From the mailbag: Barney Carroll, a former Blue Devil psychiatrist who blogs here, took the time to make a lengthy comment, which is meaty enough to give its own post, and to respond to in some depth.

It seems we have a major case of cognitive dissonance here, Gary. When I read your post I was bothered first by the dismissive references to Ike. It does not advance the dialogue to say that Ike was sucking the MIC tit all his life. His farewell speech in 1961 contained an enduring insight: that national security is paradoxically threatened by an unchecked military-industrial complex because both partners commit to flawed paradigms out of misguided self-interest and perverse incentives. This insight finds other applications today, such as in the academic-industrial-government complex. Ike’s warning went to other stakeholders besides the military and the executive branch of government.

I agree that Eisenhower’s farewell address contained a great deal of wisdom, but whether or not it advances the dialogue to point out that it was a case of biting the tit that feeds you depends on the dialogue you are trying to advance. I think what’s interesting about the address is not the insights it provided, which, true as they were, were nothing terribly original. For example, Dr Strangelove came out in 1964, three years after Ike’s swan song, and Kubrick always said it was based on Red Alert, published in 1958, so I think it’s safe to say that people outside government were onto the MIC problem before the farewell address.

This doesn’t mean it’s not to Eisenhower’s credit that he could see it at all, or that he said anything about it. It is surely impressive that he could get outside himself enough to do what he did. One only wishes he had had the insights before he was leaving office, i.e., when he still could do something about it. Maybe if he had, we wouldn’t be where we are today. (On the other hand, as the most recent presidency has shown, a president has limited powers to turn the ship of state off its course.) So the dialogue I wish to advance, or at least the point I was trying to make, is that the question of what Ike said is not as interesting as the question of when he said it, and why.

But more to the point, I mentioned Eisenhower only because the example is so obvious, the parallels with Frances unmistakable. And I say that at first it looks like what Frances is doing is what Eisenhower did. But I dont’ think he is. Unlike Eisenhower, who stopped short of drawing out the connections between the MIC and the way capitalism and empire work, and to his great credit, Frances did more than chide his institution on the way out the door. As much as he wanted (and continues to want) to pin the whole DSM-5 fiasco on bad management at the APA, he also (at least to me, which he may well regret) spoke openly and often about the problem that the APA was, at least in its own account, trying to fix, first with its abortive attempts at brain-based diagnosis, then with its unsuccessful stab at dimensional measures: that the DSM is, by necessity, a book of useful constructs. And he said that this was why the APA’s behavior was so maddening: that the DSM was fragile, that it might not be able to withstand incompetence and overreaching. So Al went Ike one better, getting at the root causes in a way that cannot help but call into question the authority of psychiatry over our inner lives.

Now of course Al would say, “but they’re not only constructs” but publicly discussing this fact at all was a risky move, because psychiatry (like all medicine) is based on a myth: that disease is a biochemical entity whose pathogens can be specified and targeted. It’s an infectious disease model that works pretty well for tuberculosis but not so well for many other conditions, including psychiatric disorders. (I’ll have a blog on this at newyorker.com later this week.) It’s risky to bring attention to the way that psychiatric diagnosis fails to conform to this myth, because, unlike the rest of medicine, psychiatry doesn’t have slam-dunks like pneumococcus, which conform quite nicely. Once you point out that its diagnoses are constructs, you open the door to a kind of public scrutiny that is reminiscent of the scrutiny of the late 60s and early 70s. You give the Scientologists ammunition. You invite wise guys like me who are naturally suspicious of people with power over our inner lives to say, “Now just a second here!” So the question I’m raising (and accusing myself of having failed to answer) is why he would do that.

Next I was bothered by the attitude that calls psychiatric diagnosis “closer to fiction than to fact.” Here cognitive dissonance enters again. We should recall that patients afflicted by serious disorders existed before the healing professions arose. The history of the healing professions is in large part a history of trying to make sense of those disorders – efforts at nosology, that is. Nosology is a prelude to differential treatments. But I think you invert the issue by the way you frame it. We are not bent on seizing sovereignty over the inner lives of patients, as you put it. The patients have always been there, afflicted by psychosis, mania, melancholia, crippling anxiety, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. The members of the healing professions did not manufacture these disorders – rather, people suffering from them came to us for help.

As you know if you are reading my book, I don’t entirely disagree with this. Where we disagree is over whether or not these disorders are best understood as medical disorders. Historically,it’s not clear to me that people have always gone to doctors about all the troubles that psychiatry currently claims to treat, but even if they have, that doesn’t occur in a vacuum. The last 20 or 30 years have been a case study in how to grow a market by convincing people that their everyday troubles are a deficiency that a particular product–psychiatric treatment–is best suited to correct. Pharma has done the heavy lifting on this, but psychiatry has helped–for instance by turning the ECA and NCS numbers into the myth of undertreatment. And what psychiatry has not done a very good job of is delimiting its domain. None of this would be happening if we had stuck with the original 14 diagnoses of the Washington group, or the 21 (?) of the RDC.

I also don’t think it’s fair to say that I believe psychiatrists are “bent on seizing sovereignty” over our inner lives. It’s clearly a dance between people who want magic bullet cures and doctors who would like to provide them. To me, however, there is no question who is leading the dance, and who therefore has the obligation to pay attention to whether or not the couple is about to bang into someone else, or to slip out the door of the dance hall and over a cliff.

Finally, I would say that fiction and fact are probably not categorical but dimensional. Even the bacteriological model of disease is still a model.You can watch bacteria multiply in a petri dish and then watch penicillin kill them and extrapolate from there to the person who recovers from pneumonia after a dose of antibiotic, but you still have some storytelling to do about why and how that actually happened, and what its relationship is to what happened in the petri dish. So the mere fact that the DSM is a collection of stories doesn’t bother me. What bothers me is that it is not presented that way, disclaimers at the beginning notwithstanding. ONe purpose of the modern DSM, according to Spitzer, was to restore the credibility of psychiatry, whose woes at the time were largely nosological. “Open it up,” he says. “It looks scientific.” And indeed it does. So what is troublesome about psychiatric nosology that at least some of the people who promulgate it have an interest in it appearing to be toward one end of the spectrum when it really is closer to the other.

When you say Allen Frances believes that power in the right hands does not necessarily corrupt but can be used for good, I would disagree. Enter cognitive dissonance again. It is not a matter of power but of duty and obligation, essential features of a disinterested profession. I would make the same argument in the case of Ike: he was less interested in power for its own sake than in discharging what he saw as his duty over a lifetime in the military.

Here we do disagree. I don’t believe there is any such thing as a disinterested profession. Power is always at work. That’s why Freud’s notion of countertransference was so important. (Although I don’t think he meant it as a check onanalyst power. There’s not much indication that Freud was very interested in that issue.)

I have made my share of criticisms of DSM-5 but I take second place to nobody in affirming the reality of major psychiatric diagnoses. I caution against your inclination to over-generalize about the weaknesses of psychiatric diagnoses. Yes, there have been serious missteps – pediatric bipolar disorder and the elimination of the bereavement exclusion for major depression, for instance. Yes, some of the players seem driven by therapeutic zeal rather than by good clinical science. Yes, the black and white perspective turns to gray as we move further from ‘show stopper’ disorders to the extremes of normal variation. But I take exception when you say psychiatry has been granted a license to medicalize our suffering. The suffering was already there, as were the calls for help. Allen Frances does not hold such a license… he is discharging a duty.

I’m not sure why you take exception. We have collectively placed our mental health in the hands of psychiatrists, no less than we have placed our digestive health in the hands of gastroenterologists. That gives doctors a license. They don’t have to go out on the street with nets to snag patients, but that doesn’t mean they haven’t been granted authority. Here again, we disagree about the inescapability of power.

AS for the reality of major psychiatric diagnoses, I am sure there are mental disorders that properly come under the purview of medicine in general and psychiatry in particular, and that do so because they are fundamentally organic in nature, no less than kidney disease or TB. But I don’t think we know yet what they are, or how to find them, or how to distinguish them from those extremes of normal variation. No doubt this is true all over medicine, but only in psychiatry, I would argue, is it the norm.

Thanks for your comments, Barney, and for your respect in the way you frame them.

I wrote the Book of Woe really fast, at least for me. I signed the contract in May 2011. It always takes me a few months to get my head out of my ass after I sign a contract, so I started around Labor Day. I had my first draft finished in September 2012, edits done by xmas, with a publication date of May 2013. By way of contrast, I signed my Manufacturing Depression contract in June 2007. Before I could even put my head up my ass, I had to finish The Noble Lie, which I did in August. Around November, my wife said to me, “When are you going to start that book?”

“Book?” I said, although she may not have heard me, given the location of my mouth. A few days later, my editor called and asked the same question. So I started around Thanksgiving 2007. I finished in April 2009, with edits and so on through the summer and a publication date of Feb 2010. I never felt hurried.

I not only had less time with BOW, and an impending deadline that was real–the May 2013 release date for DSM-5–but I was writing about events that were happening as I wrote, and people who were not shy about contacting me with the latest developments, whereas with MD I was mostly writing about historical events and people who were dead. Dead people can’t sue, nor can they call you up and fight with you about their quotes. And then there were the google alerts–three or four a day on the DSM-5 account, thousands of links to click (or not to click and then to feel guilty for ignoring them.) I would be a terrible newspaper reporter.

All of which is to say that because I wrote the thing in a hurry, I left out some stuff. Actually, I didn’t leave it out. I just didn’t think of it. The story hadn’t percolated sufficiently. And some of what I didn’t see, I just can’t believe I didn’t see.

I wrote about one of the important points that I missed in a blog on newyorker.com. It’s about the way that the DSM-5 may not affect the overall prevalence of mental disorders, but rather simply reallocate the existing market to different products listed in the catalog. That’s part of an overall point  that I do think I made, but not as clearly as I could have: that concerns over the DSM-5 are to some extent misplaced. The problem is not this particular revision, but the  idea behind the book, which is that mental suffering can be understood and treated like infectious disease. That idea is wrong at so many levels that I don’t know where to begin. You’ll just have to read my book. But one thing is for sure: the American Psychiatric Association LOVES that idea, and has flogged it for all it’s worth. Which is, to judge from DSM-IV sales, hundreds of millions of dollars.

But something else I didn’t write enough about is perhaps more consequential. And that is the mystery of Allen Frances. It is hard to believe this, since he probably appears on about, I’m guessing, one-third of the pages in my book, and is surely what Larry Wright calls the “donkey” of my story, the character who carries the narrative. And what a narrative it is, or at least seems to be. Top psychiatrist comes out swinging against his own, and by his own analysis damages his profession by revealing what has always been implicit: that psychiatric diagnosis is closer to fiction than fact, and that the result has been rampant overdiagnosis and overtreatment.

It looks at first like a case of Ike Farewell Disorder, named (by me) for President Eisenhower’s famous farewell address, in which he warned the country of the necessity to “guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist.” What a strange way to exit public life–with a warning that the tit you’ve been sucking all your life, and that over the last eight years you have been largely responsible for swelling beyond recognition with the juice of your Cold War, is too big, and maybe filled with poison. Of course, Eisenhower counseled moderation–a strong security state that doesn’t overstep–and would have been the first to cry foul if your average peacenik had suggested he’d crossed over to their side, but there was one question he just couldn’t answer: why should we leave the military-industrial complex in the hands of the military and industrialists? Or to put it another way, wasn’t his whole point that the government, the economy, and increasingly the society had been taken over, such that there really wasn’t anyone left to keep it the MIC in  its place? Maybe Eisenhower didn’t grasp it, or maybe he didn’t want to, but the MIC was the natural offspring of capital and empire. Not even a bastard child, but the progeny that is inevitable when you put those two together.

It’s impossible to know what prompted Ike to renounce the MIC, even in the limited way he would cop to. And it is also impossible to know why Frances did it. But there is a difference–and not only that Eisenhower is dead and Frances very much alive. It’s also that I got to talk endlessly with Frances, and not a bit with Eisenhower. And I could not get anywhere with him on the subject. To hear him tell it, it was not any kind of about-face for him to go on a jihad against the DSM-5. Like Ike, he just wanted to give his successors the benefit of his experience and warn them against the excesses that needed to be checked. He was just being reasonable. He had kept silent in the face of other psychiatric overstepping, so in this sense he was atoning. But as for the way that psychiatrists had seized sovereignty over out inner lives–about this he remained sanguine. No conversion, no atonement, no penance, no second thoughts.

Like Ike, Frances wasn’t criticizing the institutions that gave rise to the pathology. He was criticizing the pathology itself. But, unlike Ike, Frances felt compelled to address that institution at its heart:  the DSM’s overall reliance on expert consensus rather than scientific fact. The reason the DSM-5 was so dangerous, he argued, was that it overlooked just how fragile a system the DSM is, how prone to pointless argument, to public embarrassment, and ultimately to diagnostic epidemics and other psychiatric excess. The APA was abusing its power, apparently out of ignorance of how difficult it is to steward the DSM, how easily it can be exploited, especially by drug companies, and how crucial it is to protect its flaws from public scrutiny.

But for Frances, power does not necessarily corrupt. He believes that it is, in the right hands, something that can be used for good. He took umbrage anytime I, or anyone else, suggested that the problem with DSM-5 was only the latest instance of the problem of DSM. He accused me of indulging in conspiracy theories when I argued that there were deep historical forces at work here. His was a one bad apple theory, the bad apples being the current regime at the APA and their patrons in the drug industry. And here is where I think I might have let him off the hook too easily.

Why do people haul out the one bad apple theory? Why did the US Government fall all over itself to blame Abu Ghraib on a girl who liked to take pictures and a man who got a kick out of humiliating prisoners? Why do politicians argue enthusiastically for gun control via plucking out those w ho shouldn’t have weapons rather than via controlling guns? There are surely lots of reasons, but at least one has to be damage control. The Pentagon wants to keep the spotlight off the volunteer army, off the admixture of sex and violence it uses to motivate soldiers (see or read Jarhead if you don’t believe me), off the utter vileness of the Iraq war, off the themes of domination and rape that have characterized empire since, well, since empires began. The politicians…oh, don’t get me started. You know why they want to divert attention from the longstanding historical tensions about the 2nd Amendment. Talking like that gets you in trouble with the not-so-well-regulated militia called the NRA.

So what was it for Frances? What was he protecting? He’ll tell you it was the patients, the people who, upon hearing that psychiatrists really don’t know what mental illness is, let alone which ones exist, will go off their meds and push people in front of subway trains or shoot up schools. And while there must be people who will do that, I’m not sure we have any evidence that mayhem committed by the mentally ill spikes whenever someone publicly questions psychiatry’s authority over them. I mean, Robert Whitaker wrote a pretty well researched book about the way that mental illness was caused by psychiatric drugs, but I don’t recall hearing about an epidemic of noncompliance among mental patients. I wrote a pretty convincing (if I do say so myself) takedown of the depression industry, and Jerry Wakefield and Allen Horwitz, not to mention Irv Kirsch, have weighed in on the drug side of that “epidemic,” but that hasn’t stopped 11 percent of American adults from sticking with their antidepressants. So this just can’t be the whole reason.

So I doubt that this is the only reason, and if it is, then Frances’s mission is pretty misbegotten. It’s also unnecessary. Regimes at the APA come and go,. If the organization continues in its current direction, bleeding money and members, it will eventually go the way of the Soviet Union (which, by the way, we mostly spent into the ground) and we won’t have it to kick around anymore. If not, then a more enlightened leadership will solve the DSM problem soon enough. And the drug industry–well, they’ve figured out that between the bad press and the bad clinical results (not to mention the complexity of the brain), they’re getting out of the psychiatric drug industry. There is not one major new psychiatric drug in the pipeline. The great thing about capitalism: once in awhile it kills something that ought to be dead.

No, I think the problem is more parochial even than that. I think Frances wants to protect his profession because it is his profession. He believes in it, and he is deeply offended by what he sees as its running off the rails. In this he’s no different from any of us. When our government or our sports team or our children do something we don’t approve of, it is really hard not to take that personally, as some kind of reflection of our own worth. And we will do what we have to to shatter that mirror without changing ourselves.

My favorite example of this is what happens every time a hunter kills a person, usually a fellow hunter, by mistake. Other hunters will quickly say, “Well, he wasn’t a real hunter. Real hunters don’t (fill in the blank with whatever mistake the hunter made). But of course he is a real hunter. He was in the woods with a gun, stalking animals, and nailed a person instead. What the hunters don’t want to say is that dead people are an occasional, but inevitable, result of having a bunch of armed people stumbling around the woods in close proximity to each other. And psychiatric overstepping is the inevitable result of having a bunch of experts armed with the power society invests in doctors stumbling around in the fields of the human mind, with no reliable safety on their rifles. Someone is going to get hurt, no matter who is in charge.

Of course, Frances knows this. There’s plenty of evidence that lots of people have been hurt since 1994, when his DSM came out. But strangely, it’s not possible to correlate the increase in diagnosis and treatment with the advent of the DSM-IV. That may be because we just don’t know how to measure something so protean as the effect of a diagnostic manual on the mental health of a society. But it may also be because the problem isn’t even in the DSM, let alone the DSM-5. It’s in the license psychiatry has been granted to medicalize our suffering, of which the DSM, any DSM, is only a symptom.

Allen Frances, as honest and forthright as he is, cannot possibly cop to this, because he holds that license and believes he deserves it. I wish I had taken him on more directly about this in my book.

Another blog post at newyorker.com

http://www.newyorker.com/online/blogs/elements/2013/04/psychiatry-dsm-melancholia-science-controversy.html

This just in, from my keyboard to the New Yorker’s new Elements blog

http://www.newyorker.com/online/blogs/elements/2013/04/the-dsm-and-the-nature-of-disease.html

Big news this week from the paper of record, or at least the The Consumer category of the Well blog of the paper of record: The Dodo Bird is dead.

What’s that? You already knew that? You knew that it took European sailors all of about seventy-five years to wipe the species off the face of the earth back in the 17th century? Well, you are correct, or at least wikipedia says you are.

But Lewis Carroll, writing a couple hundred years later resurrected the bird as the inventor of the Caucus Race (not to be confused with the Caucasian race), wherein he tells the animals of Wonderland that the best way to dry themselves off is to race around in circles. The Dodo calls a halt to the proceedings when everyone looks dry. The participants want to know who won. “Everybody has won, and all must have prizes,” says the Dodo.

I’m sure Carroll was making some kind of topical allusion here, but  in 1936, a psychologist named Saul Rosenzweig re-resurrected the dodo and gave it a whole new meaning. Rosenzweig studied various forms of psychotherapy and concluded that they all worked about the same. Psychoanalysis was no more or less effective than behaviorism, he said. He christened it the dodo bird effect.

Now, the dodo bird  has haunted the mental health field ever since. Study after study has replicated it, leading some to conclude that all therapy is is equally dependent on what scientists call “non-specific factors” or “placebo effects.” To some people, this is a bad thing, an embarrassment, as it indicates that therapy is bunkum. To others, it’s a vindication of their belief that psychotherapy is an art, and that it is all about the relationship between two people, rather than about any specific technique.

I am firmly in the second category. But, as with many things, science is always proving me wrong. In this case, it’s because a group of researchers, most of them cognitive behavioral therapists, have,over the past fifteen or twenty years, done a series of studies showing that cognitive-behavioral therapy works better than other therapies. By “manualizing” therapy–i.e., by having a therapist work strictly out of an instruction book–they have, so they claim, managed to isolate the active ingredient in therapy from the therapist’s personality or other nonspecific factors. And by operationalizing outcomes–i.e., by deciding what constitutes successful therapy and developing scales to measure it–they have managed to provide a means to correlate therapy and outcome. And when they do that, they say, it turns out that CBT leads to superior outcomes.

There are all sorts of problems with this line of research, not the least of which is that it’s done by advocates, and advocacy is the enemy of scientific objectivity. But there’s also the problem of the comparison group, which is generally either a no-treatment group or a sham-treatment group. How do you do a sham treatment of a therapy that works via the placebo effect? you ask. Good question. The answer is that you make up a therapy as a stalking horse, one that not only doesn’t exist but that is being implemented by a therapist with no reason to believe in it. (Therapist belief being a major factor in therapy efficacy.) There are many other flaws in this research, detailed in Manufacturing Depression, chapter 13 (where I infiltrate a CBT training program) and in many academic papers, like this one.

But the obvious flaws have been eagerly overlooked by therapists and bureaucrats enchanted by the possibility of measuring something, anything, that can answer the demand for “evidence-based practice.” (Click here to see my account of this blight, along with a nice takedown of Marty Seligman and his cryptofascist maunderings about human flourishing.) And the recent Times article makes it clear just how effective this mythmaking has been. “In 2009,” Harriett Brown reports, “a meta-analysis conducted by leading mental-health researchers found that psychiatric patients in the United States and Britain rarely receive C.B.T., despite numerous trials demonstrating its effectiveness in treating common disorders.” Only 17 percent of us therapists are going by the book, which means, she writes, that “many patients are subjected to a kind of dim-sum approach — a little of this, a little of that, much of it derived more from the therapist’s biases and training than from the latest research findings.” It is as if we are still treating infections with bloodletting instead of antibiotics.

Brown doesn’t report any of the reservations about CBT research. She doesn’t even raise the question of how the outcome measures are tailor made to the therapy, let alone how the whole business is driven by a bottom-line approach that, at least according to some of us therapists (the ones who are going to go the way of the dodo, I guess), is inimical to the central genius of psychotherapy, which is that it allows people to step out for a moment from the continual preoccupation with the bottom line. She doesn’t even bother with the de rigeur “to be sure” paragraph that reporters use to cover their asses. Which means to me that while I was not paying attention, CBT’s superiority moved from the realm of contentious claim to uncontested fact.

Oh, well, I guess it’s time for me to wake up and smell the coffee. Or is that Kool-Aid I’m smelling?