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?

When it comes to criticism of the DSM-5, the loudest and most trenchant voices belong to those who think it’s going to extend the reach of psychiatry further into everyday life. Allen Frances is leading this charge, but he’s joined by Christopher Lane, Paula Caplan, and just about every other sentient being who’s not on the DSM-5 committees. (That would include me; I’m sure if I searched the phrase “extend the reach” in the searchable pdf file of my book that my publisher made the mistake of providing me with, I would find it often enough to make me cringe. But I won’t.) And when they lodge this charge, the case in point is often the soon to be defunct bereavement exclusion, that little diagnostic codicil that currently prohibits doctors from diagnosing people in mourning from being diagnosed with depression for the first two months after their loss. Bereft of the bereavement exclusion, the criticism goes, the DSM-5 will result in more people diagnosed with depression, more antidepressant prescriptions, and more diseasing of America.

The wisdom of crowds is a beautiful thing, unless you’ve ever actually been in one. Having spent way too much of my pre-1995 life at Grateful Dead shows, I have had the opportunity to do just that. Even when it’s pretty, it’s scary, and if you don’t believe me, just watch Triumph of the Will.

Anyway, I digress. (I can’t help it. I haven’t been in a synagogue more than five times in thirty years, but still the Jew lies deep in me.) Point is, when so many people are saying the same thing, even when that thing is quite plausible, even (or especially) when you agree with it, it’s time to wonder about it, or maybe about yourself. So to the question: Will removing the bereavement exclusion really lead to more psychiatric diagnosis?

In a way, it’s hard to imagine psychiatry extending its reach any further. I mean, it’s already reaching so far you can feel it palpating your prostate (or, I suppose, your ovaries, if you are lucky enough  not to be of the gender that possesses those walnut-sized cancer factories embedded deep in its collective groin). The DSM-IV, like the DSM-III, has a psychiatric diagnosis to suit just about any complaint you might have about the life of your psyche. That’s not an accident. Diagnostic expansion was part of the mission of the DSM-III, the one that has been the template for diagnosis since 1980: not only to provide the criteria for discerning a particular psychiatric disorder, but to provide psychiatric disorders for everything that ailed us. Bob Spitzer, the Khalid Sheik-Mohammed of the DSM-III, was a nosological diplomat, and he recognized that if he stuck with only the 21 criterion-based diagnoses (of really severe mental illnesses like schizophrenia and manic depression) that had been developed when he started the revision, he’d lose the support of the rank and file, who needed their depressive neuroses and their anxiety reactions if they were to stay in business.

Now that’s not to say that psychiatrists weren’t already reaching deep into our psyches. Of course they were, but they weren’t doing it by declaring us mentally ill. They were doing it by providing psychoanalysis to the walking wounded, transforming the language of the self in the process, but without diagnosing any of that population with what could plausibly be thought of as a medical illness. That’s what changed with the DSM-III. Psychiatrists, for mostly parochial reasons (like saving their profession from charges of pseudoscience), started to give quasi-medical names to our pain. When the drug companies got interested in psychiatric drugs, those names became extremely useful. And the two industries have been doing the tango ever since.

But none of this would have worked without a market. There is a demand side to the economy of mental disorder. In the three decades since the DSM-III was introduced, the impetus to declare ourselves sick gathered the force of a constant windstorm. So long as you’re willing to join the ranks of the diseased, it blows at your back. To say, “I am clinically depressed” is to stake a claim to many goods: sympathy, tolerance, time off from work, the right to take mind-altering drugs on the insurance companies’ tab every day without being accused of being a stoner. To say, “I have Asperger’s” opens other doors (which the APA is going to shut; that one worked too well). And so on. There’s a premium on illness; it’s increasingly how we define ourselves, how we demand resources from society, how we understand our lives. And not just mental illness. There’s a reason health care is gobbling up more and more dollars every year, and it ain’t all the fault of greedy doctors and drug companies. It’s also because, as Peter Sedgwick said in 1972, and as i never get tired of quoting, “The future belongs to illness.” Forty years later, the future is here.

Or, to put it another way, the market may have reached saturation. I mean, how much more saturated can it get? Already, bereavement exclusion or not, the DSM provides criteria and labels by which half of us will suffer a mental illness in our lifetimes. That may be because the DSM is an evil disease-generating book. But it may also be because consumers know what they want and psychiatrists know how to give it to them. Removing the bereavement exclusion may not increase the market but only reapportion the share from other diagnoses, in the same way that opening a Lowe’s next to a Home Depot does not necessarily create more DIY home improvers, but only gives them a better choice of where to go to buy faucets.

So here’s my prediction: the removal of the bereavement exclusion (and the DSM-5 in general) won’t put the fingers of psychiatry further up our collective rectum. (or is it recta?) It will only give it a new orifice to probe.