by Jon Ronson
He glared at me. He repeated his position. At no point during the operation did he cross the line.
“Not even when you said that the chance of there being two such ‘highly sexually deviant’ men on Wimbledon Common at the same time was incredibly small?” I asked.
“Well, remember,” he replied, “Robert Napper was there, Colin Stagg wasn’t. Therefore . . .”
“Colin Stagg was there that morning,” I said.
“But he wasn’t on the Common at the same time!” said Britton.
He shot me a victorious look.
“Do you think Colin Stagg has a deviant sexual personality?” I asked.
“I don’t know Colin Stagg,” he replied.
There was a frosty silence.
“Are these the questions you came to ask?” he said.
We got the bill.
10.
THE AVOIDABLE DEATH OF REBECCA RILEY
On a balmy evening I was invited to a black-tie Scientology banquet at L. Ron Hubbard’s old manor house in East Grinstead. We drank champagne on Hubbard’s terrace, overlooking uninterrupted acres of English countryside, and then we were led through to the Great Hall where they sat me at the head table, next to Tony Calder, former manager of the Rolling Stones.
The night began with a strange ceremony. The Scientologists who had increased their donations to over £30,000 were invited onto the stage to accept crystal statuettes. They stood there, beaming, in front of a painted panorama of heavenly clouds as the five-hundred-strong audience rose to its feet in applause, dry ice pumping around them, giving them a kind of mystical glow.
Then Lady Margaret McNair, head of the UK branch of the CCHR, Scientology’s anti-psychiatry wing, made a long and quite startling speech detailing the new mental disorders proposed for inclusion in the forthcoming edition of DSM—DSM-V.
“Have you ever honked your horn in anger?” she said. “Well! You’re suffering from Intermittent Explosive Disorder!”
“Yeah!” the audience yelled. “Congratulations!”
Actually, Intermittent Explosive Disorder is described as “a behavioral disorder characterized by extreme expressions of anger, often to the point of uncontrollable rage, that are disproportionate to the situation at hand.”
“Then there’s Internet Addiction!” she continued. The audience laughed and catcalled.
Actually, Internet Addiction had already been rejected by the DSM-V board. It had been the idea of a Portland, Oregon–based psychiatrist named Jerald Block: “Internet addiction appears to be a common disorder that merits inclusion in DSM-V,” he wrote in the March 2008 American Journal of Psychiatry. “Negative repercussions include arguments, lying, poor achievement, social isolation, and fatigue.”
But the DSM-V board had disagreed. They said spending too long on the Internet might be considered a symptom of depression, but not a unique disorder. They agreed to mention it in DSM-V’s appendix, but everyone knew the appendix was the graveyard of mental disorders.
(I didn’t want to admit it to the Scientologists, but I was secretly in favor of Internet Addiction being classified a disorder, as I rather liked the idea of those people who had debated whether I was a shill or stupid being declared insane.)
Lady Margaret continued her list of outrageous proposed mental disorders:
“Ever had a fight with your spouse? Then you’re suffering from Relational Disorder!”
“Woo-hoo!” yelled the audience.
“Are you a bit lazy? Then you’ve got Sluggish Cognitive Tempo Disorder!”
Then there was Binge Eating Disorder, Passive-Aggressive Personality Disorder, Post-Traumatic Embitterment Disorder . . .
Many in the audience were successful local businesspeople, pillars of the community. I had the feeling that the freedom to argue with their wives and pump their horns in anger were freedoms they truly held dear.
I didn’t know what to think. There are a lot of ill people out there whose symptoms manifest themselves in odd ways. It seemed untoward for Lady Margaret—for all the anti-psychiatrists, Scientologists, or otherwise—to basically dismiss them as sane because it suited their ideology. At what point does querying diagnostic criteria tip over into mocking the unusual symptoms of people in very real distress? The CCHR had once sent around a press release castigating parents for putting their children on medication simply because they were “picking their noses”:Psychiatrists have labeled everything as a mental illness from nose picking (Rhinotillexomania) to altruism, lottery and playing with “action dolls.” They market the spurious idea that DSM disorders such as spelling and mathematics disorders and caffeine withdrawal are as legitimate as cancer and diabetes.
—JAN EASTGATE, PRESIDENT, CITIZENS COMMISSION
ON HUMAN RIGHTS INTERNATIONAL, JUNE 18, 2002
The thing was, parents weren’t putting their children on medication for picking their noses. They were putting them on medication for picking them until their facial bones were exposed.
But as Lady Margaret’s list continued, it was hard not to wonder how things had ended up this way. It really did seem that she was on to something, that complicated human behavior was increasingly getting labeled a mental disorder. How did this come to be? Did it matter? Were there consequences?
The answer to the first question—How did it come to be?—turned out to be strikingly simple. It was all because of one man in the 1970s: Robert Spitzer.
“For as long as I can remember, I’ve enjoyed classifying people.”
In a large, airy house in a leafy suburb of Princeton, New Jersey, Robert Spitzer—who is in his eighties now and suffering from Parkinson’s disease, but still very alert and charismatic—sat with his housekeeper and me, remembering his childhood camping trips to upstate New York.
“I’d sit in the tent, looking out, writing notes about the lady campers,” he said. “What I thought about each. Their attributes. Which ones I was more taken with.” He smiled. “I’ve always liked to classify things. Still do.”
His camping trips were a respite from his tense home life, the result of a “chronic psychiatric outpatient mother. She was a very unhappy lady. And she was well into psychoanalysis. She went from one analyst to another.”
And she never got better. She lived unhappy and she died unhappy. Spitzer watched this. The psychoanalysts were useless, flailing around. They did nothing for her.
He grew up to be a psychiatrist at Columbia University, his dislike of psychoanalysis remaining undimmed. And then, in 1973, an opportunity to change everything presented itself.
David Rosenhan was a psychologist from Swarthmore College, in Pennsylvania, and Princeton. Like Spitzer, he’d grown tired of the pseudoscientific, ivory-tower world of the psychoanalyst. He wanted to demonstrate that they were as useless as they were idolized, and so he devised an experiment. He co-opted seven friends, none of whom had ever had any psychiatric problems. They gave themselves pseudonyms and fake occupations and then, all at once, they traveled across America, each to a different mental hospital. As Rosenhan later wrote:They were located in five different states on the East and West coasts. Some were old and shabby, some were quite new. Some had good staff-patient ratios, others were quite understaffed. Only one was a strict private hospital. All of the others were supported by state or federal funds or, in one instance, by university funds.
At an agreed time, each of them told the duty psychiatrist that they were hearing a voice in their head that said the words “empty,” “hollow,” and “thud.” That was the only lie they would be allowed to tell. Otherwise they had to behave completely normally.
All eight were immediately diagnosed as insane and admitted into the hospitals. Seven were told they had schizophrenia; one, manic depression.
Rosenhan had expected the experiment would last a couple of days. That’s what he’d told his family: that they shouldn’t worry and he’d see them in a couple of days. The hospital didn’t let him out for two months.
In fact, they refused
to let any of the eight out, for an average of nineteen days each, even though they all acted completely normally from the moment they were admitted. When staff asked them how they were feeling, they said they were feeling fine. They were all given powerful antipsychotic drugs.
Each was told that he would have to get out by his own devices, essentially by convincing the staff that he was sane.
Simply telling the staff they were sane wasn’t going to cut it.
Once labeled schizophrenic the pseudopatient was stuck with that label.
—DAVID ROSENHAN, “ON BEING SANE IN INSANE PLACES,” 1973
There was only one way out. They had to agree with the psychiatrists that they were insane and then pretend to get better.
When Rosenhan reported the experiment, there was pandemonium. He was accused of trickery. He and his friends had faked mental illness! You can’t blame a psychiatrist for misdiagnosing someone who presented himself with fake symptoms! One mental hospital challenged Rosenhan to send some more fakes, guaranteeing they’d spot them this time. Rosenhan agreed, and after a month, the hospital proudly announced they had discovered forty-one fakes. Rosenhan then revealed he’d sent no one to the hospital.
The Rosenhan experiment was a disaster for American psychiatry. Robert Spitzer was delighted.
“It was very embarrassing,” he said to me now. “The self-esteem of psychiatry got very low as a result of it. It had never really been accepted as part of medicine because the diagnoses were so unreliable, and the Rosenhan experiment confirmed it.”
Spitzer’s respect lay instead with psychologists like Bob Hare, who eschewed psychoanalysis for something more scientific—checklists—emotionless catalogs of overt behavior. If there was only some way of bringing that kind of discipline into psychiatry.
Then he heard there was a job opening, editing the new edition of a little-known spiral-bound booklet called DSM.
“The first edition of DSM had been sixty-five pages!” Spitzer laughed. “It was mainly used for state hospitals reporting on statistics. It was of no interest to researchers at all.”
He happened to know some of the DSM people. He’d been around when gay activists had lobbied them to get the mental disorder of Homosexuality removed. Spitzer had been on the activists’ side and had brokered a deal that meant being gay was no longer a manifestation of insanity. His intervention gained him respect from everyone, and so when he expressed interest in the job editing DSM-III, it was a foregone conclusion.
“Anyway,” he said, “there was nobody vying for the job. It wasn’t regarded as a very important job.”
What nobody knew was that Spitzer had a plan—to remove, as much as he could, human judgment from psychiatry.
For the next six years, from 1974 to 1980, he held a series of DSM-III editorial meetings inside a small conference room at Columbia University. They were, by all accounts, chaos. As The New Yorker’s Alix Spiegel later reported, the psychiatrists Spitzer invited would yell over each other. The person with the loudest voice tended to get taken the most seriously. Nobody took minutes.
“Of course we didn’t take minutes,” Spitzer told me. “We barely had a typewriter.”
Someone would yell out the name of a potential new mental disorder and a checklist of its overt characteristics, there’d be a cacophony of voices in assent or dissent, and if Spitzer agreed, which he almost always did, he’d hammer it out then and there on an old typewriter, and there it would be, sealed in stone.
It seemed a foolproof plan. He would eradicate from psychiatry all that crass sleuthing around the unconscious. There’d be no more silly polemicizing. Human judgment hadn’t helped his mother. Instead it would be like science. Any psychiatrist could pick up the manual they were creating—DSM-III—and if the patient’s overt symptoms tallied with the checklist, they’d get the diagnosis.
And that’s how practically every disorder you’ve ever heard of or have been diagnosed with came to be invented, inside that chaotic conference room, under the auspices of Robert Spitzer, who was taking his inspiration from checklist pioneers like Bob Hare.
“Give me some examples,” I asked him.
“Oh . . .” He waved his arm in the air to say there were just so many. “Post-Traumatic Stress Disorder. Borderline Personality Disorder, Attention Deficit Disorder . . .”
Then there was Autism, Anorexia Nervosa, Bulimia, Panic Disorder . . . every one a brand-new disorder with its own checklist of symptoms.
Here, for instance, is part of the checklist for Bipolar Disorder from DSM-IV-TR:Criteria for Manic Episode
A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least one week.
Inflated self-esteem and grandiosity.
Decreased need for sleep (e.g., feels rested after only 3 hours of sleep).
More talkative than usual or pressure to keep talking.
Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments).
With Melancholic Features
Loss of pleasure in all, or almost all, activities.
Lack of reactivity to usually pleasurable stimuli (does not feel much better, even temporarily, when something good happens).
Excessive or inappropriate guilt.
Problems include school truancy, school failure, occupational failure, divorce, or episodic antisocial behavior.
“Were there any proposals for mental disorders you rejected?” I asked Spitzer.
He thought for a moment.
“Yes,” he finally said. “I do remember one. Atypical Child Syndrome.”
There was a short silence.
“Atypical Child Syndrome?” I said.
“The problem was when we tried to find out how to characterize it. I said, ‘What are the symptoms?’ The man proposing it replied, ‘That’s hard to say because the children are very atypical.’ ” He paused. “And we were going to include Masochistic Personality Disorder, but there were a bunch of feminists who were violently opposed.”
“Why?”
“They thought it was labeling the victim.”
“What happened to it?”
“We changed the name to Self-Defeating Personality Disorder and put it into the appendix.”
I’d always wondered why there had been no mention of psychopaths in the DSM. It turned out, Spitzer told me, that there had indeed been a backstage schism—between Bob Hare and a sociologist named Lee Robins. She believed clinicians couldn’t reliably measure personality traits like empathy. She proposed dropping them from the DSM checklist and going only for overt symptoms. Bob vehemently disagreed, the DSM committee sided with Lee Robins, and Psychopathy was abandoned for Antisocial Personality Disorder.
“Robert Hare is probably quite annoyed with us,” Spitzer said.
“I think so,” I said. “I think he feels you plagiarized his criteria without crediting him.”
(I later heard that Bob Hare might get his credit after all. A member of the DSM-V steering committee, David Shaffer, told me they were thinking of changing the name of Antisocial Personality Disorder—it sounds so damning—and someone suggested calling it Hare Syndrome. They’re mulling it over.)
In 1980, after six years inside Columbia, Spitzer felt ready to publish. But first he wanted to road test his new checklists. And there were a lot. DSM-I had been a sixty-five-page booklet. DSM-II was a little longer—134 pages. But DSM-III, Spitzer’s DSM, was coming in at 494 pages. He turned the checklists into interview questionnaires and sent researchers out into America to ask hundreds of thousands of people at random how they felt.
It turned out that almost all of them felt terrible. And according to the new checklists, more than 50 percent of them were suffering from a mental disorder.
DSM-III was a sensation. Along with its revised edition, it sold more than a million copies. Sales to civilians hugely outweighe
d sales to professionals. Many more copies were sold than psychiatrists existed. All over the western world people began using the checklists to diagnose themselves. For many of them it was a godsend. Something was categorically wrong with them and finally their suffering had a name. It was truly a revolution in psychiatry, and a gold rush for drug companies, who suddenly had hundreds of new disorders they could invent medications for, millions of new patients they could treat.
“The pharmaceuticals were delighted with DSM,” Spitzer told me, and this in turn delighted him: “I love to hear examples of parents who say, ‘It was impossible to live with him until we gave him medication and then it was night and day.’ That’s good news for a DSM person.”
But then something began to go wrong.
Gary Maier—the psychiatrist who invented the dream workshops and the chanting rituals at Oak Ridge and was eventually fired for giving LSD to twenty-six psychopaths simultaneously—was recently invited for lunch by some drug company reps. He works at two maximum-security prisons in Madison, Wisconsin, now and his department had just made the decision to have nothing more to do with the drug companies. So a few of the reps invited him for lunch to find out why.
“It was two beautiful women and a pretty nice guy,” Gary told me after the lunch was over.
“What did they say?” I asked him.
“Well, if you look for me on the Internet, you’ll find essays I’ve written about Indian effigy mounds,” he replied. “They’re my hobby. So the two beautiful women spent most of the lunch asking me about effigy mounds. They had me drawing pictures of effigies on the tablecloth.”