“Did this change the way you treated her?” I asked.
“No,” he replied.
“So what was its value, would you say?”
“I got paid.”
For everyone, from lunchbucket therapists like me to the nation’s psychiatrist-in-chief, making a DSM diagnosis is the ritual you have to perform to get the system to work. It may not be quite as silly as Fred’s ritual at work, at least not on the surface, but we therapists have responded to it just as Fred did (which makes sense, since I crafted Fred to serve my interests here, just as the APA crafted a book of diagnoses to serve its interests). Like Fred, we’ve engaged in all sorts of evasions and subterfuges to avoid the glaring and simple truth: the DSM is our Great Gazoo. Invoke it, and the cash rolls in.
Most of us have groused about the absurdity of this situation—that the cornerstone of a practice presumably devoted to ferreting out and facing the truth is, in fact, a fiction. Some of us have struggled with the irony, resolved to do something about it, and maybe even engaged in some organized protest of it. But it’s easy to tire of this, to decide that the neurosis is in us, that resistance is no more than a childish insistence on having things our way; and besides, there are mortgages to pay and children to educate and retirement plans to fund, so we stand on our right foot, raise our left hand, and declare our obeisance. It’s possible, however, that the time has come to stop doing that, to take our dismay seriously and to turn it into something other than a bitter complaint.
The philosopher who carried a lamp around Athens was known as Diogenes the Cynic. As much fun as cynicism can be, what with its opportunities for black humor and ironic detachment, we can do better. The cynical stance is a victim’s stance, a weary shrug of the shoulders at conditions beyond our control. But unlike mortality and perfidy, the DSM isn’t part of nature, human or otherwise. Neither did it land on us from outer space. It’s tightly woven into the history—and the allure—of our profession. As with many troubling behaviors, understanding that history might help us understand how we arrived in this dark place, and point us in a direction out of it.
Swallowed by Medicine
The origins of our DSM discontent syndrome can be found in a tawdry primal scene. In 1925, a woman named Caroline Newton applied for membership to the New York Psychoanalytic Society. She was by all accounts qualified; she’d been in treatment with Freud in Vienna, was translating Otto Rank’s psychoanalytic writing, and was a member of the International Psychoanalytic Association. Nonetheless, the society refused to admit her and objected to her opening a practice as a psychoanalyst on the grounds that she wasn’t a physician. At first, she was given guest privileges instead, but later, the society voted to “restrict attendance of our meetings to members of the [medical] profession,” and ultimately it announced its “unanimous decision that it is opposed to laymen practicing therapeutic psychoanalytic therapy.” A year later, it voted to make the restriction official. Newton was sent into professional exile, as were all the other lay analysts then and in the future. Henceforth, psychoanalysis in the United States could be practiced only by medical doctors.
Freud was bitterly opposed to this move. Although a doctor himself, he thought medical education was exactly the wrong preparation for being an analyst. “It burdens [a physician] with too much of which he can never make use,” he wrote, like “anatomy, biology, and the study of evolution.” It subjects him or her to the “temptation to flirt with endocrinology and the autonomous nervous system.” Left to physicians alone, Freud feared, psychoanalysis would become just another “specialized branch of medicine, like radiology.”
“As long as I live,” Freud vowed, “I shall balk at having psychoanalysis swallowed by medicine.”
But that’s exactly what the physicians of the New York Psychoanalytic Society wanted to do. They and their colleagues had been competing with neurologists for the business of the worried well for a decade or so, and psychoanalysis seemed to offer them a technique that the neurologists, with their rest cures, electrical stimulators, and special diets, didn’t have. On the other hand, those treatments had the cachet of scientific medicine. Focusing on bodily mechanisms, they capitalized on the increased confidence of the American public in medicine that followed upon the seminal discoveries of the previous 50 years—viruses and bacteria as the cause of infection, lack of insulin as the culprit in diabetes, and so forth. Psychoanalysis was hard-pressed to match this standard, and psychiatrists, who’d long been worried about their status in medicine, saw in lay analysts a threat to their credibility. As A. A. Brill, founder of the New York Psychoanalytic Society and chief architect of the exile of the lay analysts, put it, the profession had “attracted many charlatans and quacks who find in it a medium for the exploitation of the ignorant classes.” Claiming the franchise only for themselves and eliminating people like Newton, they sought to reassure the public (and themselves) that the talking cure was a legitimate medical practice.