Book Review
Miles Clapham
"Making us Crazy" is a book for those who want to look at the politics of how certain psychiatric diagnoses have been included or excluded from the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association (APA). It is a history of the downfall of homosexuality as a psychiatric illness, of masochistic personality disorder (read Stepford Wives Syndrome), and the, somewhat ironic, battle to include post traumatic stress disorder (PTSD) as a diagnosis. It also examines some of the vicissitudes of the diagnosis of borderline personality disorder, particularly when it seems to let male psychiatrists and therapists off the hook for sleeping with their screwed up but ever so seductive female patients. Importantly it looks at the effects of racism on psychiatric diagnosis both historically and as it continues today.
There is a lot of detailed reportage on the pressure groups, such as Vietnam veterans and gay and lesbian groups as well as the psychiatrists who responded to or opposed these groups. In some areas the debate still rages, for example there was fury a few years ago when Socarides, who is a major proponent of the position that homosexuality is an illness, came to speak in the UK about his ideas.
The book raises some serious general issues. At one level there is the tie up between the health insurance industry and the APA, which are perhaps not so uneasy bed partners in deciding what is a disorder, and what treatment is appropriate, or at least what treatment will be funded by the insurers. There is a crucial point here for those that see the NHS following the US model. In order to get treatment paid for a person has to have a classifiable disorder - so according to Kutchins and Kirk, supposedly rigorously determined criteria may be bent; and the treatment must fit the disorder - so, although the authors don't draw this point out, there is an ever greater tendency towards practice guidelines, "evidence based" practice, and conformity in treatment.
The DSM, ever since the third edition, has had a descriptive approach to diagnosis, listing the necessary criteria for each disorder. As "Making us Crazy" shows, it is possible with some disorders, especially of personality, to have a very different symptom list and still have the same diagnosis. This has implications for both the validity and reliability of these diagnostic categories, which are the twin pillars of both clinical practice and research. The authors also discuss how changes from DSM III, to DSM III R, to the current DSM IV, also raise the issue of validity and reliability, especially when research evidence based on changed categories from DSM III is used to inform current service delivery. For example, obsessive compulsive disorder according to DSM III affected 2.6% of the population (lifetime risk) but the more restrictive DSM III R criteria categorize far fewer people as having OCD.
The authors do ask the question, what is a mental disorder? They point out some of the philosophical and ethical issues here but do not manage to really address them. How do we say what it is about a particular state of being that makes it a mental illness? For example, is Hamlet mad, or do the twists of his thought reflect and interpret the murder of his father by his uncle, and the incestuous marriage between his uncle and his mother? Are both true? Is a multiply sexually abused girl who hears voices of her abusers telling her to kill herself, and frequently tries to obey, responding understandably to the abuse, or psychotic, or both?
Others have attacked psychiatry for its diagnostic systems and its self-justification. Notoriously Laing said, "schizophrenia is a condition attributed by psychiatrists to people they call schizophrenic." Kutchins and Kirk also show the circularity inherent in many psychiatric diagnoses but cannot arrive at a more fundamental critique. They are not helped by an Introduction by Dorothy Rowe that gives itself over to the sort of anti-psychiatric polemic that Laing himself repudiated later in his life. Rowe's mocking of attempts to find "the schizophrenia gene" takes no account of the science nor the humane efforts involved and runs the risk of putting off more serious readers.
Foucault has shown in "Madness and Civilization" how psychiatric power can be used as one arm of social control, and how diagnosing madness invalidates the experiences of the mad. But psychiatry also is fundamentally informed by concern for the other's suffering, and the tragedy of mental illness. This ambivalence is to some extent addressed by the chapter on PTSD, and the long campaign by Vietnam veterans and supporters to get this diagnosis recognized so that veterans could get help for the effects of the combat they had to live with. In this case the recognition of the disorder was seen as validating the experiences of the ex-soldiers.
The chapter on borderline personality disorder addresses more the question of doctors and therapists having sexual relationships with their patients. This is an important area that involves an exploitation of power and trust. The argument that patients' claims of abuse are invalidated by labeling them as personality disordered is off the point. There is an inherent invalidation of the patient in such a situation, as there is in any abuse, and any abuser worth the term will do everything he or she can to wiggle out of responsibility. The claim that the borderline diagnosis "purports to explain how difficult and angry women seduce their unsuspecting therapist" is spurious. There are many other questions about this diagnosis that require serious discussion that the authors do not take up.
"Making us Crazy" is a social history of some aspects of recent psychiatric practice, and the behind the scenes goings on that "inform" some diagnostic categories. It is an interesting read, allowing for its polemical intent. Its weakness is that although its intention is to call into question the validity of psychiatric diagnoses, its focus on historical detail means that it cannot address the fundamental issues involved when one person sits down with another, and one attempts to objectively categorize the other for the purposes of psychiatric treatment. Kutchins and Kirk are saying that psychiatry often makes us crazy when we are "just human", but they do not show the deep complexity of the problem, and of the ethical and practical issues involved.