as a mental illness until 1973 and did not acknowledge Asperger’s as one until 1994 – only to fold Asperger’s into the general diagnosis of autism in the preparation of DSM-V.
Greenberg expands on these arguments, frequently dramatically, and often in rather overdone language that strives mightily to be “popular” and succeeds only in sounding rather silly, as in the matter of pedophiles. “Our destination is a meeting of lawyers. The royal fuckup was the kind that only they could love, an opportunity buried deep in the interstices of the DSM text, ready to be excavated and exploited – in this case by prosecutors who, aided by psychiatrists, can use it to keep certain sex offenders locked up well beyond the end of their sentences, indefinitely or maybe forever.” Oh yes, Greenberg practically sees the DSM and APA as the fount of all sorts of evil in modern life. His discussion of sex offenders and the diagnosis of pedophilia is typical of his handling of the issues in this book. “[A]s any scandal-scarred politician will tell you, vigorous defenses against charges of turpitude are mostly self-defeating. If you run an organization of healing professionals, you don’t want to have to prove that your members aren’t really human missiles intent on blasting us all into a secular humanist hell. …[S]tarting in 2000, a person who had sex with a child was ipso facto mentally ill. Now, that may seem obvious to you. But that’s only because of how reflexively we attribute all our peccadilloes and quirks (or, more likely, those of other people) to mental rather than moral defect.” And so on.
Leave aside the flip reference to “peccadilloes” in connection with the sexual abuse of children, and it turns out that Greenberg makes a good point here, as he does in many places in The Book of Woe: there is a difference between criminality and diagnosis of mental illness, even if Greenberg gets to that valid statement with deliberately lurid language. But The Book of Woe often seems designed more to shock and dismay the reader than to engage in serious issues of societal consequence. The APA, Greenberg suggests, is corrupt, or at the very least purchasable, needing the funds generated by the DSM to maintain itself in light of a decrease in revenue from the pharmaceutical industry. Psychiatric treatment has inherent flaws in the way it is practiced, he says, attacking Freud’s underlying notion of a medical basis for mental-health issues without mentioning the founder of the field by name: “[T]he idea that gives psychiatry the power to name our pain in the first place – that the mind can be treated like the body, that it is no more or less than what the brain does, that it can be carved at its joints like a diseased liver – is perhaps the most important of all. It reflects what is best about us: our desire to understand ourselves and each other, to use knowledge to relieve suffering. …It also reflects what is worst – the desire to control, to manipulate, to turn others’ vulnerabilities to advantage.”
Therefore, Greenberg argues, the flawed DSM should be replaced with….umm, what? Well….Greenberg has no suggestions here – he tears down but does not build up. And it vitiates the power of his arguments – some of which are powerful – to realize that while he sees the flaws in the DSM, he does not see an alternative to it. Yet this is extremely important, because the whole point of the DSM is to provide diagnoses on the basis of which insurance claims are processed, medical information is placed in patient records (often permanently), data are gathered in research studies, treatment protocols are implemented or modified, and much more. Whether or not Freud was right in seeing psychoanalysis as a branch of medicine as codifiable as any other, the modern world – including insurance, government, law enforcement and all its other complications – must have something on which to rely so that a person will receive similar treatment for similar conditions, and insurers (including the government) will handle comparable cases in comparable ways. Greenberg is correct, if shrill, in arguing that the DSM has flaws, although his claims of the venality of the APA seem overdone and overly argumentative. Still, there is substance to The Book of Woe. What Greenberg does not offer is any way for either clinicians or patients to find their way to a manual, much less a system, that is less woeful.