a hard lesson…

Posted on Sunday 27 May 2012

Spitzer Recants: Why Can’t APA Admit Mistakes and Correct Them
Huffington Post
by Allen Frances

Ben Carey’s front page story in the New York Times movingly recounts Bob Spitzer’s apology for an ill-advised study he conducted more than a decade ago. The background is dramatic. Spitzer had been a hero to the gay and lesbian community because he was the person most responsible for removing homosexuality from DSM II. Lifting the cloud of mental disorder from sexual choice was a big step in the civil rights movement that only now is bringing full equality. I once attended an award dinner honoring Bob for his contributions to the gay/lesbian cause. I never saw a group more appreciative or a recipient so proud. How surprising then that Spitzer would later publish a methodologically flawed paper suggesting that psychotherapy might have some value in changing sexual orientation. Bob had serious misgivings almost immediately when fundamentalists exploited the paper to pursue their anachronistic agenda. He decided recently to make a very public apology. "I believe I owe the gay community an apology for my study making unproven claims of the efficacy of reparative therapy. I also apologize to any gay person who wasted time and energy undergoing some form of reparative therapy because they believed that I had proven that reparative therapy works with some `highly motivated’ individuals."

Let’s compare Bob’s forthrightness to the consistently evasive stonewalling that has characterized every step in the development of DSM 5. The American Psychiatric Association has a lot to apologize for — but instead maintains a doggedly defensive posture that prevents insight and self correction. Bob was the first to point out the absurdity of the DSM 5 confidentiality agreements and to predict the poor results that would come from the resulting secretive and closed process. Each of his dire predictions has turned out to be right on target. DSM 5 badly missed every one of its deadlines — then with time running short, it quietly cancelled its quality control step because publishing profits trumped the public trust of producing a safe product. No apology for that.

When its field trial results were unacceptably low by historical standards, DSM 5 lowered its standards rather than working to improve its product to meet them. Again no apology. DSM 5 persists in offering proposals that would inappropriately inflict the label mental disorder on many millions of people now considered normal. These suggestions are unsupported by science and are strongly opposed by 51 mental health associations — but APA continues to refuse demands for independent external review. The shabby DSM 5 enterprise has reduced the credibility of psychiatry and the stature of the APA. It may well have forfeited APA’s right to continue as custodian of the DSM franchise. Yes, indeed, APA has a lot to apologize for and DSM 5 has a long way to go before it will be safe and scientifically sound…

And Bob Spitzer has shown the way. A clear parallel can be drawn between Bob’s openly apologizing and withdrawing his paper and the need for APA to apologize and to withdraw its untenable proposals, end its closed process, and drop its slavish adherence to unrealistic timelines. If a legendary figure like Bob can correct his mistakes, surely the APA can do the same — for the sake of protecting our patients and keeping the mental health field united.

There is always regret for having made errors along the way, but the far greater shame is in pressing forward when your own results reveal them. Inertia is one of the most powerful forces in nature — it takes real courage to oppose it. If APA changes gears, none of us is going to say, "I told you so!" We’re going to applaud and feel proud that APA is finally on the right track. As with Bob Spitzer, sometimes the greatest honor is to admit mistakes and do the very best we can to correct them. If it fails to reform DSM 5 now, the APA leadership will have much more to apologize for in the future — to its members, to our colleagues, and of course most important to our patients.

Psychiatry was under siege in the 1970s on any number of fronts but one of the main areas was the heavy influence of psychoanalysis which was, itself, not amenable to scientific proof. In response, psychiatry rededicated itself to the scientific method and the watchwords evidence-based medicine – hard work given the subjectivity of mental illness itself. It has been a rocky road and we’ve learned more than we ever wanted to know about the many ways scientific methodology can be twisted and distorted, but the general commitment perseveres. That commitment was launched by the process of the diagnostic revision called the DSM-III released in 1980. I’ve been reviewing those days in other posts, and while I’ll find plenty to criticize, I can’t argue that Dr. Spitzer certainly brought as much of the scientific method as he could muster to the process. The major example is the use of the Kappa Statistic to quantify reliability – a statistic basically developed to fit the task.

Psychiatry is again under siege. This time, it’s not for being unscientific. It’s because there has been so much deceitful science, pseudoscience, including gross negligence in conflicts of interest and a remarkable amount of data-massage and fudging in reported studies. And once again, the focus of the siege is on a revision of our diagnostic system. This particular group, the DSM-5 Task Force, actually started its life with the battle-cry of putting psychiatry on an even more solid scientific footing, but the longed-for breakthroughs failed to materialize. And in their own process, they failed to follow one of the cardinal rules of good science – hands-on attention to procedures and details – that failure nowhere more apparent than in the recently released Field Trials for reliability which so badly missed the mark.

One can make a reasonable analogy between the DSM-5 Field Trials and our ubiquitous clinical drug trials. The point was to test the new proposals from the group for reliability. They came up short [attenuated psychosis, mixed anxiety and depression]. But something else happened. The active comparators [generalized anxiety disorder, major depressive disorder], diagnoses found reliable in the past, had some of the lowest Kappa values. In clinical trial parlance, the Field Trials were a failed study. And this is where psychiatry as a science has floundered. This is where rampant data-massage and fudging has corrupted our whole field.

A failed study is not a negative study. In a negative study, the new diagnoses would’ve been declared unreliable, but the reliability of the old standbys would’ve been maintained. So don’t add the new proposals to the Manual. This was a failed study. New proposals and the oldies were unreliable. It doesn’t matter how much work has gone into things, or how much is riding on the outcome, the scientific thing to do is reach no conclusions, and start anew.

In the example Dr. Frances uses here, Dr. Spitzer decided he’d used a flawed methodology and reached a wrong conclusion, so he retracted his study. And that’s what the DSM-5 Task Force can give to psychiatry at this point – following the commitment to the rules of science no matter how hard it is. That would be a fine legacy, an example that might do a lot for our morale, our reputation, and our future. It’s the lesson we badly need to learn…
    May 27, 2012 | 9:16 AM

    “That would be a fine legacy, an example that might do a lot for our morale, our reputation, and our future.”

    What would do a lot for patients/victims?

    Why are patients consistently absent from psychiatry’s stated goals and aims?

    Neglect as in post-stroke? Paternalism? Assumption of beneficence? Don’t rise to the level of significance (as in answering the two questions: “so what?” and “who cares?”)? Objects as means to a professional/financial end?

    Until that changes, psychiatry, IMO, continues as a failed profession, having broken the social contract. It does not meet minimal requirements to be a self-regulated, autonomous entity.

    An analogy of predatory banksters comes to mind…

    May 27, 2012 | 10:25 AM

    fyi Psychiatry in Dissent revisited


    “Influential when it was published during the 1970s, how relevant is Anthony Clare’s Psychiatry in Dissent today? ”

    The first two chapters of the book are perhaps the strongest. They explain the concept of psychiatric illness and the process of diagnosis, both of which have undergone little change. ”

    There’s no mention of ADHD, PTSD or bipolar spectrum – these didn’t ‘exist’ then. ”

    The final chapter “Contemporary psychiatry” is notable in that in many respects it echoes many of the problems of psychiatry today, as if nothing has changed: poor recruitment to the specialty and under provision of services.”

    Henry Hall
    May 27, 2012 | 12:11 PM

    Dr. Frances writes: Lifting the cloud of mental disorder from sexual choice was a big step in the civil rights movement that only now is bringing full equality.

    To an extent history repeats itself. Lifting the cloud of mental disorder from gender choice is big step in the human rights movement that is only now happening in 2012.

    Most recently in Argentina and soon enough in the ICD-11 where Gender Dysphoria aka Gender Identity Disorder will be given NON-PATHOLOGIZING classifications. As as result of government action by the Parliament of the European Union. For details see Paragraph 16 after searching (eg Google) for

    “European Parliament resolution of 28 September 2011 on human rights, sexual orientation and gender identity at the United Nations”

    Yet, “Gender sickness” is still slated to be a mental disorder in DSM-5 unless this much called-for independent scientific review is imposed by US government.

    So Why does the APA through the DSM want to come down on the wrong side of history with regards to the human rights of queer people? And for that matter why is Dr. Spitzer silent on the harm his has done to transsexual people repenting only as to homosexuals and bisexuals?

    May 27, 2012 | 1:06 PM

    I agree with aek. There’s so much about conflict of interest — Daniel Carlat devoted a lot of time to this — bad studies, overprescription, medicalization of everyday life, etc. but precious little about the lack of patient safety and injuries resulting from all the above.

    Patient injury from bad diagnosis and pharmapsychiatry is the rhinoceros in the corner. No one, including Carlat, goes anywhere near it.

    On the other hand, Allen Frances knows his audience. Maybe appealing to psychiatry egos and fantasies of greatness is the best way to get his message across.

    May 28, 2012 | 2:00 PM

    As an example of how the DSM has increased diagnosis of mental illness and promoted stigma of normal traits in popular opinion, see http://psychiatryonline.org/article.aspx?articleid=1109030&journalid=13

    “Respondents heard a brief vignette describing a person who experiences discomfort in social situations and often avoids social events. These symptoms were labeled as either social phobia or social anxiety disorder, and respondents indicated whether the person should seek mental health treatment.”

    On the basis of that vague description of symptoms, 75%-83% of the respondents were willing to award a DSM diagnosis.

    Curiously, the proportion of introverts in the general population is about 25%. The 75%-83% matches pretty closely the extroverts, who seem happy to give a psychiatric label to their introverted fellows.

    May 28, 2012 | 4:02 PM

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