Among the many books published about learning disabilities and the associated debates, few authors could approach the issues better qualified than Dr. Frances who in addition to serving as Chair of the DSM-IV Task Force and serving as part of the leadership group for the DSM-III and DSM-IIIR, is professor emeritus and former chair of the Department of Psychiatry and Behavioral Science at Duke University School of Medicine. His attacks on the assumptions guiding the directions of modern psychiatry are profound in their implications. This is a book that cannot be recommended enough to those interested in the subject matter or who have a child or family member who has been subject to a psychiatric or psychological evaluation. The DSM or Diagnostic and Statistical Mannual of Mental Distorders has become the standard reference for all mental health issues and as a definitive authority few dare question it. Having served a pivotal role in the DSM, the author is in a unique position to question it.
Dr. Frances states a main argument with regard to his concerns;
“Human difference was never meant to be reducible to an exhaustive list of diagnosis drawn carelessly from a psychiatric manual. It takes all types to make a successful tribe and a full palette of emotions to make a fully lived life. We shouldn’t medicalize difference and attempt to treat it away by taking the modern day equivalent of Huxley’s soma pills. The cruelest paradox of psychiatric treatment is that those who need it most often don’t get it, while those who do get it often don’t need it. So how do we save normal, preserve diversity, and achieve a more rational allocation of scarce resources?”
This diagnostic inflation has its roots in a form of emotional reductionism in which the emotional ups and downs of life are rendered as treatable abnormalities requiring medication or therapy or both. His concerns are that with this inflation has come the danger of discrediting the central core of diagnostic progress initiated by the DSM. So what is the DSM and how did it reach this state of influence and crisis?
The author gives an informative history of psychiatry leading up to a crisis in the 1970s where psychiatry was thoroughly discredited as a result of two studies. The first of these focused on a study where videotapes of patients were given to different psychiatrists in America and England only to show very serious discrepancies in the diagnostic results. In another study, graduate students staged that they were hearing voices in order to be admitted to psychiatric wards and despite behaving in a perfectly normal manner were held for prolonged periods of time. The net result was to hold the reliability of psychiatric practice in question.
The solution to this problem was seen in the creation of the DSM III (Diagnostic and Statistical Manual of Mental Disorders) which aimed to standardize diagnostic practice in the same manner as a dictionary would standardize spelling and definitions. The aim of this was to create consistency. Whereas the first DSM published in 1952 and the second printed in 1968 had been largely unread and ignored, the success of the much enlarged DSM III was extraordinary. It shortly became a runaway best seller as well as a standard text of reference throughout many countries. This was followed by the DSM III (Revised), the DSM IV and the current DSM V with each edition increasing exponentially in terms of size and content. So how were the DSM editions created?
The DSMs were created by panels of experts who came together to decide what would be included or excluded as well as what the exact defining conditions were for each condition. As such, conditions were given a name and then defined in terms of the specific descriptors required as the necessary and sufficient conditions to qualify. The process was therefore inherently subjective and as the sufficient and necessary qualifications were either tightened or loosened the number of people who could be described as falling under that condition would be either increased or decreased. As a result of other pressures such as the ability to qualify for special services or insurance coverage, the inherent dynamic was to relax the standards. Additionally, the influence of pharmaceutical companies to promote their products as well as their unique ability to advertise directly to the public (unique among all countries in the Western Hemisphere) contributed to this tendency. As a result, throughout the history of the various editions there is a notable decrease in the requirements for major conditions as well as an increase in the number of named or identified conditions. This double thrust has resulted in a monumental level of diagnostic inflation that now appears to have taken on a life of its own.
To give a concrete example of this in terms of impact, a person might be considered as being accurately diagnosed as being ADHD according to the DSMV who would not have qualified according to the DSM IV. As such, the attribution is conditional upon the defining characteristics. But as any first year philosophy student will tell you, defining the characteristics of something does not determine existence. For example, determining the characteristics of Santa Claus does not confer existence upon him. Therefore, whatever existence ADHD may be said to have is not the same as say measles in which there is an identifiable and discrete biological causative agent that generates the symptoms. In other words, there is an existent thing independent of the attributes. In the event of all mental conditions, the underlying assumption is that there is some biological, neurological underpinning that though not identified is the causative agent. Therefore, in keeping with the best traditions of behaviorist psychology, the DSM focuses on observed behaviors and does not concern itself with explanations involving the inner mechanisms of conscious or unconscious motivations or intent. This however is suggestive of a naïve sense of Cartesian dualism in which mind and body or mind and brain are two distinct things that somehow interact or in which mental phenomena is in some manner merely derivative of the brain. Sophisticated explanations of this issue are involved in what in philosophy are referred to as The Mind/Body problem. The most satisfactory explanations involve the view that mind and brain are one and the same thing but looked upon from different aspects leading to a description of individuals as mind/bodies. As such, mental states can be described in terms of chemical balances but are not ultimately reducible to them any more than the Mona Lisa can be reducible to five primary colours.
As such the consistency offered by virtue of the DSM though necessary has also given rise to an inherent reductionism or simplicity of interpretation. Although Dr. Frances alludes to this, he does not in my opinion go far enough because looking closely at some conditions can arguably undermine the very foundations from which they are formed. In short, inferences based upon behavior devoid of intention can give rise to simplistic interpretations. Repeated behaviors around not paying attention can lead to the conclusion that the subject has difficulty paying attention but if asked might say that no effort to pay attention is forthcoming because the subject has no interest or perceived benefit from engaging in the activity. The term ‘disability’ has as an underlying assumption that the subject wishes to do something but has the desire to. A cunning proponent will argue that the subject has no desire to because they experience difficulty doing so. However, this argument is clearly circular and is of the same form as defining good as what is not bad and what is bad as is not good. We know from our own experience that our interests are largely dictated by whether we find value in something or not. Therefore some people will experience great excitement watching a hockey game and be able to remember all of the events in detail while another may follow a chess tournament with equal attention.
In talking to boys over the years about why they have exhibited so little effort in individual classes or school generally it is common to discover that it is not an inability to focus or put forward effort but a lack of willingness based upon a lack of interest in doing so. This is often tied in with three important factors. First, they perceive no immediate useful utility in what they are learning. Second, there is no immediate tangible reward for this effort or disincentive either. Third, many believe that there is no sense in learning what can be readily accessed on a smart phone. As such, access to information and its repetition is equated with the ability to know and process information.
However, the consistent theme in all learning disabilities as with all behavioral and mental disabilities is the focus on the observed behaviors as a cluster of information not unified or directed by an agent or self. The result of this is language such a John has ADHD when in fact it might be more accurate to say that John is ADHD. The language itself directs the narrative along the lines of an affliction impinging upon the individual from the outside as opposed to behaviors for which the individual has control or is accountable. In this manner, personal responsibility for behaviors is removed and the individual is then represented as a victim of an agency external to their control. Just as you would not blame a person for having measles the same implication results from the diagnosis that a person has ASDHD.
As such, the dysfunctions identified by clinical psychologists and psychiatrists are largely a result of reified clusters of behaviors that are then interpreted in terms of an affliction largely addressable by prescription drugs as opposed to any cognitive adjustment in terms of processing and accountability. This is where the talk therapy that emanated from what used to be referred to as depth psychology has given way to prescriptions and pharmaceutical solutions. Talk therapy once practiced by psychiatrists and psychoanalysts has increasingly given way to medication partly as a result of their success in suppressing the symptoms of mental illness but also in part as a result of cost effectiveness. The talk therapies practiced by figures such as Freud, Adler, Jung and others could involve hundreds of hours of patient contact and as such even if they proved to be effective would be financially untenable for any general applicability. These practical underpinnings have resulted in talk therapies being used by therapists and social workers under such banners as Mindfulness and Cognitive Behavioral Therapy.
However, to return to the issue of the medicalization of ‘normal’ behaviors I am reminded of a television commercial that was current a few years ago. It started with a scene of a party in a room in a house or apartment with people standing around engaged in happy conversation contrasted by a single young woman seated by herself on a sofa looking quite uncomfortable. A deep voice then materialized asking the questions “Do you feel awkward in social settings?’ “Do you find yourself lacking the confidence to interact with others?” “Do you feel alone and hopeless?” Then the answer comes that if you say yes to these questions you are probably suffering from Social Anxiety Disorder. The good news being that once identified, the problem can be addressed and solved. There is a medication, the name of which is given prominently on the screen, and with this your problems can be solved. You are advised to see your physician and to ask for this medication. The next scene in this commercial consists of a repeat of the initial scene but with the solitary female now standing and happily interacting with an eligible male who is equally animated.
This commercial serves as an excellent example of the overall template used to market pharmaceutical solutions. First there is an identified problematic behavior quickly followed by the naming of the behavior or behaviors as if in some manner the process of naming it implies some power, control or understanding of it. Then there is the presentation of a medication that will instantaneously solve the problems by eliminating the problematic behaviors with the assumption that once the behaviors are eliminated or controlled the causes are no longer relevant ---assuming of course that they ever were. In the case of the woman in question, the internal mental conditions responsible for her behaviors or causing her to behave in this manner become irrelevant. Once the symptoms are addressed the problem is viewed as solved. The formula involves the exaggeration of a problem to the level of a crisis followed by the suggestion that the problem having been named is understood followed by a simple solution step resolving the issues and bring about a hopeful future. In such a manner, a shy or timid person is rendered dysfunctional and in need of normalization through medication. The complexities of thought, feeling and personality vanish.
I think that Dr. Frances’s book is a valuable and thought-producing work. It should be carefully read and digested in terms of its implications both in terms of mental health issues but also within the framework of human diversity of personality, temperament and abilities.