The DSM 5 controversy: readings and related criticisms of the mental health profession

The two biggest critics of the DSM 5 are Allen Frances, former lead psychiatrist for the DSM-IV, and Gary Greenberg, psychotherapist and author of The Book of Woe: the DSM and the Unmaking of Psychiatry. Frances wants to save the psychiatric profession from the particular problems of the DSM 5; Greenberg is skeptical of the scientific validity of the entire profession.

I’ve learned from some folks in the industry that insurance companies are about to move over to the ICD-10. But others mental health professionals I know think the DSM-5 problems were merely the worst and most obvious, and that corruption and bad practices are endemic.

Here’s some further reading on the controversy, and some related issues from critics and questioners of the mental health industry

Allen Frances

Allen Frances has been writing furiously in criticism of the DSM 5 since he resigned from the DSM task force. His view is that the DSM 5 is a particular problem, but that something like it is absolutely vital to psychiatry as a profession and as a long-term research project.

DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes summarizes Frances’ criticisms, including the expansion of “Major Depressive Disorder” to include normal grieving for the death of a loved one, diagnosing excessive eating 12 times in 3 months as a new “Binge Eating Disorder,” and creating a new set of loosely defined “Behavioral Addictions”.

He also thinks that Attention Deficit Disorder Is Over-Diagnosed and Over-Treated – he ties the tripling of ADD diagnosis rates to the deregulation of the FDA, and increased legality of pharmaceutical advertising.

He sums up his views in this NY Times op-ed: “D.S.M.-5 promises to be a disaster — even after the changes approved this week, it will introduce many new and unproven diagnoses that will medicalize normality and result in a glut of unnecessary and harmful drug prescription…. Many critics assume unfairly that D.S.M.-5 is shilling for drug companies. This is not true. The mistakes are rather the result of an intellectual conflict of interest; experts always overvalue their pet area and want to expand its purview, until the point that everyday problems come to be mislabeled as mental disorders. Arrogance, secretiveness, passive governance and administrative disorganization have also played a role…”

Gary Greenberg

Gary Greenberg’s opus, The Book of Woe, is generally considered the most intimate and carefully researched criticism of the DSM-5. It’s a terrifying, meticulous hit-job, based on two years of interviews and research, that paints a portrait of the DSM-5 team as a desperate, scientifically shoddy, financially corrupted grab for authority and money. He’s more skeptical of scientific validity of the entire profession.

Inside the Battle to Define Mental Illness | WIRED is the 2010 article that would eventually become The Book of Woe

Some reviews: Gary Greenberg ‘The Book of Woe’ Reviewed by Martha … is particularly good. Book of Woe: The DSM and the Unmaking of Psychiatry by … gives a breezy overview of the whole scene. “The Book of Woe”: Psychiatry’s last stand takes a more scandals-and-payoffs overview of the whole scene.

More on the DSM 5

Lisa Cosgrove summarizes her team’s findings about conflict of interest in the DSM-5 task force, published in the New England Journal of Medicine: 70% of the task force has financial ties to the pharmaceutical industry, up from 20% in the DSM-IV. And: the DSM has entirely inadequate reporting of known side-effects from pharmaceuticals, even life-threatening ones.

Ian Hacking is one of the sharpest philosophers of science. Though frequently skeptical of arguments that scientific concepts are socially constructed, he’s also a critic of the DSM 5. Lost in the Forest is his review of the DSM 5. But it grows out of Kinds of People – his very subtle treatment of how classifying people changes the people classified.

Other interesting material

Marcia Angell has an extraordinary set of reviews overviewing some of the recent literature critical of the psychiatric and pharmaceutical industry.

There’s a lot of really interesting research about the effects of labeling somebody as mentally ill, or as having a chemical imbalance:

The role of biological and genetic casual beliefs in the stigmatization of ‘mental patients’ is a fascinating study that shows that ascribing biological causes, rather than psychological causes, to a patient’s mental illness creates, in others, decreased blame for the patient, but increases the others’ beliefs that the patient is unpredictable, dangerous, antisocial, and decreases the willingness to become romantically involved with the patient.

The Rosenhan Study, from 1973, is a terrifying study, in which non-psychiatric psuedopatients were inserted into mental institutions. They made a single statement of abnormal mental behavior at admission, and then reverted to normal behavior. The institutions were unable to detect any change in their behavior, and continued to believe the patients to be schizophrenic. The psuedopatients report the experience as alienating and dehumanizing. Rosenhan writes: “A psychiatric label has a life and an influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be schizophrenic… Such labels, conferred by mental health professionals, are as influential on the patient as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy.”

Ray Moynihan is an academic and journalist who specializes in medical overdiagnosis.

Special thanks to Elle Hipol for helping me assemble much of this material.

The philosophy writing workshop sequence

Most undergraduates who come into my classroom seem to have no idea what it’s like to work on a paper with other human beings, or work on a paper in stages. They just sort of crap out a paper in one long go and throw it at you, starting with an empty screen and making it up as they went along. So I started forcing them to do what most serious writers do: write down their ideas at every stage, show them to other human beings, and get feedback. I tried to gather as many of the different methodologies I knew about for paper-writing, and turn them into a set of exercises. I’ve been fine-tuning it for about eight years.

The biggest thing is to break apart writing into a conceptual stage, and a communication stage. I mean doing an outline first, settling what you want to say, and then starting to actually write prose only after most of the conceptual work is settled. Most students, I think, start writing by opening up their word-processor, with no idea of where they’re going, and just start writing.  (I polled a class of thirty philosophy majors once about how many did at outline first, or anything like that, before starting to put prose to page. The answer: one.) I emphasize that separating the stages makes it easier: you don’t have to worry about communication when you’re figuring out your arguments, and when you’re writing, you can focus on the task of clearly presenting your ideas.

Most importantly, this introduces a low-cost stage where students are willing to change and revise their ideas.  I used to comment on rough drafts, but my students were almost never do any deep surgery when they’d already written a draft. It’s just too easy to get too attached to your own prose, and the sunk effort. But if you get the criticism in at the outline level, it’s so much emotionally easier to pivot. The moment I started doing outline-level work, the quality of argument in the final papers took a major jump up.

Students often hate it at first. And then they love it. Usually, they get frustrated and ego-wrecked for the first few sections. By the end of the term they’ve come to terms with it. And then so many of them come back to me in a year or two and tell me that they think this is how they actually learned to write, that they’ve been using this style of thing forever paper since, that this workshop sequence was one of the most valuable things they’d gone through.

There are many variations. Below is how I run it in a standard upper-division philosophy class. It’s designed for maximum impact for minimum in-class time expenditure. Here’s how it goes:

First Paper Outline Workshop

Students write a one to two page outline of their future paper, based on several provided essay prompts. It helps to be very explicit about the fact that I’m asking them to separate the conceptual stage from the communication stage. When they’re thinking about their arguments, they only think about their arguments. And by the time they’re actually writing a paper, they’re supposed to already know what they want to say, and only have to worry about how they’re going to say it. I say, for the outline, to not worry at all about reading clarity, and just to worry about their arguments.

They come into class with copies of their outline. I break them into groups of four or five. Each students takes about twenty minutes to stand up in front of their group, and present their thoughts. I tell them to do it in two stages: first stage, present the argument, where the audience only asks clarificatory questions. Second stage: the audience raises challenges, look for gaps in the argument. I emphasize that the goal in the second stage not to be antagonistic, or to crush the presenter, but to help them locate weaknesses in the paper, and to think together about how the paper might be improved. The goal is for each student to use their fellow students to locate weaknesses in their paper, so that they might be improved. And, more importantly, to figure out which criticisms are deepest and will lead to the most interesting dialogue

I also tell the students not to be too attached to where they originally thought their paper was going. It’s easy for students to get broken-hearted if their original line of argument seems to fall apart. But if you tell them that the goal of this session is not to defend their original argument, but to search for the most interesting version of their paper possible – if you tell them it’s OK to modulate, or restrict, or even switch directions for their conclusion – things go a lot better.

I give them colored markers and white-board space and usually make them sketch out their arguments in some sort of logical flow-chart. Usually, students resist doing this at first, but it seems to really help a lot of the groups talk about the structure of the argument.

I usually give them about 1.5 to 2 weeks to generate a final paper from this workshop.

Second Paper Outline Workshop

The second paper outline workshop is much like the first, but I provide no essay prompts. Typically, students struggle with choosing topics of appropriate size. Thus, the second paper outline workshop often forces students to focus their topic, refine their thesis, and clarify their direction of argument.

It’s really important here that students have a sense of ownership over their ideas. Having to present an original idea in front of their peers seems to force students towards coherency, and towards actually thinking about the motivations for taking on a particular topic. Without this, papers often have an automatic quality, as if the students are simply filling out a template passed down from on high. There’s a sense I often have that students have been taught this thing, this essay form that they plug through, which is completely disconnected from any sense of communication. But by doing peer presentations of their own ideas, the students suddenly seem to start viewing themselves as actually communicating, and their natural sense of clarity and order emerges.

Second Paper Draft Workshop

A week after the second paper outline workshop, the students bring a draft of the paper into class. I break them into groups of four or five, and circulate their papers, reading and commenting on them. I tell them that, though they’re free to raise criticisms, the primary goal of this session is to focus on writing clarity. I tell the students that they are not editors today – they don’t need to provide fixes. They are simply reporting their reading experience. They’ll write down where they become confused, what words they don’t understand, what questions they had, where they got lost about the structure. I say: “It’s often so hard to see your own writing, because you often don’t actually see what you put on the page – you just fill in what you wanted to say, from your own head. But a lot of times, the most important thing is so obvious to you that you don’t put it on the page. So now, as a reader, your job is to communicate to the writer what the experience of reading was like for you, where you stumbled or got lost, so the writer knows what got through into the writing, and what was left out.”

I have a theory here that most important thing here is being on the reading end of this exercise. Of course, getting feedback is great. But having to trudge through all these other students’ papers for an hour or more is the heart of it. They see: how easy it is to get lost, how important structural transitions are. They see how, over and over again, little tiny vaguenesses in grammar or simple pronoun ambiguity accumulate and destroy communication. They see how hard it is to understand argumentative material when it is anything less than absolutely lucid. And usually, in a batch of papers, there’s one or two that are much more clearly written, and it suddenly becomes clear to them how much work the little transitional and structural details are doing, to help the reader.

They usually end up in a state of misery and nausea, and a lot of the times what I hear is, “How the hell do YOU manage to read papers like this without shooting yourself?” And then they get their own papers back, covered with marks from their peers about the very same problems – the ambiguities, the confusions. And it’s so much easier to understand what’s missing in their paper when they’ve just been in the confused-reader role on their peers’ papers.

Peer-commentary is also, I think, more emotionally convincing. A lot of students are, I think, ready to dismiss their professor’s comments as coming from some weird, nit-picky, ivory-tower sort of place, but willing to accept their peers’ comments about unclarity or incomprehensibility.

The final drafts I get after this work are so, so, so much clearer.

Feel free to use these ideas in your own class. One request: if you do, let me know how it goes, and let me know any tweaks or improvements you come up with.