For many years, the union of psychoanalysis and medicine was a successful one. Doctors received the status and money accorded to healthcare professionals. They billed insurance companies to treat conditions like depressive reaction and adult situational reaction, and insurers paid without demanding prior authorizations or treatment reports. And starting in the 1960s, psychologists and other mental health professionals found their way onto the gravy train—not by wresting psychotherapy out of the hands of the medical doctors, but by fashioning themselves as medical professionals.
But this golden age of psychotherapy began to wane in the late 1960s, when the mental health industry, and psychiatry in particular, suffered a series of embarrassments, all of them having to do with diagnosis. First, a number of studies showed that doctors disagreed more often than not about what diagnosis a particular patient warranted. Specifically, it seemed British doctors were much likelier to diagnose a psychotic patient with manic depression (as it was known at the time) than schizophrenia, while the reverse was true in the United States. Then in 1972, David Rosenhan scandalized the profession when he sent graduate students into various emergency rooms complaining of no more than hearing the word “thud” in their heads. All were diagnosed with schizophrenia and hospitalized, and some were released only when their colleagues went to the hospital to spring them.
The following year, after repeated high-profile protests, the members of the APA voted to delete homosexuality from the DSM, signaling the first time in history that a disease was eliminated at the ballot box. It was the right thing to do, but it came at a huge cost, for it indicated that psychiatrists had failed to agree on what constituted a mental illness, which mental illnesses existed, and how to recognize them.
As far back as 1880, psychiatrists had worried among themselves about the effects of diagnostic confusion on their credibility. The APA’s diagnostic manuals—which first appeared in 1917; the first DSM was published in 1952—were, in part, an attempt to address their anxiety. But this time around, the consternation wasn’t only in-house. Insurance companies and government bureaucrats had taken notice of the chaos and were threatening to cut off funding of treatment and research. In 1975, a Blue Cross executive told the Psychiatric News, the APA’s in-house paper, that his company was reducing its benefits for mental health treatment because “compared to other types of services, there is less clarity and uniformity of terminology concerning mental diagnoses.” And in 1978, a presidential commission charged with setting priorities for healthcare funding concluded that “documenting the total number of people who have mental health problems . . . is difficult not only because opinions vary on how mental health and mental illness should be defined, but also because the available data are often inadequate or misleading.”
The message was clear. As Robert Spitzer, the man to whom the APA turned to solve the problem, told me, “Psychiatry was regarded as bogus. I knew it would be better off if it was accepted as a medical discipline.” If therapists wanted continued access to healthcare resources, they’d have to prove that they deserved them. Spitzer spearheaded the effort to create the DSM-III, the first of the DSMs to define mental disorders by criteria checklists. The book was four times as long as the DSM-II and featured twice as many diagnoses. It provided labels for virtually every kind of suffering that clinicians might encounter, and because it defined disorders purely in terms of symptoms, with no external validation, there was nothing to stop a clinician from providing a diagnosis that didn’t really fit the patient. A doctor who diagnoses strep throat on the basis of a sore throat and fever, but without a throat culture, is practicing bad medicine; but a doctor who diagnoses major depression on the basis of sadness and four of the other eight symptoms is, in the post-DSM-III age, simply practicing psychiatry.
The DSM-III was a huge success. Enormous numbers of copies were sold. (The APA claims not to have sales figures for it, but DSM-IV reaped in excess of $100 million.) As important, it reaffirmed the credibility of psychiatric diagnosis. It’s not an exaggeration to say that Spitzer saved psychiatry, and with it, the rest of the mental health professions. He understands exactly how the book achieved this: “If you open it up,” he said, “it looks like they must know something.”
Commanding scientific authority without actually being scientific, the book functions as a mythology, a powerful way of understanding the world of mental illness. But that power is not so much explanatory, or even descriptive, as it is social and economic. Like it or not, the DSM gives us our authority, and not only insofar as it secures us a place at the healthcare finance trough. With its imprimatur, we’re more like brain surgeons and cardiologists than ministers or rabbis. We’re not just people with opinions drawn from our ideologies about what ails our clients; we’re experts with scientific knowledge that gives us the power to pronounce the truth about the Jared Loughners and Adam Lanzas, about traumatized veterans and raving street people, about our fractured families and our shattered love lives.
The modern DSM has fulfilled Brill’s dream. It’s provided us with a comfortable living and a respectable place in society. But it’s also saddled us with the bad faith we enact every time we hold our noses and put a diagnosis on a bill, or fill out a treatment report, or kneel at the altar of evidence-based therapy. We’re the children of a shotgun marriage between psychoanalysis and medicine, and since our parents aren’t about to get divorced, then perhaps it’s time we leave the troubled home they’ve created and build one for ourselves.