Shrinks (12 page)

Yet even this aspirational decree was still not sufficient for the ambition of the psychoanalysts. The movement believed that Freud’s theory was so profound that it could solve the political and social problems of the time. A group of psychoanalysts led by William Menninger formed the Group for the Advancement of Psychiatry (GAP), which in 1950 issued a report entitled “The Social Responsibility of Psychiatry: A Statement of Orientation,” advocating social activism against war, poverty, and racism. Although these goals were laudable, psychiatry’s faith in its power to achieve them was quixotic. Nevertheless, the report helped persuade the APA to shift its focus toward the resolution of significant social problems and even helped shape the agenda of the largest federal institution devoted to mental illness research.

On April 15, 1949, Harry Truman formally established the National Institute of Mental Health (NIMH) and appointed Robert Felix, a practicing psychoanalyst, as its first director. In the psychoanalytically decreed spirit of social activism, Felix announced that early psychiatric intervention in a community setting using psychoanalysis could prevent mild mental illnesses from becoming incurable psychoses. Felix explicitly forbade NIMH expenditures on mental institutions and refused to fund biological research, including research on the brain, since he believed that the future of psychiatry lay in community activism and social engineering. The energetic and charismatic Felix was adept at organizational politics, and persuaded Congress and philanthropic agencies that mental illness could only be prevented if the stressors of racism, poverty, and ignorance were eliminated. From 1949 to 1964, the message coming out of the largest research institution in American psychiatry was
not:
“We will find answers to mental illness in the brain.” The message was: “If we improve society, then we can eradicate mental illness.”

Inspired by the urgings of GAP and NIMH, psychoanalysts pressured their professional organizations to take a stand against U.S. involvement in Vietnam and school segregation; they “marched with Martin Luther King on psychiatric grounds.” The psychoanalysts didn’t just want to save your soul; they wanted to save the world.

By the 1960s, the psychoanalytic movement had assumed the trappings of a religion. Its leading practitioners suggested that we were all neurotic sinners, but that repentance and forgiveness could be found on the psychoanalytical couch. The words of Jesus might have been attributed to Freud himself: “I am the way, and the truth, and the life; no one comes to the Father but through Me.” Psychoanalysts were consulted by government agencies and Congress, were profiled by
Time
and
Life
, and became frequent guests on talk shows. Being “shrunk” had become the ne plus ultra of upper-middle-class American life.

Galvanized by psychoanalysis, psychiatry had completed its long march from rural asylums to Main Street and had completed its evolution from alienists to analysts to activists. Yet despite all the hype, little was or could be done to alleviate the symptoms and suffering of people living with the day-to-day chaos of severe mental illness. Schizophrenics weren’t getting better. Manic-depressives weren’t getting better. Anxious, autistic, obsessive, and suicidal individuals weren’t getting better. For all of its prodigious claims, psychiatry’s results fell far short of its promises. What good was psychiatry if it couldn’t help those who were most in need?

The rest of medicine was fully aware of psychiatry’s impotence and its closed-off, self-referential universe. Physicians from other disciplines looked upon psychiatrists with attitudes ranging from bemusement to open derision. Psychiatry was widely perceived as a haven for ne’er-do-wells, hucksters, and troubled students with their own mental issues, a perception not limited to medical professionals. Vladimir Nabokov summed up the attitude of many skeptics when he wrote, “Let the credulous and the vulgar continue to believe that all mental woes can be cured by a daily application of old Greek myths to their private parts.”

As psychoanalysis approached its zenith in the late 1950s, psychiatry was careening off course, as oblivious to danger as an intoxicated driver asleep at the wheel. In retrospect, it is easy to see why American psychiatry veered so wildly astray: It was guided by a mangled map of mental illness.

Chapter 3

What Is Mental Illness?: A Farrago of Diagnoses

The statistics on sanity are that one out of every four Americans is suffering from some form of mental illness. Think of your three best friends. If they’re okay, then it’s you.

—R
ITA
M
AE
B
ROWN

To define illness and health is an almost impossible task. We can define mental illness as being a certain state of existence which is uncomfortable to someone. The suffering may be in the afflicted person or those around him or both.

—P
SYCHOANALYST
K
ARL
M
ENNINGER
,
T
HE
V
ITAL
B
ALANCE
: T
HE
L
IFE
P
ROCESS IN
M
ENTAL
H
EALTH AND
I
LLNESS

The Most Important Three Letters in Psychiatry

If you have ever visited a mental health professional you have probably come across the letters D, S, and M, an acronym for the archaically titled
Diagnostic and Statistical Manual of Mental Disorders
. This authoritative compendium of all known mental illnesses is known as the Bible of Psychiatry, and for good reason—each and every hallowed diagnosis of psychiatry is inscribed within its pages. What you may not realize is that the
DSM
might just be the most influential book written in the past century.

Its contents directly affect how tens of millions of people work, learn, and live—and whether they go to jail. It serves as a career manual for millions of mental health professionals including psychiatrists, psychologists, social workers, and psychiatric nurses. It dictates the payment of hundreds of billions of dollars to hospitals, physicians, pharmacies, and laboratories by Medicare, Medicaid, and private insurance companies. Applications for academic research funding are granted or denied depending on their use of the manual’s diagnostic criteria, and it stimulates (or stifles) tens of billions of dollars’ worth of pharmaceutical research and development. Thousands of programs in hospitals, clinics, offices, schools, colleges, prisons, nursing homes, and community centers depend upon its classifications. The
DSM
mandates the accommodations that must be made by employers for mentally disabled workers, and defines workers’ compensation claims for mental illnesses. Lawyers, judges, and prison officials use the manual to determine criminal responsibility and tort damages in legal proceedings. Parents can obtain free educational services for their child or special classroom privileges if they claim one of its pediatric diagnoses.

But the
Manual
’s greatest impact is on the lives of tens of millions of men and women who long for relief from the anguish of mental disorder, since first and foremost, the book precisely defines every known mental illness. It is these detailed definitions that empower the
DSM
’s unparalleled medical influence over society.

So how did we get here? How did we go from the psychoanalytical definitions of schizophrenogenic mothers and unconscious neuroses to
DSM
diagnoses ranging from Schizoaffective Disorder, Depressive Type (code 295.70) to Trichotillomania, hair-pulling disorder (code 312.39)? And how can we be confident that our twenty-first-century definitions of mental illness are any better than those inspired by Freud? As we shall see, the stories of psychoanalysis and the
DSM
ran parallel for almost a century before colliding in a tectonic battle for the very soul of psychiatry, a battle waged over the definition of mental illness.

We can trace the primordial origins of the Bible of Psychiatry back to 1840, the first year that the American Census Bureau collected official data on mental illness. The United States was barely fifty years old. Mesmer was not long dead, Freud was not yet born, and virtually every American psychiatrist was an alienist. The United States was obsessed with the statistical enumeration of its citizens through a Constitution-mandated once-a-decade census. The 1830 Census counted disabilities for the first time, though limiting the definition of disability to deafness and blindness. The 1840 Census added a new disability—mental illness—which was tabulated by means of a single checkbox labeled “insane and idiotic.”

All the myriad mental and developmental disorders were lumped together within this broad category, and no instructions were provided to the U.S. Marshals tasked with collecting census data for determining whether a citizen should have her “insane and idiotic” box checked off. Based on the prevailing ideas at the time, the census makers probably considered “insanity” to be any mental disturbance severe enough to warrant institutionalization, encompassing what we would now consider schizophrenia, bipolar disorder, depression, and dementia. Similarly, “idiocy” likely referred to any reduced level of intellectual function, which today we would subdivide into Down syndrome, autism, Fragile X syndrome, cretinism, and other conditions. But without any clear guidance, each marshal ended up with his own idiosyncratic notion of what constituted a mental disability—notions that were often influenced by outright racism.

“The most glaring and remarkable errors are found in the Census statements respecting the prevalence of insanity, blindness, deafness, and dumbness, among the people of this nation,” the American Statistical Association informed the House of Representatives in 1843, in perhaps the earliest example of a civil protest against excessive labeling of mental illness. “In many towns, all the colored population are stated to be insane; in very many others, two-thirds, one-third, one-fourth or one-tenth of this ill-starred race are reported to be thus afflicted. Moreover, the errors of the census are just as certain in regard to insanity among the whites.” Even more troubling was the fact that the results of this census were used to defend slavery: Since the reported rates of insanity and idiocy among African Americans in the Northern states were much higher than in the Southern states, advocates of slavery argued that slavery had mental health benefits.

Amazingly, the same elementary separation of mental conditions into insanity and idiocy remains to this day in our modern institutions. As I write this, every state has a separate administrative infrastructure for mental illness and for developmental disability, despite the fact that each of these conditions affects similar brain structures and mental functions. This somewhat arbitrary division reflects historic and cultural influences on our perception of these conditions rather than any scientifically justified reality. A similarly artificial categorization has resulted in services for substance-use disorders often being administered by a separate government agency and infrastructure, even though addiction disorders are treated by medical science no differently than any other illness.

By the twentieth century, the census had begun to focus attention on gathering statistics on inmates in mental institutions, since it was believed that most of the mentally ill could be found there. But every institution had its own system for categorizing patients, so statistics on mental illness remained highly inconsistent and deeply subjective. In response to this cacophony of classification systems, in 1917 the American Medico-Psychological Association (the forerunner of the American Psychiatric Association) charged its Committee on Statistics with establishing a uniform system for collecting and reporting data from all the mental institutions of America.

The committee, which was comprised of practicing alienists rather than researchers or theorists, relied on their clinical consensus to categorize mental illness into twenty-two “groups,” such as “psychosis with brain tumor,” “psychosis from syphilis,” and “psychosis from senility.” The resulting system was published as a slender volume titled
The Statistical Manual for the Use of Institutions for the Insane
, though psychiatrists quickly took to calling it the
Standard
.

For the next three decades, the
Standard
became the most widely used compendium of mental illnesses in the United States, though its sole purpose was to gather statistics on patients in asylums; the
Standard
was not intended (or used) for the diagnosis of outpatients in psychiatrists’ offices. The
Standard
was the direct forerunner to the
Diagnostic and Statistical Manual of Mental Illness
, which would eventually lift the phrase “Statistical Manual” from the
Standard
, a phrase that had in turn been borrowed from the language of nineteenth-century census-taking.