On December 25, 2015, renowned psychiatrist
Robert Spitzer died. Spitzer was a giant in world psychiatry, best known as the
architect of the third edition of the psychiatry’s diagnostic bible -- The Diagnostic and Statistical Manual of
Mental Disorders (DSM-III) -- the edition that effected a turnaround and
became the template for how psychiatric diagnosing has proceeded ever after. As
such, this death has hardly gone unnoticed, with stories about him proliferating.
Most of what is written is highly laudatory. We are told, for instance, that he
placed psychiatric diagnosis on a scientific foundation, that he introduced
rigor (see, for instance, http://www.nytimes.com/2015/12/27/us/robert-spitzer-psychiatrist-who-set-rigorous-standards-for-diagnosis-dies-at-83.html),
that he was a “pro-gay psychiatrist” who “campaigned to remove homosexuality
from the Diagnostic and Statistical Manual of Mental Disorders.” (Newsmax, http://www.newsmax.com/Health/Health-News/robert-spitzer/2015/12/29/id/707468/
This article takes serious issue with the most significant of the claims.
To be clear, it is always sad when someone
dies -- and I in no way wish to detract from the personal tragedy. Nor do I intend
to make any pronouncement about Spitzer the individual. What concerns me in
this article is one thing only—how to understand his “psychiatric contribution”
to society. Now no one denies that Spitzer was enormously influential. However,
it is precisely because his legacy endures and because vulnerable people are
forced to live with what was set in motion that I felt compelled to write this
article.
So what are we to make of the claims? And
what in fact is Spitzer’s legacy?
Claim:
Spitzer Was Enlightened and Opposed the Pathologizing of Gays
It is claimed that Spitzer was largely
responsible for removing “Homosexuality” as a disorder from the DSM. This claim
has some merit —nonetheless, the situation is not as straight forward as appears.
The American Psychiatric Association (APA) was in difficulty at the time. Gay
rights activists were skillfully protesting the inclusion of said disorder,
interrupting meeting after meeting of the APA (see Teal, 1971). Spitzer was
called in to help. His actions eventually culminates in a postal vote and the concomitant
removal of the offending diagnosis from the DSM. That this is an important
legacy is without question. At the same time, Spitzer was hardly the great
liberator suggested by most who tell this story. What is significant in this
regard, he went on to introduce another disorder which also pathologized gay
life -- ego-dystonic homosexuality. This was a particular worrisome diagnosis
for it pathologized discomfort with being gay -- a reaction totally expectable
in a homophobic world. Herein we find an unfortunate default mode which
characterized Spitzer and those who followed him -- totally ignoring context. As
for the question of gay existence per se, for most of his professional career, Spitzer
flip-flopped on it, in the early 2000s, for example, mounting a study in
support of a therapy to “cure” people of being gay, in 2012 retracting said
study -- albeit only after it was exposed as shoddy scholarship (see https://www.washingtonpost.com/national/health-science/robert-spitzer-psychiatrist-of-transformative-influence-dies-at-83/2015/12/26/b6851764-ac46-11e5-bff5-905b92f5f94b_story.html).
The
Major Claim: With the DSM-III, Spitzer Introduced Rigorous Science and Thereby
Made Diagnostic Psychiatry Credible
This brings us to the main claims and without
question the central “contribution” for which Spitzer is known –the revolution
that constitutes DSM-III. On this “contribution” clarity is critical -- for to
misunderstand it is precisely to misunderstand the nature of the psychiatric
quagmire that we as a society are facing to this day.
The claim put forward by almost all
psychiatrists, including those of a reformist bent, is that Spitzer placed psychiatric
assessment on a more or less solid scientific foundation. States psychiatric
reformer Dr. Allen Frances in this regard, “He [Spitzer] saved the field…from a
crisis of credibility, raising its scientific standards (see http://www.nytimes.com/2015/12/27/us/robert-spitzer-psychiatrist-who-set-rigorous-standards-for-diagnosis-dies-at-83.html).
There are two sets of claims involved. The
first is that psychiatry was suffering a crisis of credibility, that Spitzer
introduced a new approach to diagnoses with DSM-III, and that in the process,
he shepherded psychiatry through the crisis. To start at the beginning, there was
indeed a crisis at the time: Psychiatric diagnoses had been shown to have
extremely low inter-rater reliability. That is, the chances of different
psychiatrists assigning the identical diagnostic category to the same patient was
low -- little more than chance. Moreover, a major experiment by Rosenhan (1973)
had exposed psychiatry on an even more basic level.
The experiment involved Professor Rosenhan
sending students pretending to be disturbed into hospitals. While the students
proceeded to act “normal” except for initially
telling staff that they had heard a voice saying, “hollow,” “thud,” and
“empty,” all were kept a sizeable time and all were assigned major diagnoses. When
the results of the experiment became known, the public’s reaction was that
psychiatrists could not even distinguish between “real patients” and
“pseudo-patients” -- never mind between different “disorders.” And as such, the
credibility of the diagnoses, and by extension, psychiatry itself, was at an all-time
low.
Did the reputation of each improve after the
introduction of DSM-III (1980)? Yes, it very much did. And was this because of how
DSM-III was constructed? To a significant degree, yes. And was this because, as
claimed, psychiatric diagnosing had finally been placed on a sound scientific footing?
In a word, no.
By way of explanation, Spitzer for sure
created discrete diagnoses. Correspondingly, unlike in the past, they came
complete with explicit sets of criteria, superficially at least reflecting how
physical disorders are delineated. And for sure, tests were conducted and
validity thereby “claimed” for each of the included disorders. The point is,
however, mirroring the trappings of medicine, that is, using medical-sounding
language has no bearing on validity.
Aside from the inherent persuasiveness of medicalized
language, what exactly was Spitzer’s claim to validity? Quite simply, that the
research conducted by his team had established high inter-rater reliability. The
problem here is that high inter-rater reliability similarly has nothing to do
with validity. To quote a passage from Burstow (2015) in this regard:
The fact that
people can be trained to apply a label in a consistent way, note, does not mean
that the label points to anything real. To use an extreme example, let us say
that we want doctors to be able to identify people walking about who secretly
hail from Mars. We might provide clear criteria for such people and so
carefully train the doctors that they achieved a high level of agreement when
making their determinations. None of this gets around the problem that there
are in all likelihood no people from Mars walking the earth. (p. 78)
A still further problem enters in with
Spitzer’s very claim to high inter-rater reliability. At their most successful,
there was miniscule difference
between the reliability ratings for DSM-III diagnoses and the rating for previous
“disorders.” Often there was no difference at all; and at times the DSM-III
scores were lower, this despite the fact, as Kirk and Kutchins (1997, p. 52
ff.) demonstrate, experiments were rigged so as to create superior results,
including providing the DSM-III raters with extensive training so that their
scores would be bolstered. Additionally, different criteria were used when re-evaluating
the DSM-II studies than when interpreting the DSM-III studies -- thereby
creating the impression/misimpression that the DSM-III categories yielded superior
results. One obvious example is the very same level of agreement that was
deemed “only satisfactory” in the reevaluation studies (e.g., 7) was deemed
“high” or “very high” in the studies involving the DSM-III categories.
This is not medicine; this is not science;
and this is not rigor.
So if the claim to high scientific
standards will not hold—and as you can see, it will not-- exactly what was the
revolution that constituted DSM-III?
What was introduced was a classification schema
that was avowedly neo-Kraepelian (see Kraepelin, 1907 and Burstow, 2014) --
that is, an etiology-free schema which has little tie-in with the realities of
people’s actual lives and as such, is largely classification for
classification’s sake. In the DSM as it emerged, there is no thought to why
people are acting as they are. The not-so-hidden benefit to psychiatry is that
the new schema put an end to most internal squabbles, for it is precisely when
it comes to issues of cause and what something is “about” that arguments break
out. The ramification of such a system, correspondingly, is that the label or
diagnosis itself ends up treated as causal. The circularity thereby engendered
is visible in this comment which I made in a recent interview:
[The DSM) sets
practitioners up to look at distressed and/or distressing people in certain
ways. So, if they go into a psychiatric interview, they’re going to be honing
on questions that follow the logic of the DSM, or to use their vocabulary, the “symptoms”
for any given “disease” they’re considering. In the process it rips people out
of their lives. And so now there’s no explanation for the things people do, no
way to see their words or actions as meaningful because the context has been
removed. In essence, the DSM decontextualizes people’s problems, then re-contextualizes
them in terms of an invented concept called a “disorder.” Let me give you an
example. “Selective Mutism” is a diagnosis given to people who elect not speak
in certain situations. So, if I were…trying to get a handle on what’s going on
with somebody—I would try to figure out what situations they aren’t speaking
in, try to find out if there’s some kind of common denominator, to ascertain
whether there’s something in their background or their current context that
would help explain what they are doing. You know, as in: Is it safe to speak? Is
this, for example, a person of color
going silent at times when racists might be present? Alternatively, is this a
childhood sexual abuse survivor who is being triggered? Whatever it is, I would
need to do that. But this is not what the DSM, as it were, prompts. In the DSM,
“Selective Mutism” is a discrete disease. So, according to psychiatry, what causes these “symptoms” of not speaking? Well, “Selective Mutism” does.
(Burstow’s response in Spring and Burstow, 2015)
Combine this vacuousness and this
circularity with medicalized language, such is the revolution that was
DSM-III.
Concluding
Remarks
I began this article by taking issue with
claims about Spitzer’s legacy. Clearly Spitzer’s most formidable contribution to
psychiatry is his overall contribution to diagnostic psychiatry via introducing
a whole new way of constructing diagnoses, as spearheaded in DSM-III. On this,
everyone agrees. However, what is it that Spitzer -- and his colleagues -- set
in motion? Contrary to the claims being made, through the use of scrupulously medicalized terms and through the pretense of carefully conducted research
they created “the appearance” of science, medicine, and rigor. That is, they
set psychiatric diagnosing decisively on a path where it would look scientifically rigorous, where it
could claim the authority of medicine on the basis of appearance, while in
point of fact, being vacuous. Correspondingly, subsequent DSMs have continued
in the same vein -- hence the difficulty combating psychiatry.
In ending, I would remind readers once again
that a human life has been snuffed out. At the same time, I invite readers not to
lose sight of the real legacy of Spitzer and his brainchild -- DSM-III.
Otherwise, how are we to keep our bearings
in the struggle ahead?
References
Burstow, B. (2014). Neo-Kraepelinian Psychiatry. In Cultural Sociology of Mental Illness
(Andrew Scull, Ed.). (pp. 575-576). Thousand Oaks, California: Sage.
Burstow, B. (2015). Psychiatry
and the business of madness. New York: Palgrave Macmillan.
Rosenhan, D. L. (1973). On being sane in insane places. Science, 179, 250-258.
Kraepelin, E. (1907). Clinical
psychiatry. (Ross Diefendorf, Trans. and Ed.). New York: Macmillan.
Kutchins, H. and Kirk, S. (1997). Making us crazy. New York: The Free Press.
Spring, L. and Burstow, B. (2015). Probing Psychiatry and the business of madness. Retrieved January 5, 2016
from http://rabble.ca/books/reviews/2015/07/probing-psychiatry-and-business-madness
Teal, D. (1971). The gay
militants. New York: Steiner and Day.