Making Us Crazy

Kevin Vail

Making Us Crazy

Making Us Crazy Kevin Vail P 637 – Psychopathology and Assessment Dr. Liesel Polizi – instructor

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Introduction The last 100+ years have seen the rise to prominence of the science of psychology and the practice of psychotherapy. American and other Western societies turn to the psychologist to explain human behavior in nearly all its facets. A psychiatric diagnosis of pathology can affect everything from your personal freedom, to your employment and the custody of your children. The tool used by the psychiatric community to validate these life-altering decisions is called the “Diagnostic and Statistical Manual of Mental Disorders” (henceforth the D.S.M.). The D.S.M. is open to critique on a number of fronts. Herb Kutchins and Stuart A. Kirk explore several of them in their book Making Us Crazy: DSM The Psychiatric Bible and the Creation of Mental Disorders. Some of the areas they explore in their critique include: its lack of empirical foundation; the politicized nature of its’ content; and its’ imbedded racism, sexism and Western cultural bias. The authors offer scathing, if at times polemical, analyses of these problems but few solutions. This paper will explore their criticism and offer a few criticisms of its own of both the D.S.M. and of Kutchins’ and Kirk’s critique itself.

Kevin Vail The Science

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The first part of Kutchins’ and Kirk’s critique charges that the D.S.M. lacks empirical foundation. The authors assert that the diagnoses within the D.S.M. lack both reliability and validity. The authors of the constructs in the D.S.M. have gone to great lengths to give their formulations the appearance of scientific certainties but fail to provide the users with information on any supporting research. Kutchins and Kirk argue that the D.S.M. is not a carefully formulated work based on peer-reviewed scientific research but is rather “a strange mix of social values, political compromise, scientific evidence and material for insurance claim forms” (1997, p. x). The authors deconstruct the D.S.M. definition of “mental disorder”, which appears in the last three editions of the D.S.M., concluding that the definition “does not govern what conditions get included as disorders”; “the content and number of criteria that must be met to qualify for each disorder are largely arbitrary”; and it “has no consistent requirements that everyday behaviors used as diagnostic criteria actually be the result of mental disorder and not the result of other life experiences” (pp. 36-37). The construction of the psychiatric nosology has been more a process of negotiation “among contending interest groups of theoreticians, researchers, clinicians, hospitals, clinics, and drug companies” than a compiling of objective psychological and clinical research (p. 37). The process of revising the D.S.M. has become a “cycle of denigration, enthusiasm, and denigration” (p. 38). Each revision requires that the prior revisions be made to appear “antiquated”. The first edition to undergo this cycle was the D.S.M.-III published in 1980. The developers of this edition hailed it as a major breakthrough in the field of clinical psychiatry. It had removed the

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theoretical biases of the two previous versions and for the first time presented a detailed symptomology for each diagnosis, which was intended to improve reliability. According to Kutchins and Kirk, it was the increase of the involvement of the pharmaceutical industry and third-party payers for psychiatric care influenced the developers to emphasize both reliability and validity of the constructs. The D.S.M.-III sought to define the mentally ill as “those seen by psychiatrists” and “desired for every client a reimbursable diagnosis” (p.43). The D.S.M.-III radically expanded the number of psychiatric diagnoses to 265 and included “information about age of onset, course, impairment, complications, predisposing factors, prevalence, sex ratio and familial pattern” which gave it the appearance of scientific validity. (p. 45). However, the authors argue that “there is still not a single major study showing that [the] D.S.M. (any version) is routinely used with high reliability by regular mental health clinicians. Nor is there any credible evidence that any version of the manual has greatly increased its reliability beyond the previous version”. (p. 53). The process of revision from the D.S.M.-III to the D.S.M.-IV-tr (the current version) “ratified the sweeping changes first incorporated into the D.S.M.-III”, despite the “shaky empirical foundation” of those changes. (p. 48).

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At the root of this controversy appears to be the need for psychiatry to present itself as “objective science”. This has been its attitude and goal since the first writings of Sigmund Freud. Modern psychology was born into the cultural Weltanschauung of empiricism of the 19th century. But if indeed “we have had a hundred years of psychotherapy – and the world’s getting worse” as James Hillman lamented in his book of that title, is it not time to evaluate these largely unacknowledged assumptions of modern psychology? Kutchins’ and Kirk’s critique exposes the deceptive and even fraudulent claims of empiricism in the D.S.M. constructs but is this the right question? Has psychology lost itself and any hope of understanding its object by distancing itself from the nonquantifiable? A number of writers have directly questioned these empiricist assumptions and have argued for a return to a fuller definition of “science”. Dr. Wolfgang Smith, a prominent physicist and philosopher of science has argued that due to the metaphysical assumptions which underlie this cultural Weltanschauung of empiricism, “scientists have promulgated philosophic opinions of the most dubious kind as established scientific truths, and in the name of science have thrust upon an awed and credulous public a shallow world-view for which in reality there is not a shred of scientific support” (2000).

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Nearly 2500 years ago Aristotle formulated a definition of science as “an organized body of knowledge of things through their causes” (McKeon, 2001). For “the master of those who know” those causes were four – the material, the formal, the efficient and the final. Modern science, including the science of psychology, typically limits itself to discussions of only one, the efficient cause. Kutchins and Kirk stumble upon this when they noted that in order to classify something as a “dysfunction”, this “requires that the natural function of mental mechanisms be known before claims of dysfunction can be made” (1997, 35). This is what is known as teleology, or among Aristotle’s causes, it is known as the “final” cause. It is precisely the final cause that psychology is most reluctant to ask about and since modern psychology “does not have a solid foundation in an authentic view of man…[it] has made little real progress in helping the mentally ill” and “cannot help but produce useless and sometimes even harmful theories and remedies for mental illness” (Ripperger, 2003, xiii). A truly “post-modern” approach to psychology must transcend this assumption and embrace a greater epistemological pluralism if it hopes to understand its object.

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If then the diagnostic categories of the D.S.M. do not rest on empirical foundations, as Kutchins and Kirk contend, what do they rest on? The authors of Making Us Crazy argue that the D.S.M.’s formulations were attempts by psychiatry to make “claims about what is normal” and what is psychiatry’s legitimate domain. Instead of an objective process of compiling research data, the development of the D.S.M.’s constructs has been a process of political compromise between various special interest groups, which represent mental health practitioners, the pharmaceutical industry and third-party payers including insurance companies and government agencies. This process often took place surrounded by an aura of secrecy with handpicked committees and “tightly controlled” processes. The D.S.M.-IV in particular was created in an atmosphere that sought to avoid public controversy and “to reap the huge and unexpected profit that [the] D.S.M.-III … generated” (1997, p. 49). The authors subsequently detail the political wrangling and infighting which surrounded such issues as the removal of the term “neurosis” from D.S.M.-III; the removal of homosexuality as a disorder; the inclusion of a new disorder, PostTraumatic Stress Disorder (P.T.S.D.); and the unsuccessful attempt to create a “Masochistic Personality Disorder” all of which illustrates the various factions and ideologies that have to be satisfied in order to arrive at a finished product. Arguably the most sinister factor in these debates has been the lobbying of pharmaceutical companies and insurance companies for the creation or exclusion of certain diagnostic constructs.

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Finally, Kutchins and Kirk describe the history of racism and Western cultural bias that is imbedded in many of the diagnostic constructs. They cite studies which demonstrate that even when clinicians are presented with identical symptomologies, racial minorities and women receive more and more severe diagnoses than white men. The D.S.M. – IV did include “(1) a discussion of ‘cultural variations in the clinical presentation’ in the description of each of the official diagnoses and (2) an appendix that contains both an ‘Outline for Cultural Formulation’ and a ‘Glossary of Culture-Bound Syndromes” (1997, p. 233) However, they argue that the effect of this approach “implies there is a universal quality to the D.S.M.-IV diagnoses that is not to be found in culture-bound syndromes, even if a certain example of the latter occur in areas of the world that encompass a billion or more people and many cultures” (p. 236). In other words, the disorders of white American males are “universal” while those that pertain to those living in Asia or Africa are “culturally-bound”. This would seem to not differ significantly from the terminology used in 19th and early 20th century psychology texts that differentiated between “advanced” and “primitive” cultures or peoples.

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For the immediate future it would seem the dominance of the D.S.M. is nearly assured but as we move into post-modernity and away from the outdated or worse conceptions of mental illness, diagnosis, and treatment, mental health professionals should begin asking hard questions as Kutchins and Kirk have. People such as Dr. Wolfgang Smith, Fr. Chad Ripperger, Dr. Paul Vitz, who have illuminated the unspoken metaphysical and epistemological assumptions in modern science in general and modern psychology in particular, have taken the first steps. Students in graduate programs and practitioners in the field should be made aware that simply going along with the status quo is to tacitly participate in its racism, sexism and cultural imperialism.

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Bibliography Kutchins, H. & Kirk, S.A. (1997). Making Us Crazy. DSM: The Psychiatric Bible and the Creation of Mental Disorders. New York, NY: Free Press. McKeon, R. (ed.). (2001). The Basic Works of Aristotle. New York, NY: Modern Library. Ripperger, C. Fr. (2003) Introduction to the Science of Mental Health. Vol. 1: Philosophical Psychology 2nd Ed. (w/ Forward and Imprimatur by Rev. Fabian Bruskewitz). Lincoln, NE: Fraternity Publications. Smith, W. (2000). The Plague of Scientistic Belief. Homiletic & Pastoral Review, Vol. C, No. 7. Retrieved May 5, 2008, from http://www.catholic.net/rcc/Periodicals/HPR/April%202000/belief.html.