Shrinks

by Jeffrey A. Lieberman

  The DSM was still considered useless by the vast majority of psychiatrists, and nobody viewed the bureaucratic cataloging of diagnoses as a stepping-stone toward career advancement. But Spitzer thought he would enjoy the intellectual puzzle of carving apart mental illnesses more than the vague and inconclusive process of psychoanalysis. His enthusiasm and diligence as the DSM-II scribe was quickly rewarded by his promotion to an official position as a full-fledged member of the Task Force, making him at age thirty-four the youngest member of the DSM-II team.

  After the new edition of the Manual was completed, Spitzer continued to serve as a member of the APA’s soporifically titled Committee on Nomenclature and Statistics. Under most circumstances, this was a humdrum position with little professional upside, and Spitzer had zero expectation that his involvement would lead anywhere—until controversy abruptly thrust him into the national spotlight: the battle over the DSM diagnosis of homosexuality.

  Classifying Homosexuality

  American psychiatry had long considered homosexuality to represent deviant behavior, and generations of psychiatrists had labeled it a mental disorder. DSM-I described homosexuality as a “sociopathic personality disturbance,” while the DSM-II gave homosexuality priority of place as the very first example of its “sexual deviations,” described as follows:

  This category is for individuals whose sexual interests are directed primarily toward objects other than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward coitus performed under bizarre circumstances. Even though many find their practices distasteful, they remain unable to substitute normal sexual behavior for them.

  One leading proponent of the homosexuality diagnosis was psychiatrist Charles Socarides, a prominent member of the Columbia University Center for Psychoanalytic Training and Research. He believed that homosexuality was not a choice, crime, or immoral act—it was a form of neurosis that originated with “smothering mothers and abdicating fathers.” Thus, Socarides argued, homosexuality could be treated like any other neurotic conflict. From the mid-1950s through the mid-1990s, he attempted to “cure” gay men by trying to help them unearth childhood conflicts and thereby convert their sexual orientation to heterosexuality. There’s precious little evidence, however, that anyone was ever “cured” of homosexuality through psychoanalysis (or any other therapy, for that matter).

  It often happens that one’s personal theories of mental illness are put to the test when a family member comes down with the illness, such as when R. D. Laing’s theory of schizophrenia as a symbolic journey was challenged after his own daughter became schizophrenic. (Laing ultimately discarded his theory.) Charles Socarides’s son Richard was born the same year that he began treating homosexual patients, and as an adolescent he came out as gay, denouncing his father’s ideas. Richard went on to become the highest-ranking openly gay man to serve in the federal government, as an advisor to President Clinton. Unlike Laing, Socarides remained unwavering in his conviction that homosexuality was an illness until the end of his life.

  Homosexuals viewed their condition quite differently than psychiatrists did. In the late 1960s, many gay men felt empowered by the tremendous social activism going on around them—peace rallies, civil rights marches, abortion law protests, feminist sit-ins. They began to form their own activist groups (such as the Gay Liberation Front) and hold their own demonstrations (such as Gay Pride protests against sodomy laws that criminalized gay sex) that challenged society’s blindered perceptions of homosexuality. Not surprisingly, one of the most visible and compelling targets for the early gay rights movement was psychiatry.

  Gay men began to speak publicly about their painful experiences in therapy, especially during psychoanalysis. Inspired by psychiatry’s rosy promises of becoming “weller than well,” gay men sought out shrinks in order to feel better about themselves, but ended up feeling even more unworthy and unwanted. Especially harrowing were the all too common stories of psychiatrists attempting to reshape homosexuals’ sexual identity using hypnosis, confrontational methods, and even aversion therapies that delivered painful electrical shocks to a man’s body—sometimes targeting his genitals.

  John Fryer in disguise as “Dr. H. Anonymous,” with Barbara Gittings and Frank Kameny, at a 1972 APA conference on homosexuality and mental illness entitled “Psychiatry: Friend or Foe to Homosexuals? A Dialogue.” (Kay Tobin/©Manuscripts and Archives Division, New York Public Library)

  In 1970, gay rights groups demonstrated at the APA annual meeting in San Francisco for the first time, joining forces with the burgeoning antipsychiatry movement. Gay activists formed a human chain around the convention center and blocked psychiatrists from entering the meeting. In 1972, the New York Gay Alliance decided to “zap” a meeting of behavior therapists, using a rudimentary form of a flash mob to call for the end of aversion techniques. Also in 1972, a psychiatrist and gay rights activist named John Fryer delivered a speech at the APA annual meeting under the name Dr. H. Anonymous. He wore a tuxedo, wig, and fright mask that concealed his face while speaking through a special microphone that distorted his voice. His famous speech started with the words, “I am a homosexual. I am a psychiatrist.” He went on to describe the oppressive lives of gay psychiatrists who felt compelled to hide their sexual orientation from their colleagues for fear of discrimination while simultaneously hiding their profession from other gay men due to the gay community’s disdain for psychiatry.

  Robert Spitzer was impressed by the energy and candor of the gay activists. He did not know any gay friends or colleagues before he was assigned to deal with the controversy and suspected that homosexuality probably merited classification as a mental disorder. But the passion of the activists convinced him that the issue should be discussed openly and ultimately settled through data and thoughtful debate.

  He organized a panel at the next annual APA meeting, in Honolulu, on the question of whether homosexuality should be a diagnosis in the DSM. The panel featured a debate between psychiatrists who were convinced that homosexuality resulted from a flawed upbringing and psychiatrists who believed there was no meaningful evidence to suggest homosexuality was a mental illness. At Spitzer’s invitation, Ronald Gold, a member of the Gay Alliance and an influential gay liberationist, was also given the opportunity to express his views on the legitimacy of homosexuality as a psychiatric diagnosis. The event drew an audience of more than a thousand mental health professionals and gay men and women and was heavily covered by the press. Afterward, it was widely reported that the anti-illness proponents had carried the day.

  A few months later, Gold brought Spitzer to a secret meeting of a group of gay psychiatrists. Spitzer was stunned to discover that several of the attendees were chairs of prominent psychiatry departments and that another was a former APA president, all living double lives. When they first noticed Spitzer’s unexpected presence, they were surprised and outraged, viewing him as a member of the APA establishment who would likely out them, destroying their careers and family relationships. Gold reassured them that Spitzer could be trusted and was their best hope for a fair and thorough review of whether homosexuality should remain in the DSM.

  After talking with the attendees, Spitzer was persuaded that there was no credible data indicating that being homosexual was the result of any pathologic process or impaired one’s mental functioning. “All these gay activists were really nice guys, so friendly, attentive, and compassionate. It became clear to me that being homosexual didn’t impair one’s ability to effectively function in society at a high level,” he explains. By the meeting’s end, he felt convinced that diagnosis 302.0, homosexuality, should be eliminated from the DSM-II.

  But Spitzer found himself in a troubling intellectual bind. On one hand, the antipsychiatry movement was stridently arguing that all mental illnesses were artificial social constructions perpetuated by power-hungry psychiatrists. Like everyone at the APA, Spitzer knew these arguments were taking a toll on the credibility of his
profession. He believed that mental illnesses were genuine medical disorders rather than social constructs—but now he was about to declare homosexuality to be exactly such a social construct. If he disavowed homosexuality, he could open the door to the antipsychiatrists to argue that other disorders, such as schizophrenia and depression, should also be disavowed. Even more worrying, perhaps insurance companies would use the decision to rescind the diagnosis of homosexuality as a pretext to stop paying for any psychiatric treatments.

  On the other hand, if Spitzer maintained that homosexuality was a medical disorder in order to preserve psychiatry’s credibility, he now realized that it would cause immeasurable harm to healthy men and women who just happened to be attracted to members of their own sex. Psychoanalysis offered no way out of this bind, since its practitioners’ staunch position was that homosexuality arose from traumatic conflicts in childhood. Spitzer finally resolved the conundrum by inventing a new psychiatric concept, a concept that would soon prove pivotal in the next, groundbreaking edition of the DSM: subjective distress.

  Spitzer began to argue that if there was no clear evidence that a patient’s condition caused him emotional distress or impaired his ability to function, and if a patient insisted he was well, then a label of illness should not be imposed. If someone claimed that she was content, comfortable, and functioning adequately, then who was the psychiatrist to say otherwise? (According to Spitzer’s line of reasoning, even if a schizophrenic insisted he was well, the fact that he was unable to maintain relationships or a job would justify the label of illness.) By endorsing the principle of subjective distress, Spitzer made it plain that homosexuality was not a mental disorder and on its own did not warrant any kind of psychiatric intervention.

  This view still allowed for the possibility that if a gay person asked for help, insisting he was experiencing anxiety or depression as a direct result of being gay, then psychiatry could still intervene. Spitzer suggested such cases should be considered as a new diagnosis of “sexual orientation disturbance,” an approach that left open the possibility of psychiatrists attempting to change the orientation of someone who asked psychiatrists to do so. (Spitzer eventually came to regret endorsing any form of sexual orientation conversion.)

  When Spitzer’s proposal reached the APA Council on Research to which the Committee on Nomenclature and Assessment reported, it voted unanimously to approve the deletion of the diagnosis of homosexuality disorder from the DSM-II and to replace it with the more limited diagnosis of sexual orientation disturbance. On December 15, 1973, the APA Board of Trustees accepted the council’s recommendation, and the change was officially incorporated as a revision to the DSM-II.

  Spitzer expected that this would evoke an uproar from within psychiatry, but instead his colleagues praised him for forging a creative compromise that was humane and practical: a solution that forestalled the antipsychiatrists and simultaneously announced to the world that homosexuality was not an illness. “The irony was that after all was said and done,” recalls Spitzer, “the strongest criticism that I received was from those at my home institution, the Columbia Psychoanalytic Center.”

  In 1987, sexual orientation disturbance was also eliminated as a disorder from the DSM. In 2003, the APA established the John E. Fryer Award in honor of Fryer’s masked speech as Dr. Anonymous. The award is given annually to a public figure who has made significant contributions to lesbian, gay, bisexual, and transgender (LGBT) mental health. Then in 2013, Dr. Saul Levin became the first openly gay leader of the American Psychiatric Association when he was appointed chief executive officer and medical director.

  While American psychiatry was disgracefully slow in eliminating homosexuality as a mental illness, the rest of the world has been even slower. The International Classification of Disease published by the World Health Organization did not eliminate “Homosexuality Disorder” until 1990 and to this very day still lists “Sexual Orientation Disturbance” as a diagnostic condition. This prejudicial diagnosis is often cited by countries that pass antihomosexuality laws, such as Russia and Nigeria.

  However, the media did not treat the 1973 elimination of homosexuality disorder from the Bible of Psychiatry as a progressive triumph for psychiatry. Instead, newspapers and antipsychiatrists mocked the APA for “deciding mental illness by democratic vote.” Either a mental illness was a medical condition or it wasn’t, these critics jeered—you wouldn’t find neurologists voting to decide whether a blocked blood vessel in the brain was actually a stroke, would you? Instead of providing a much-needed boost to its public image, the episode proved to be another embarrassment for the beleaguered profession.

  Despite the fact that the rest of the world didn’t see it that way, Spitzer had managed to orchestrate an impressive feat of diagnostic diplomacy. He had introduced an influential new way of thinking about mental illness in terms of subjective distress, satisfied the gay activists, and effectively parried the antipsychiatry critics. These feats were not lost on the leaders of the American Psychiatric Association.

  When the APA Board of Trustees met in the emergency special policy meeting at the peak of the antipsychiatry crisis in February of 1973, they realized that the best way to deflect the tidal wave of reproof was to produce a fundamental change in the way that mental illness was conceptualized and diagnosed—a change rooted in empirical science rather than Freudian dogma. The leaders agreed that the most compelling means for demonstrating this change was by transforming the APA’s official compendium of mental illness.

  By the end of the emergency meeting, the trustees had authorized the creation of the third edition of the Diagnostic and Statistical Manual and instructed the forthcoming DSM Task Force “to define Mental Illness and define What is a Psychiatrist.” But if the APA wanted to move beyond Freudian theory—a theory that still dictated how the vast majority of psychiatrists diagnosed their patients—then how on earth should mental illness be defined?

  One psychiatrist had the answer. “As soon as the special policy meeting voted to authorize a new DSM, I knew I wanted to be in charge.” Spitzer recalls. “I spoke to the medical director at the APA and told him I would love to head this thing.” Knowing that the new edition of the DSM would require radical changes, and observing how adroitly Spitzer handled the contentious quandary over homosexuality, the APA Board appointed Spitzer to chair the DSM-III Task Force.

  Spitzer knew if he wanted to change the way psychiatry diagnosed patients, he would need an entirely new system for defining mental illness—a system rooted in observation and data rather than tradition and dogma. But in 1973, there was only one place in the entire United States that had ever developed such a system.

  The Feighner Criteria

  In the 1920s, the sparse contingent of American psychoanalysts felt lonely and ignored, tucked away on their own little psychiatric island apart from a continent of alienists. But by the time of the 1973 emergency session of the APA, the tables had turned. Psychoanalysts had managed to recast the entire body of American psychiatry in Freud’s image, causing the few surviving biological and Kraepelinian psychiatrists to feel isolated and beleaguered.

  Only a handful of institutions had managed to resist the psychoanalytic invasion and maintain a balanced approach to psychiatric research. The most notable of these rare holdouts was appropriately located in the “Show-Me” State of Missouri. Three psychiatrists at Washington University in St. Louis—Eli Robins, Samuel Guze, and George Winokur—broke from their colleagues in academic psychiatry by taking a very different approach to diagnosis. They rested their iconoclastic sensibilities upon one indisputable fact: Nobody had ever demonstrated that unconscious conflicts (or anything else) actually caused mental illness. Without clear proof of a causal relationship, Robins, Guze, and Winokur insisted that diagnoses should not be contrived out of mere inference and speculation. The Freudians might have convinced themselves of the existence of neurosis, but it was not a scientific diagnosis. But if medicine lacked any concrete knowledge of
what caused the various mental illnesses, then how did the Washington University trio believe they should be defined? By resurrecting the approach of Emil Kraepelin focused on symptoms and their course.

  If a specific set of symptoms and their temporal course for each putative disorder could be agreed upon, then each physician would diagnose illnesses in the same way, no matter what her training background or theoretical orientation. This would finally ensure consistency and reliability in diagnosis, asserted the Washington University group—qualities that were egregiously absent in the DSM-I and II. The trio believed Kraepelin could save psychiatry.

  Robins, Guze, and Winokur all came from eastern European families that had recently immigrated to the United States. They ate lunch together every day, brainstorming ideas, united by a sense of common purpose and by their isolation from the rest of psychiatry. (Their outcast status meant that the NIMH denied them funding for clinical studies from the 1950s until the late 1960s.) According to Guze, in the 1960s the Washington University psychiatrists gradually began to realize, “There were people around the country who wanted something different in psychiatry and were looking for someone or some place to take the lead. For many years that was a big advantage to us when it came to recruitment. Residents who were looking for something other than psychoanalytic training were always told to go out to St. Louis. We got a lot of interesting residents.” One of these interesting residents was John Feighner.

  After graduating from medical school at the University of Kansas, Feighner initially planned to train in internal medicine, but he was drafted into military service. He served as an army physician caring for Vietnam veterans. The experience left him so shaken by the psychic devastation of the soldiers he treated that after he was discharged, he changed direction, and in 1966 he went to Washington University for training in psychiatry.