Gary Greenberg’s The Book of Woe is an insightful critique of how we understand mental illness.
The Book of Woe is an insightful, often funny and sometimes moving account of the travails of psychiatry. The focus of the book is another book, one which is rather less funny and moving – the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association since 1952. The Book of Woe focuses on this year’s latest (fifth) edition of the DSM, but usefully, it also provides a longer historical perspective.
Author Gary Greenberg charts the tensions that have surrounded the status of psychiatry since the days of Sigmund Freud and Emil Kraepelin, who came to represent contrasting traditions of psychoanalysis and scientific psychiatry respectively. Psychiatry has repeatedly and ever more fervently sought to repudiate the Freudian tradition as unscientific (Greenberg argues that the tradition survives most stubbornly in the DSM’s section on personality disorders), but this has proved insufficient to enable psychiatry to satisfy either itself or others that it is indeed a scientific enterprise.
Greenberg himself is no psychiatrist, but rather an experienced psychotherapist – ‘a mental-health professional who has been faithfully filling out insurance forms for 30 years, jotting down those five-digit codes from the DSM that open the money taps’ – as well as a noted author and journalist in this area. His first encounter with the vagaries of psychiatric diagnosis came when he was in his early 20s, and his family became concerned about his habit of isolating himself for long periods in a remote cabin with no modern amenities. Expert advice was sought, and he was bemused to find himself diagnosed with ‘adjustment disorder’, rather than (to give his imaginary alternatives) ‘back to the land disorder’ or ‘why don’t you grow up already disorder’.
There is an inevitable contingency about diagnostic categories, particularly when it comes to psychiatry. Greenberg argues that for all the useful work that goes into constructing these categories, psychiatric diagnosis has a ‘self-validating nature…by which once you’ve created a diagnostic category, the fact that people fit into it becomes evidence that the disorder exists’. Greenberg reminds us that ‘while many diagnoses are made on clinical signs and symptoms rather than on lab tests or other external validators, only in psychiatry are all diagnoses made that way’.
It’s worth adding that this may be changing. As psychiatry seeks to predicate itself more and more upon genetics and neuroscience, there are expectations in some circles that biochemical diagnostic tests for psychiatric disorders will follow ineluctably. This prospect does not reassure me. Psychiatry is attempting the difficult feat of relocating its foundations without toppling its façade, and this involves elisions – several of which are discussed by Greenberg – that leave me feeling less persuaded of the profession’s credentials, not more.
One way of understanding the recent history of psychiatry and the DSM is as a series of competing strategies for concealing, denying, evading, reducing or transcending contingency. In a different world – one that had a surer grasp of historical and social dynamics – I’d like to think that contingency could be more openly acknowledged and embraced by psychiatry, without this necessarily undermining all of its credibility or ambitions. But in our world, contingency is experienced as an embarrassment to psychiatry. Behind the vexed process of revising the DSM for each of its editions lies the disquieting possibility that (as Greenberg puts it) ‘doctors…might be no more reliable at judging whether a person needs psychiatric treatment than barbers are at judging whether a person needs a haircut’.
The leaders of the psychiatric profession are certainly in no mood to countenance this possibility. Greenberg quotes a recent claim by the psychiatric researcher Darrel Regier, vice chair of the team that created the fifth edition of the DSM, that ‘psychiatric disorders have existed since the beginning of recorded history’. This is a strikingly ahistorical thing to say, and could only have been said by someone convinced (or, if one wants to indulge in armchair psychoanalysis, seeking to convince both himself and us) that psychiatry can somehow transcend altogether the history of the humans whose minds it purports to understand. Presumably, it can do this by means of genetics, neuroscience and other natural scientific disciplines. I’m not convinced, and neither is Greenberg.
That said, one can certainly appreciate the need for psychiatry to appear coherent and confident, given the far-reaching consequences of the DSM’s contents. Greenberg explains, for example, how the use of a single ‘and’ where an ‘or’ might have been used, in the definition of ‘paedophilia’ that made its way into the fourth edition, inadvertently made it far easier for US authorities to detain indefinitely (on psychiatric grounds) people who had been convicted of sexual offences against minors. In other words, a single use of the word ‘and’ in the DSM led to a complex domain of morality and law – the culpability (or otherwise) of people charged with sexual offences in various circumstances, and proportionate sentencing for their crimes – becoming subordinate to the considerations of psychiatry.
This fascinating and disturbing fact emerges during the course of Greenberg’s dealings with the psychiatrist Allen Frances. Frances chaired the team that developed the fourth edition of the DSM, and has latterly been one of the most outspoken critics of the development of the fifth edition. Greenberg also meets Robert Spitzer, chair of the team that developed the third edition, who has been similarly critical of the development of the fifth. One could put these criticisms by the most eminent psychiatrists of yesteryear down to sour grapes, and indeed representatives of the American Psychiatric Association have attempted damage limitation by doing precisely that. But as Greenberg documents the friendship he formed with Frances in the course of writing his book, it becomes clear that there’s a lot more to psychiatry’s bitter internecine feuds.
Greenberg’s precarious friendship with Frances forms the narrative backbone of The Book of Woe, as the formidable psychiatrist launches public broadside after public broadside against those faced with the unenviable task of revising the work he once oversaw. The relationship between Greenberg and Frances eventually becomes strained, however, as it emerges that while both of them are highly critical of the creation of the new DSM, their criticisms come from different perspectives that are difficult to reconcile. As I followed Greenberg’s account of their friendship, I found that my own views about psychiatry seemed to be embodied in both of their perspectives, with my uncertainties manifest in the disagreements between them.
Initially, I found myself siding more with Frances than Greenberg – mainly because, of the two of them, he seemed to have the better grasp of psychiatry’s contingency. Greenberg sums up Frances’ position as being that ‘psychiatry…has to live in the tension between the desire for certainty about the nature of our suffering and the impossibility of understanding it (or ourselves) completely’. This leads to the view that ‘to criticise…psychiatry itself because it can’t achieve certainty was to erect a straw man and then burn it – and to endanger the good the profession could do’.
This position sounds very reasonable to me. Indeed, it’s not far removed from arguments I’ve had occasion to make myself.
Ultimately, however, and with several caveats, my sympathy for Greenberg’s side of the argument came to prevail over my sympathy for the views of Frances. Greenberg’s most devastating critique of Frances is that the latter’s position involves an unconscionable degree of bad faith – at one point, Frances argues (drawing upon Plato’s Republic) that psychiatry’s claims are a ‘noble lie’ that must be upheld. Greenberg detects – diagnoses, even – an element here not just of nuance but of insecurity, a reluctance ‘to let the rest of us in on what psychiatrists already know: that there is no fixed principle for their revelations’.
Greenberg doesn’t like being condescended or lied to. He refers sardonically to ‘lunchbucket therapists like me who…may not be sophisticated enough to grasp the nobility of the lie that sustains the DSM or to be trusted as its keepers’. To his credit, he doesn’t like condescending or lying to others either. He therefore refuses to couch his criticisms of psychiatry in terms that will assure the lay public of the profession’s fundamental validity, and this refusal finally puts paid to his friendship with Frances.
Whatever the merits and demerits of psychiatry, and however one couches one’s criticisms of it, the question remains of how to account for the relentless expansion of its influence. After all, as Greenberg points out, if the DSM were any other specialist medical tome ‘then it might live in the same dusty obscurity as, say, Interventional Radiology in Women’s Health or Consensus in Clinical Nutrition’. Furthermore, it’s worth reiterating that we live in a time when one of the leading figures behind the most recent edition of the DSM can make the risible claim, with a straight face, that the profession concerns itself with disorders that ‘have existed since the beginning of recorded history’.
Confronted with the question of how and why psychiatry has come to assume its contemporary role, the two explanations Greenberg tends to fall back upon are the overweening disease-mongering of the psychiatric profession and the malign influence of commerce (in particular, the machinations of the pharmaceutical and insurance industries). These factors are certainly significant, but in my view, they do not suffice as an explanation. For this, we need to examine social developments more broadly.
One condition where Greenberg is forced to concede this is Asperger’s syndrome. This disorder is (arguably) related to and yet distinct from autism (disclosure: I myself was diagnosed with Asperger’s in my teens), and was first granted its own categorical status in the fourth edition of the DSM, only to then be controversially subsumed within the category of ‘autism spectrum disorder’ in the fifth. Marvelling at the rapid increase in the syndrome’s prevalence and prominence, and conceding that neither developments within psychiatry nor any commercial intrigue can account entirely for this rise, Greenberg – a sucker for a baseball metaphor, hence presumably the allusion to the film Field of Dreams – says ‘they had built a diagnosis, and the patients had come’.
For reasons I explore elsewhere on spiked, I think the recent popularity of Asperger’s syndrome – both in terms of the disorder’s apparently high prevalence, and in terms of the way that people with the diagnosis and/or associated characteristics are now lauded – speaks to important broader dynamics. These developments also have profounder ramifications for Greenberg’s critique than he seems to realise. He does touch upon this when he observes astutely that in the 1970s campaigners lobbied furiously for conditions (most notably homosexuality) to be removed from the DSM, whereas latterly campaigners have lobbied furiously for conditions (most notably Asperger’s syndrome and gender-identity disorder) to remain in the DSM. Had Greenberg developed this observation further, I believe he might have cast even more light upon the reasons for psychiatry’s latter-day ascendancy.
‘Once you start to think of your troubles as a disease, your idea of yourself, which is to say who you are, changes’, warns Greenberg. But while psychiatry gives a diagnostic imprimatur to our expectations of ourselves and of one another, psychiatry is not solely capable of bringing about a wholesale alteration of these expectations. To understand what else might account for a psychiatric turn in society, one needs to recognise that we live in a culture in which our adult capacities are constantly denigrated, in which victimhood has become one of the few widely recognised sources of authority, and in which we are constantly encouraged from all directions not only to put our problems on public display (rather than addressing them within the intimate confines of trusted friends, family or – in extremis – psychotherapists or even psychiatrists), but also to assume that our problems will most likely afflict us in perpetuity.
It’s not so much the case that psychiatry now seeks to colonise everyday life – rather, everyday life now invites colonisation by psychiatry. In circumstances such as these, even the most well-meaning and scrupulous psychiatrist might struggle to parse the suffering and idiosyncrasy they encounter, so as to partition it sensibly into the pathological and the normal. Greenberg’s barbs against psychiatry may be well deserved, and are certainly grounded in tantalising insider detail and no small amount of wit. But they represent an incomplete picture of the dynamics he sets out to get to grips with, which lie outside the institution of psychiatry as much as they lie within.
Greenberg at least grasps the crucial point that ‘the line between sickness and health, mental and physical…can’t be drawn without deciding how a human life is supposed to go, how it ought to feel, and what it is for – questions for which science, no matter how robust, is no match’. Unspoken and foreclosed answers to these questions, in the form of received wisdom, are very much entangled within contemporary psychiatry. The danger we now face is that a rapid accretion of natural scientific detail, which psychiatry is earnestly building around itself in order to assure us of the grounds for its authority, doesn’t mitigate this unscientific received wisdom – instead, it buries assumptions in places where we will be harder pressed to perceive and contest them.
A full-frontal assault on the institution of psychiatry may or may not be a productive course of action at the present time. After reading The Book of Woe, I have the uncanny sensation (thankfully not with sufficient verisimilitude to meet the clinical definition of a hallucination) that Allen Frances and Gary Greenberg are sitting on my shoulders, trying to persuade me either way. I am, however, certain of one thing. The least we can do, following Greenberg’s lead, is refuse to be deterred by psychiatry’s presumed scientific authority, and disinter the political and philosophical questions that lie obscured beneath the DSM’s thousand-odd pages. These questions shouldn’t (and moreover, can’t) be settled by psychiatry – the task of answering them belongs to all of us.
Sandy Starr is communications officer at the Progress Educational Trust, and a member of the Ethics Advisory Board of the research project European Autism Interventions: A Multicentre Study for Developing New Medications.
The Book of Woe: The DSM and the Unmaking of Psychiatry, by Gary Greenberg, is published by Scribe. (Buy this book from Amazon (UK).)