But that’s not how Linda Bowles, a contributor to the conservative Christian news site WorldNetDaily, took it. To her, it was just more evidence of the secular humanist conspiracy to further the gay agenda. “While we have been preoccupied6 with the dangers posed to our children by inanimate objects, namely guns,” she wrote in the summer of 1999, “they were under a much more dangerous assault from animate objects, namely psychologists and psychiatrists.” The blitz had begun with the deletion of homosexuality from the DSM, she continued, and had gotten worse with Criterion B, which she read to mean that “no matter how heinous the sexual perversion, if the pervert does not feel shame or remorse, he does not have a psychiatric problem.”
Bowles’s accusations rocketed around the right-wing blogosphere, picking up endorsements from the head of the National Association for Research and Therapy of Homosexuality, the medical wing of the pray-the-gay-away movement, and Charles Socarides, the psychiatrist who had led the opposition to the deletion in 1973, along with radio scold Laura Schlessinger. It also made its way to the APA, whose lawyers wrote to Bowles demanding that she “acknowledge the ‘APA’s clear opposition7 to pedophilia.’” The APA also issued a press release reiterating its stance that “an adult who engages in sexual activity with a child is performing a criminal and immoral act which never can be considered normal or socially acceptable behavior.”
But as any scandal-scarred politician will tell you, vigorous defenses against charges of turpitude are mostly self-defeating. If you run an organization of helping professionals, you don’t want to have to prove that your members aren’t really human missiles intent on blasting us all into a secular humanist hell. To forestall the necessity of further defenses, Frances and First recalled in their editorial, they removed the clinical significance clause from the diagnosis when the DSM-IV-TR came out in 2000. In its place was the old DSM-III-R version of Criterion B, according to which if someone “has acted on these urges8 or is markedly distressed by them,” he qualifies for the diagnosis.
This was the royal fuckup: the offender no longer had to be “impaired” to warrant the diagnosis. All he had to do was act. In the original DSM-IV version, the offender also had to have children as his primary sexual object. The attraction was the “impairment,” the thing that made his behavior disordered rather than simply repellent or unusual. But in the DSM-IV-TR, this requirement was gone, and since, according to Criterion A, “fantasies, sexual urges, or behaviors” were symptoms of Pedophilia, all the offender had to do to warrant the diagnosis was to commit the offense. This meant that, starting in 2000, a person who had sex with a child was ipso facto mentally ill.
Now, that may seem obvious to you. But that’s only because of how reflexively we attribute all our peccadilloes and quirks (or, more likely, those of other people) to mental rather than moral defect. The DSM, with its reach into daily life, has given us an ample vocabulary for expressing this intuition. But in fact, technically speaking anyway, this is not the case. Or at least it’s not supposed to be. It is surely not what First and Frances believe.
“Fewer than half of child molesters9 have Pedophilia,” First told me. “Often the child is a victim of convenience for an antisocial person.” Without “an underlying pattern of arousal,” as he put it, there is no mental disorder, at least not in the sex department; there is only criminality. That’s what First and Frances meant the DSM-IV-TR to say, in any event—that having sex with a kid was always criminal, but not always a symptom of Pedophilia, or of any psychiatric diagnosis for that matter.
But to a lawyer, or at least to a prosecutor in a state with sexually violent predator (SVP) laws, which allow diagnosed sex offenders to be kept in “treatment units” even after they have served out their sentences, a diagnosis based on behavior alone is an opportunity to protect (and score political points with) a public disgusted and frightened by sex offenders. The DSM-IV-TR diagnosis had turned into a different kind of opportunity for mental health experts, spawning a cottage industry of doctors ready to testify that the offender has indeed offended, and that this behavior is the symptom of a mental illness. Their practice is not limited to pedophiles. Because Sexual Sadism, Exhibitionism, Voyeurism, and Frotteurism all have the same behavior-only criterion as Pedophilia, rapists, flashers, peepers, and humpers all can be put away until they are “cured”—which may well mean forever. (And if the behavior in question doesn’t meet the criteria for one of those diagnoses, the forensic psychiatrist can always resort to Paraphilia NOS.)
“I don’t care about the rapist being in jail,” Frances said. “Most of them deserve to be there.” But they also deserve to get out once they have paid the prescribed penalty. Some rapists—the sadists, for instance, who can’t get aroused without inflicting pain on a nonconsenting person—might be suffering from a mental disorder that requires involuntary commitment, but indefinite incarceration based on behavior alone, in Frances’s view, “is preventive detention and double jeopardy. It’s a violation of due process. It’s unconstitutional.” (The Supreme Court disagrees. It has ruled that so long as the state can show that they are not punishing mere criminality but treating a mental defect ascertained by an expert, they can keep the offender locked up.) That’s what he cares about, that and the fact that this “colossal swindle”—forensic experts teaming up with prosecutors to deprive people of their civil rights—was made possible by his DSM. “I hate the fact that we’ve made this mistake,” he said. “We didn’t understand the SVP laws. We blew it.”
“I don’t wallow in my own guilt,” he added, “but I do like to clean up my own messes.”
Which is why he testifies in civil commitment hearings, trying to explain that sexual behavior without that underlying pattern cannot be a symptom of a mental disorder, and that the convict might only be a criminal. And it is why we are on our way to this meeting, where he will reiterate that distinction to defense lawyers to help them figure out how to convince judges and juries that mental illness is one thing and evil quite another.
The mess he’s trying to clean up was caused by two tiny words: and and or. Had Criterion A read “fantasies, urges, and behaviors,” he points out, it would be much harder for those enterprising psychiatrists and prosecutors to detach behavior from psychology and condemn prisoners to endless detention. This was exactly the kind of unforeseen consequence of which the DSM-5 crew seemed heedless. “If an or for an and could create mayhem,” he says, “what unintended harm could be wrought by the paradigm shifters?”
• • •
The paradigm shifters had long ago stopped responding to Frances. But he was no longer their only nemesis.
His fellow critics included at least one person who was as surprised as anyone to find herself on the same side as Frances. Paula Caplan, a psychologist affiliated with Harvard, had been a consultant to the DSM-IV personality disorders work group, a position from which she had tormented Frances as relentlessly as Frances was now tormenting Regier. Her main complaint back then was about Self-Defeating Personality Disorder. While Frances thought it was poorly conceived and had little empirical support, Caplan thought it was just plain sexist. Frances thought Caplan’s critique was “too polemical10” and warned her that since the proposal was sure to be rejected, there was no need for “heated controversy.”
Frances’s dismissal seemed only to inflame Caplan, who submitted her own DSM-IV diagnosis: Delusional Dominating Personality Disorder (DDPD). Among the fourteen proposed criteria were “a tendency to feel inordinately threatened11 by women who fail to disguise their intelligence” and “the presence of . . . delusions that women like to suffer.” DDPD was, she wrote, “most commonly seen in males,” often in “leaders of traditional mental health professions, military personnel, executives of large corporations, and powerful political leaders of many aims.” It was a “modest proposal,” she wrote, “an antidote to . . . the institutionalized sexism in the mental health system.”
�
�I really wasn’t sure12 what to make [of ] your ‘delusional dominating personality disorder,’” Frances responded. “How serious are you about it?” Much as he thought the proposal was a provocation, the reason he gave for rejecting it out of hand was the standard DSM-IV demurral: that there wasn’t enough evidence for DDPD even to be considered. But when Caplan asked for funds to develop that evidence, Frances refused. “It is disruptive to constantly tinker13 with the classification,” he wrote, adding, in case she didn’t get the hint, “if this sounds discouraging, I’m afraid it is meant to.”
After Caplan quit the work group, she wrote They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal, a broadside against DSM-IV, in which she cast the affair as an instance of the good-old-boy politics that powered the DSM. So even if Caplan did give Frances a shout-out14 for “bravely com[ing] forward with a mea culpa,” it was very unlikely that she was in cahoots with him when she came up with a modest proposal for the DSM-5: Toxic Psychiatric Drug Syndrome. In her letter to the task force, she also made some recommendations: that the APA “join an initiative to hold Congressional hearings about psychiatric diagnoses,” that it add a black-box warning to the actual DSM-5 emphasizing that the diagnoses were not to be used as “the basis for any professional or legal decision that may limit the liberty, or discriminate against, any individual,” and that, “because of . . . ongoing significant problems in the process,” publication be indefinitely delayed.
The APA swatted away Caplan as summarily as Frances had, although without his personal touch. They used a public relations firm, which arranged a conference call between representatives of “consumer groups”—Caplan was positioning herself as a champion of people given unwarranted diagnoses and prescriptions—and the DSM leaders. Caplan heard that there would be twenty others on the hour-long call, so she tried to coordinate with the others on the questions that would be asked, but the hired guns refused to disclose the participants or forward a list of proposed questions to them. On the appointed day15, according to Caplan, after Carol Bernstein assured the callers that the APA needed “the expertise of patients, families, and their advocates,” Kupfer and Regier, along with a task force member, used the first half of the call to give their talking points. Participants who wished to ask questions were then instructed to dial a code, and after a silence during which a queue was constructed, six were allowed to ask a single question each; their phones were muted as soon as they delivered it. The APA representatives stuck to their script and, after promising (but refusing to schedule) further discussion, said good-bye.
The new bosses were no different from the old bosses, Caplan concluded. They might give the “impression of openness to debate,” she wrote in her Psychology Today blog, but in real life, critics like her would be “largely ignored,” their evidence “shoved aside,” and the world’s latest most powerful psychiatrists would once again “put in the next edition of the manual whatever they pleased.”
If Caplan was railing against the psychiatrists’ process, the British Psychological Society was going right for the content of what displeased them. In a twenty-six-page manifesto released in June, the BPS accused the APA of “the continued and continuous medicalisation16 of . . . natural and normal responses.” These responses, the BPS went on, “undoubtedly have distressing consequences which demand helping responses, but which do not reflect illnesses so much as normal individual variation.” Attenuated Psychosis Symptoms Syndrome (APSS), for instance, “looks like an opportunity to stigmatize eccentric people, and to lower the threshold for achieving a diagnosis of psychosis,” leading in turn to more drug treatments. The overall thrust of the manual, the BPS complained, was to identify the source of psychological suffering “as located within individuals,” rather than in their “relational context,” and to overlook the “undeniable social causation of many such problems.”
The APA could hardly deny any of this. As Regier had told the consumer groups on the conference call, the manual’s new organizational structure was designed to reflect “what we’ve learned about the brain, behavior, and genetics during the past two decades.” It doesn’t get much more “within the individual” and outside the “relational context” than that. And, as proposals like APSS and the elimination of the bereavement exclusion made clear, one of the purposes of the DSM-5 was to make sure that no one who was suffering would be deprived of the benefits of diagnosis.
On the other hand, the APA couldn’t ignore the British Psychological Society or treat it as a mere “consumer group.” But that didn’t mean they would acknowledge the actual criticisms, as Regier made clear in his official response17. The BPS had cited a “well known member of the ‘Critical Psychiatry Network,’” he wrote, one “that has largely adopted the Thomas Szasz approach to mental illness.” These critics, Regier reminded his readers, think “we shouldn’t consider any mental disorder, including individuals whose psychosis renders them mentally incompetent, to have a brain-based illness.” Antipsychiatry was once again deluding people into thinking that the APA was making grievous errors.
Compounding the BPS’s ideological excess, Regier went on, was plain ignorance.
What seems to be missing is an appreciation of mental disorders as the result of gene-environmental interactions that would trigger abnormal neuronal function in the brain. Why the brain should be exempt from pathology when every other organ system is subject to malfunction is left unaddressed.
To question the APA’s insistence that psychological suffering was always the result of brain pathology was to deny that the brain could malfunction at all.
“It should be recognized that mental disorders are by no means a modern construct,” Regier wrote. “Psychiatric disorders have existed since the beginning of recorded history.”
Regier didn’t offer any evidence for this extravagant claim, nor did he try to square it with his insistence in other venues that psychiatric disorders were constructs that clinicians reified at their own peril. But then again, he probably thought he was saying something nonextravagant (and self-evident): that mental suffering has always existed, and that throughout recorded history it has only been awaiting psychiatrists like him to elucidate the gene-environmental interactions that triggered the brain pathology that causes it. But to think there could be psychiatric disorders before there were psychiatrists, to think the only way to understand our suffering is as an illness to be cured by doctors, is to ignore the fact that for thousands of years of recorded history, people thought that mania and psychosis and depression and anxiety were the mark of the prophet, or manifestations of sin or witchcraft or devil possession, or just the nature of life in a fallen world. It is also to overlook the failure of psychiatry, at least so far, to prove that it is the proper venue for understanding and treating what we have come to think of as mental illness. And to think, after all the failures of the DSM to develop an accurate taxonomy, that this time it will be different, that only naysayers and dead-enders and other benighted miscreants could possibly believe that recasting sin or possession or witchcraft as illness is anything other than the mark of progress—well, that is the province of people who, as Herman Melville once wrote, despite “previous failures18, still cherish expectations with regard to some mode of infallibly discovering the heart of man.”
These people, Melville observed, are like the mathematicians who “in spite of seeming discouragement . . . are yet in hopes of hitting upon an exact method of determining the longitude.” But other scientists maintain this optimism, including, Melville wrote, “earnest psychologists.” He probably didn’t mean to slight psychiatrists. It’s just that he wrote the novel in 1857, which is long after the beginning of recorded history, but only a few years past psychiatry’s emergence as a profession, and long before it began to try, despite seeming discouragement, to enshrine its infallible understanding of mental suffering in the pages of a book.
• • •
Me
lville’s observation comes in his last novel, The Confidence-Man. In it, a colossal swindler embarks on a riverboat on an April Fool’s Day and proceeds to take advantage of the passengers’ credulity and greed. It’s a novel about trust—the reader’s as well as the passengers’—which Melville advises his readers to place not in psychologists, no matter how earnest, but in novelists, who, he says, can give us the same knowledge of the twists of our nature that a “stranger entering19, map in hand, Boston town” has of the city’s crooked streets. But Melville, ever the ironist, won’t let us forget that we place confidence in the novelist at our own peril. He is anything but earnest; whatever truth he depicts emerges from the elaborate lie of a fictive world. Even his publisher was in on the joke: The Confidence-Man hit the streets on April 1.
The APA has books to sell, too. But it doesn’t have the luxury of calling attention to its own fictions and chalking them up to art. It can’t say with Melville that “he who, in view of its inconsistencies, says of human nature . . . that it is past finding out, thereby evinces a better appreciation of it than he who, by always representing it in a clear light, leaves it to be inferred that he clearly knows all about it.” Neither can it afford Melville’s arch awareness of the fallibility of all claims to knowledge about the human heart, about the dangers of placing our confidence in anyone’s book about us. So don’t look for the DSM to be published on April Fool’s Day. And, despite the fact that it is full of fictive placeholders, don’t expect the APA to suggest that booksellers shelve it with the likes of The Confidence-Man.
Which doesn’t mean psychiatrists are above the open and intentional use of fiction, at least not when it comes to inventing mental disorders. Indeed, storytelling was central to at least one DSM-5 proposal: to add a diagnosis called Hebephilia to the sexual disorders chapter. Don’t feel bad if you’ve never heard of Hebephilia, which is what Ray Blanchard—the Canadian doctor who incurred the wrath of the transgendered—calls the attraction of grown-ups to kids in early adolescence. According to Blanchard, lead author of a paper calling for including Hebephilia in the DSM, even among professionals there is a “general resistance or indifference20 to the adoption of a technical vocabulary for erotic age-preferences.” Clinicians are more likely to have heard of “granny porn” than of gerontophilia, Blanchard said, and hardly anyone uses teleiophilia to talk about “the erotic preference for people between the ages of physical maturity and physical decline”—this despite the fact that, as Blanchard noted with some apparent bitterness, “the word normal has been off-limits for describing erotic interests for decades.”
The Book of Woe: The DSM and the Unmaking of Psychiatry Page 26